Assessment

  1. Patient’s respiratory rate is elevated (above normal range)
  2. Patient reports shortness of breath and difficulty breathing
  3. Use of accessory muscles for breathing
  4. Decreased oxygen saturation levels
  5. Coughing or wheezing may be present
  6. Patient may appear anxious or distressed

Nursing Diagnosis

  • Ineffective breathing pattern related to respiratory muscle fatigue and decreased lung function secondary to a respiratory condition (e.g., asthma, chronic obstructive pulmonary disease, pneumonia).

Planning

  1. Improve oxygenation and maintain adequate respiratory function.
  2. Reduce anxiety related to difficulty breathing.
  3. Promote effective breathing patterns and lung expansion.
  4. Minimize complications related to ineffective breathing.

Implementation

  1. Assess respiratory rate, rhythm, and depth regularly.
  2. Monitor oxygen saturation levels using pulse oximetry.
  3. Auscultate lung sounds for adventitious breath sounds (e.g., wheezing, crackles).
  4. Encourage the patient to sit up in an upright position, as tolerated.
  5. Provide a comfortable and supportive environment conducive to relaxation.
  6. Ensure a well-ventilated room with adequate humidity.
  7. Administer supplemental oxygen as prescribed.
  8. Monitor oxygen flow rate and adjust as necessary to maintain oxygen saturation within the target range.
  9. Assess for signs of oxygen toxicity or respiratory depression.
  10. Teach deep breathing exercises, such as diaphragmatic breathing.
  11. Instruct the patient to practice pursed-lip breathing during episodes of dyspnea.
  12. Provide education on effective coughing and airway clearance techniques, if necessary.
  13. Administer bronchodilators, corticosteroids, or other prescribed respiratory medications as scheduled.
  14. Educate the patient about proper medication use, including dosage, timing, and potential side effects.
  15. Implement relaxation techniques, such as guided imagery, deep breathing, or progressive muscle relaxation.
  16. Provide emotional support and reassurance to reduce anxiety and promote a sense of calm.
  17. Encourage the patient to express concerns and fears related to breathing difficulties.
  18. Consult with respiratory therapists for additional interventions and specialized assessments.
  19. Collaborate with the healthcare team to identify and address underlying causes of ineffective breathing.
  20. Coordinate referrals to other healthcare providers as needed (e.g., pulmonologist, physical therapist).

Evaluation

  1. Assess the patient’s respiratory rate, rhythm, and depth to determine if there is an improvement or normalization.
  2. Monitor oxygen saturation levels and note if they remain within the target range.
  3. Evaluate the patient’s ability to perform breathing techniques effectively.
  4. Determine if the patient’s anxiety related to breathing difficulties has decreased.
  5. Assess for any complications associated with ineffective breathing pattern.

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