Friday, November 26, 2010

Ineffective Breathing Pattern

Ineffective Breathing Pattern

NANDA Definition
Inspiration and/or expiration that does not provide adequate ventilation

Discussion of the Problem
Breathing patterns refer to the rate, volume, rhythm, and relative ease or effort of respiration. Normal respiration (eupnea) is quiet, rhythmic, and effortless. Tachypnea (rapid rate) is seen with fevers, metabolic acidosis, pain, and hypercapnia or hypoxemia. Bradypnea is an abnormally slow respiratory rate, which may be seen in clients who have taken drugs such as morphine, who have metabolic alkalosis, or who have increased intracranial pressure. Apnea is the cessation of breathing. Hyperventilation, often called alveolar hyperventilation, is an increased movement of air into and out of the lungs. One particular type of hyperventilation that accompanies metabolic acidosis is Kussmaul’s breathing, by which the body attempts to compensate (give off excess body acids) by blowing off the carbon dioxide through deep and rapid breathing. Abnormal respiratory rhythms create an irregular breathing pattern. Two abnormal respiratory rhythms are Cheyne-Stokes repirations (marked rhythmic waxing and waning of respirations from very deep to very shallow breathing and temporary apnea) and Biot’s (cluster) respirations (shallow breaths interrupted by apnea). Orthopnea is the inability to breathe except in an upright or standing position. Difficult or uncomfortable breathing is called dyspnea. Most acute pulmonary deterioration is preceded by a change in breathing pattern. 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, diabetic ketoacidosis, uremia, thyroid dysfunction, peritonitis, drug overdose, AIDS, acute alcohol withdrawal, cardiac surgery, cholecystectomy, liver cirrhosis, craniocerebral trauma, disc surgery, lymphomas, renal dialysis, seizure disorders, spinal cord injuries, mechanical ventilatory assistance and pleural inflammation. The overall managements for patients with oxygenation problems are to maintain a patent airway, improve comfort and ease of breathing, maintain or improve pulmonary ventilation and oxygenation, improve ability to participate in physical activities, and to prevent risks associated with oxygenation problems such as skin and tissue breakdown, syncope, acid-base imbalances, and feelings of hopelessness and social isolation.

Nursing Interventions Classification (NIC)
  • Airway Management
  • Respiratory Monitoring

Nursing Outcomes Classification (NOC)
  • Respiratory Status: Ventilation
  • Vital Sign Status

Goal and Objectives
  • Patient will experience no signs of respiratory compromise or complications.
  • Patient will take part in efforts to wean within individual capability.
  • Patient’s breathing pattern will be maintained as manifested by eupnea, normal skin color, normal respiratory rate and pattern, and no other sighs of hypoxia.

Subjective and Objective Data
  • Altered chest excursion
  • Apnea,
  • Changes in respiratory rate and depth
  • Cough
  • Cyanosis
  • Decreased Po2 and Sao2; increased Pco2
  • Dyspnea
  • Fremitus
  • Holding breath
  • Increased anteroposterior chest diameter
  • Increased restlessness, apprehension, and metabolic rate
  • increased work of breathing, use of accessory muscles
  • Nasal flaring
  • Noisy respirations
  • Pursed-lip breathing or prolonged expiratory phase
  • Reduced VC/total lung volume
  • Reduced vital capacity
  • Tachypnea/bradypnea or cessation of respirations when off the ventilator

Related Factors
  • Alteration of patient’s usual O2/CO2 ratio
  • Anxiety
  • Decreased energy and fatigue
  • Decreased lung expansion
  • Hypoxia
  • Inflammatory process: viral or bacterial
  • Musculoskeletal impairment
  • Neuromuscular impairment
  • Pain
  • Perception or cognitive impairment
  • Respiratory center depression
  • Respiratory muscle weakness/paralysis
  • Tracheobronchial obstruction

Assessment (Dx)
  • Note respiratory rate and depth. Shallow breathing, splinting with respirations, holding breath may lead to hypoventilation or atelectasis.

  • Watch breathing patterns. Particular breathing patterns may signify an underlying disease process or dysfunction. Cheyne-Stokes respiration signifies bilateral dysfunction in the deep cerebral or diencephalon related with brain injury or metabolic abnormalities. Apneusis and ataxic breathing are related with failure of the respiratory centers in the pons and medulla.

