Domain 4. Activity-rest
Class 4. Cardiovascular-pulmonary responses
Diagnostic Code: 00032
Nanda label: Ineffective breathing pattern
Diagnostic focus: Breathing pattern
Nursing diagnosis is an effective tool nurses use to identify and address the healthcare needs of their patients. Nursing diagnosis is not a diagnosis of physical disorder but rather an examination of a patient’s individual capabilities and how his or her current situation relates to the healthcare plan. In this article, we will be looking at ineffective breathing pattern, an important nursing diagnosis that affects how well your patient breathes, an essential element of healthy living.
NANDA Nursing Diagnosis Definition
Ineffective breathing pattern, according to NANDA (North American Nursing Diagnosis Association), is defined as a decreased oxygenation level and airway obstruction due to complications from certain medical conditions, such as chronic obstructive pulmonary disease (COPD), asthma, bronchitis, congestive heart failure, etc. This condition can lead to severe breathing difficulties, fatigue and increased shortness of breath.
Defining Characteristics
The following are some of the most common subjective and objective defining characteristics for an ineffective breathing pattern.
- Subjective: Patient reports difficulty in maintaining regular rhythm of breath, hoarse voice, difficulty in talking or speaking, anxiety or restlessness, or the appearance of being tired.
- Objective: Abnormally long pauses between breaths, restlessness, decreased cough intensity, inadequate oxygenation, increased heart rate, breathing rate, and/or respiratory rate, retractions of intercostal muscles, pursed lip breathing, use of accessory muscles, cyanosis and/or clammy skin.
Related Factors
There are various factors that can contribute to an ineffective breathing pattern. These include, but are not limited to:
- Abnormal Physiology: Conditions such as COPD, asthma, any form of bronchitis, cardiovascular problems and specific neurologic disorders can cause narrowing of the airways causing for difficult, shallow, interrupted and rapid breathing.
- Environmental Conditions: Pollutants and allergens can irritate and compromise already weakened airways, leading to increased difficulty in breathing.
- Recurring Illness: Patients with recurring illness may have issues with adequate lung expansion associated with their chest wall problems.
- Psychological State: Anxiety related to a medical condition can cause shallow and rapid breathing.
At Risk Population
Patients who are at risk of developing an ineffective breathing pattern include but are not limited to those who are elderly, sedentary, obese, asthmatic, or suffer from cardiac or pulmonary problems. Smokers, those living in high-pollution environments, and those who are constantly exposed to allergens are also at risk.
Associated Conditions
Patients with an ineffective breathing pattern may develop other conditions, including but not limited to: pneumothorax, pulmonary edema, hypoxia, atelectasis, and cardiopulmonary arrest.
Suggestions for Use
When faced with a patient who you suspect has an ineffective breathing pattern, there are several steps you can take. Begin by assessing their respiration rate, rhythm, effort and depth of breath, and auscultate the lungs to detect abnormalities. Speak with the patient to gauge the patient’s perceived exertion, fatigue, and distress. It is also important to assess the patient’s lifestyle and environment, as this can aid in making the proper diagnosis.
Suggested Alternative NANDA Nursing Diagnosis
In addition to ineffective breathing pattern, some alternative NANDA nursing diagnosis that you may want to consider include:
- Ineffective Airway Clearance: A pattern of impaired gas exchange due to excessive accumulation of secretions (mucous, protein, and debris).
- Ineffective Ventilation: This pattern is characterized by an increased amount of residual gases, CO2 retention, and hypoxemia.
- Impaired Gas Exchange: A pattern of inadequate exchange of oxygen and carbon dioxide at the alveolar-capillary membrane level.
Usage Tips
To facilitate accurate diagnosis, it is important to provide thorough client history information and engage in physical assessment to evaluate the effectiveness of airway volume and air movement. Document assessments, interventions and outcomes. Encourage patient to improve airway clearance methods, including exercise, deep breaths, and coughing exercises. Promote preventive measures such as smoking cessation and safety measures to reduce exposure to environmental pollutants and allergens.
NOC Outcomes
- Breathing Pattern: This outcome measures goal directed efforts towards determining an appropriate pace and depth of respirations.
