DEFINITIONS:
Inspiration and / or expiration that does not provide adequate ventilation
PURPOSE:
Addressing the problem of ineffective breathing pattern
CRITERIA:
- No increase in work of breathing
- No use of accessory muscles / retractions and asymmetrical chest expansion
- There was no dyspnea, and cyanosis
- Analysis of blood gases within normal limits
- Vital signs are within normal limits
- No additional breath sounds
NURSING DIAGNOSIS:
Ineffective breathing pattern related to
- Fatigue, changes in the ratio of O2 and CO2
- Anxiety, hyperventilation, hypoventilation syndrome
- Pain
- Bone deformities, spinal cord injury
- Neuromuscular dysfunction
- Obesity
NURSING INTERVENTIONS :
- Review the causes of respiratory failure
- Observations of breathing patterns
- Auscultation of lung sounds periodically, record the sound quality of breath, wheezing, expiratory lengthening and observation of chest movement symmetry
- Determine the location and extent of crackles in the sternum
- Make sure the ventilator and breathing in tune with no resistance (Fighting)
- Attach and fill the balloon with the proper ETT fixation
- Prepare resuscitation equipment close to the client, perform manual ventilation if necessary
HEALTH EDUCATION:
- Teach the client and family relaxation techniques to improve effective breathing pattern
- Teach how to cough effectively
- Discuss about home care plan
collaboration:
- Setting the ventilator and adjust ventilator pattern with the client's condition
- Observation konsintrasi O2 (Fi O2) given
- Encourage a deep breath through the abdomen during the period of respiratory distress
- Record the pressure and airway pressure waveform monitor
- Ensure humidity and air temperature inspiration and periodically checks
- Set and check ventilator alarms