Period of cessation of breathing
sustained maximal inhalation with pause
Ataxic patterns
Irregular and unpredictable pattern with periods of apnea
Biot’s respiration
Periods of normal breathing (3-4 breathes) followed by a varying period of apnea usually 10-60 seconds).
Slower than normal rate, <10 breathe/minute, with normal depth and regular rhythm
Cheyne-Stokes respiration

Regular cycle where the rate and depth of breathing increase, then decrease until apnea (usually about 20 seconds) occurs.
Normal, breathing at 12-18 breaths/minute
Increased rate and depth of breathing
Kussmaul’s respirations
Deep respirations with fast, normal, or slow rate
Rapid, shallow breathing, > 24 breaths/minute

  • Auscultate breath sounds. Areas of diminished or absent breath sounds advocates atelectasis, while adventitious sounds, such as wheezes and rhonchi, manifest congestion.

Continuous breath sounds of both rhonchi and wheezing; usually bronchodilator will help to alleviate this problem.
Expiratory grunt
A sign of distress, hypoxia, and/or increased work of breathing.
A fine crackle that can be heard during inspiration or expiration.
Coarse crackle sound that is more wet than a rale, suctioning recommended.
Usually caused by edema around the vocal cords or from an obstruction or tumor.
Wheeze ( whistling sound )
This is heard most commonly in asthmatics and CHF

  • Evaluate for dyspnea and quantify. Relate dyspnea to precipitating factors. Note for dyspnea at rest versus activity and observe changes. Dyspnea that takes place with activity may be a sign of activity intolerance.

  • Evaluate position patient assumes for normal or easy breathing.

  • Observe for diaphragmatic muscle fatigue (paradoxical motion). Paradoxical movement of the diaphragm signifies a reversal of the regular pattern and is an indicator of ventilatory muscle fatigue and/or respiratory failure. The diaphragm is the most vital muscle of ventilation, usually responsible for 80% to 85% of ventilation during restful breathing.

  • Observe muscles utilized for breathing. The accessory muscles of inspiration are not typically involved in quiet breathing. These comprise the scalenes and the sternocleidomastoid.

  • Utilize pulse oximetry to check oxygen saturation and pulse rate. Pulse oximetry is a helpful tool to detect alterations in oxygenation initially; but, for CO2 levels, end tidal CO2 monitoring or arterial blood gases (ABGs) would require to be obtained.

  • Watch for retractions or flaring of nostrils. These indicate an augmentation in work of breathing.

  • Check ABGs as indicated; observe changes. Rising PaCO2 and falling PaO2 are manifestations of respiratory failure. As the patient starts to fail, the respiratory rate falls and PaCO2 starts to increase.

1. Note the pH.  Determine if it is acidosis or alkalosis.
2. Note the PaCO2.  Is it normal, increased, or decreased?
3. Note the HCO3.  Is it normal, increased, or decreased?
4. Note the base excess or deficit.
5. Note the PaO2 to determine if there is hypoxia.
7.35 - 7.45
35 - 45
80 - 100  ( in infants normal PaO2:  60 - 80 )
20 - 24

  • Evaluate ability to mobilize secretions. The incapability to mobilize secretions may contribute to change in breathing pattern.

  • Evaluate for pain. Postoperative pain can lead to shallow breathing.

  • Evaluate skin color, temperature, capillary refill; observecentral versus peripheral cyanosis.

  • Keep away from high concentration of oxygen in patients with chronic obstructive pulmonary disease (COPD). Hypoxia triggers the drive to breathe in the chronic CO2 retainer patient. When adminestering oxygen, close monitoring is very important to avoid hazardous risings in the patient’s PaO2, which could lead in apnea.

  • Observe for alterations in orientation, augmented restlessness, anxiety, and air hunger. Restlessness is an initial manifestation of hypoxia.

  • Observe presence of sputum for amount, color, consistency. As necessary, send sputum specimen for culture and sensitivity If the sputum is discolored. An infection may be occurring. Respiratory infections augment the work of breathing; antibiotic management may be given.

Therapeutic Interventions (Tx)
  • An oxygen saturation of 90% or greater should be sustained. This offers for sufficient oxygenation.

  • Guarantee that oxygen delivery system is administered to the patient. The proper quantity of oxygen is constantly administered so that the patient does not desaturate.