- Airway Clearance: Outcome measure of the client’s ability to effectively perform airway clearance techniques and maintain adequate oxygenation.
- Ventilation: Outcome measures goal directed efforts to ensure effective exchange of oxygen and carbon dioxide.
- Gas Exchange: Goal directed actions to increase and maintain adequate transfer of oxygen from alveoli to the circulation.
- Oxygenation Status: Goal directed efforts to work towards restoring and maintaining normal levels of oxygenation.
Evaluation Objectives and Criteria
When evaluating a patient with an ineffective breathing pattern, nurse practitioners must utilize evaluation objectives and criteria to determine whether the patient is responding to therapy or not.
- Objectives: The nurse practitioner should aim to improve the patient’s breathing pattern, airway clearance and ventilation, as well as optimize the patient’s oxygenation status.
- Criteria: Patient displays an increased oxygen saturation level, improved respiratory rate and depth of breath, better airway clearance and improved overall comfort with breathing.
NIC Interventions
In addition to the nursing objectives and criteria outlined above, the following activity interventions may be utilized to asses and manage a patient’s ineffective breathing pattern:
- Oxygen Therapy: Administer supplemental oxygen to increase oxygen saturation levels to optimal levels.
- Nebulized Treatment: Utilize nebulized medications to help reduce inflammation and secretion production.
- Chest Physiotherapy: Employ chest physiotherapy to help mobilize secretions and improve expiratory flow.
- Activity Modification: Encourage patient to focus on resting, avoiding intense physical activities, preserve energy and prevent discomfort.
- Pursed Lip Breathing Exercises: Perform pursed lip breathing exercises to slow down breathing, decrease air trapping and allow improved expiration.
Nursing Activities
To ensure the best care possible for a patient suffering from an ineffective breathing pattern, the following nursing activities should be incorporated into the patient’s care plan:
- Monitor Vital Signs: Closely monitor any changes to the patient’s vital signs in order to assess the ongoing status of the patient’s health.
- Provide Clear Explanations: Ensure patient is adequately educated on the condition, treatments and the importance of following the recommended plan of care.
- Encourage Relaxation: Stress reduction techniques such as yoga and deep breathing may help improve the patient’s overall health.
- Identify Triggers: Pay attention to any triggers that may cause increased distress with breathing.
- Involve Family: Engage the family to create an environment of support, understanding and cooperation.
Conclusion
In summary, having an ineffective breathing pattern can drastically impact the wellbeing of a patient, which is why it is so important for nurses to be aware of when they see this issue presenting in their patients. Through a combination of accurate evaluation, proper diagnosis and targeted interventions, nurse practitioners can help their patients manage their ineffective breathing pattern and work to restore their good quality of living.
FAQs
- Q: What is an ineffective breathing pattern?
A: Ineffective breathing pattern is when a person experiences a decrease in oxygen levels due to issues with their lung’s ability to expel carbon dioxide and replace it with oxygen. This can lead to shortness of breath, fatigue and even a change in their heart rate. - Q: What are the common symptoms of an ineffective breathing pattern?
A: Common symptoms of an ineffective breathing pattern can consist of abnormal pauses between breaths, restlessness, decreased cough intensity, inadequate oxygenation, increased heart rate, breathing rate, and/or respiratory rate, retractions of intercostal muscles, pursed lip breathing and use of accessory muscles. - Q: Who is at risk of developing an ineffective breathing pattern?
A: Individuals who are at risk of developing an ineffective breathing pattern are those who are elderly, sedentary, obese, asthmatic, suffer from cardiac or pulmonary problems, smoke, live in high-pollution environments and those who are constantly exposed to allergens. - Q: What kind of interventions can be used to treat and manage an ineffective breathing pattern?
A: Interventions that can be used to manage an ineffective breathing pattern include oxygen therapy, nebulized treatments, chest physiotherapy, activity modifications and pursed lip breathing exercises. - Q: How can nurses help a patient with an ineffective breathing pattern?
A: Nurses can help a patient with an ineffective breathing pattern by monitoring the patient’s vital signs, providing clear explanations and educating them on the condition, encouraging relaxation and stress reduction programs, trying to identify potential triggers and involving the family in the care process.