Nursing Diagnosis : Ineffective Breathing Pattern
NANDA Definition : Inspiration and/or expiration that does not provide adequate ventilation
Respiratory pattern monitoring addresses the patient’s ventilatory pattern, rate, and depth. Most acute pulmonary deterioration is preceded by a change in breathing pattern. Respiratory failure can be seen with a change in respiratory rate, change in normal abdominal and thoracic patterns for inspiration and expiration, change in depth of ventilation (Vt), and respiratory alternans. Breathing pattern changes may occur in a multitude of cases from hypoxia, heart failure, diaphragmatic paralysis, airway obstruction, infection, neuromuscular impairment, trauma or surgery resulting in musculoskeletal impairment and/or pain, cognitive impairment and anxiety, metabolic abnormalities (e.g., diabetic ketoacidosis [DKA], uremia, or thyroid dysfunction), peritonitis, drug overdose, and pleural inflammation.
Characteristics :
- Dyspnea
- Cyanosis
- Tachypnea
- Cough
- Fremitus
- Respiratory depth changes
- Nasal flaring
- Use of accessory muscles
- Altered chest excursion
- Pursed-lip breathing or prolonged expiratory phase
- Increased anteroposterior chest diameter
Related Factors:
- Hypoxia
- Inflammatory process: viral or bacterial
- Musculoskeletal impairment
- Neuromuscular impairment
- Pain
- Anxiety
- Tracheobronchial obstruction
- Decreased energy and fatigue
- Perception or cognitive impairment
- Decreased lung expansion
Expected Outcomes : Patient’s breathing pattern is maintained as evidenced by eupnea, normal skin color, and regular respiratory rate/pattern.
NOC Outcomes :
Suggested NOC Labels
- Respiratory Status: Ventilation
- Vital Sign Status
NIC Interventions :
Suggested NIC Labels
- Airway Management
- Respiratory Monitoring