  • Place patient with appropriate body alignment for maximum breathing pattern. A sitting position permits for maximum lung excursion and chest expansion,  if not contraindicated,

  • Persuade maintained deep breaths by:
1)     Utilizing demonstration: highlighting slow inhalation, holding end inspiration for a few seconds, and passive exhalation
2)     Utilizing incentive spirometer
3)     Requiring the patient to yawn. This simple method enhances deep inspiration.

  • Foresee the necessitate for intubation and mechanical ventilation if patient is incapable to sustain sufficient gas exchange

  • Give reassurance and alleviate anxiety by staying with patient throughout acute episodes of respiratory distress. Air hunger can create an extremely anxious condition.

  • Help out with respiratory treatments, for instance, incentive spirometer. Optimizes expansion of lungs to avoid or resolve atelectasis.

  • Keep a clear airway by persuading patient to mobilize own secretions with successful coughing. If secretions cannot be mobilized, suction as necessary to clear secretions.

  • Observe universal precautions necessary. Precautions should be observed before receiving the culture and sensitivity final report, if secretions are purulent. Introduce fitting isolation measures for positive cultures.

  • Offer relaxation training as needed.

  • Pace and schedule activities giving sufficient rest periods. This avoids dyspnea resulting from fatigue.

  • Utilize pain management as needed. This facilitates for pain relief and the capability to deep breathe.

Educative (Edx)
  • Clarify the use of oxygen therapy, including the type and use of equipment and why its continuation is significant. Ratio Issues associated to home oxygen use, storage, and precautions require to be attended.

  • Coach patient or significant other proper breathing, coughing, and splinting methods. These enable sufficient mobilization of secretions.

  • Educate about medications: indications, dosage, frequency, and possible side effects. Incorporate review of metered-dose inhaler and nebulizer treatments, as needed.

  • Educate patient how to count own respirations and relate respiratory rate to activity tolerance. Patient will then know when to minimize activities in terms of his or her own boundaries.

  • Educate patient when to inhale and exhale while doing strenuous activities.  Proper breathing methods during exercise are significant in sustaining sufficient gas exchange.

  • Give details on effects of wearing restrictive clothing. Respiratory excursion is not compromised.

  • Give details on the symptoms of “cold” and awaiting problems. A respiratory infection would augment the work of breathing.

  • Give explanation on all actions before executing. This allays patient’s anxiety.

  • Give explanation on environmental factors that may exacerbate patient’s pulmonary condition and talk about potential precipitating factors.

  • Persuade diaphragmatic breathing for patient with chronic disease.

  • Help patient or significant other in learning manifestations of respiratory compromise. Submit significant other or caregiver to take part in basic life support class for CPR, as suitable.

1. Stay Safe! The worst thing a rescuer can do is become another victim. Observe universal precautions and wear personal protective equipment if you have it. Use common sense and stay away from potential hazards.

2. Attempt to wake victim. Briskly rub your knuckles against the victim's sternum. If the victim does not wake, call Emergency Medical Service (EMS) and proceed to step 3. If the victim wakes, moans, or moves, then CPR is not necessary at this time. Call EMS if the victim is confused or not able to speak.

3. Begin rescue breathing. Open the victim's airway using the head-tilt, chin-lift method. Put your ear to the victim's open mouth:
            • look for chest movement
            • listen for air flowing through the mouth or nose
            • feel for air on your cheek
If there is no breathing, pinch the victim's nose; make a seal over the victim's mouth with yours. Use a CPR mask if available. Give the victim a breath big enough to make the chest rise. Let the chest fall, and then repeat the rescue breath once more.

4. Begin chest compressions. Place the heel of your hand in the middle of the victim's chest. Put your other hand on top of the first with your fingers interlaced. Compress the chest about 1-1/2 to 2 inches (4-5 cm). Allow the chest to completely recoil before the next compression. Compress the chest at a rate equal to 100/minute. Perform 30 compressions at this rate.

5. Repeat rescue breaths. Open the airway with head-tilt, chin-lift again. This time, go directly to rescue breaths without checking for breathing again. Give one breath, making sure the chest rises and falls, then give another.

6. Perform 30 more chest compressions. Repeat steps 5 and 6 for about two minutes.

7. Stop compressions and recheck victim for breathing. If the victim is not breathing, continue chest compressions and rescue breaths.

8. Keep going until help arrives.

2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2005 Dec 13; 112 (24 Suppl):IV1-203. Epub 2005 Nov 28.

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