- Actual
- Risk for (Potential)
Related To: [Check those that apply]
- Inflammatory process: viral or bacterial
- Hypoxia
- Neuromuscular impairment
- Pain
- Musculoskeletal impairment
- Tracheobronchial obstruction
- Perception or cognitive impairment
- Anxiety
- Decreased energy and fatigue
- Decreased lung expansion
As evidenced by: [Check those that apply]
- Dyspnea
- Tachypnea
- Fremitus
- Cyanosis
- Cough
- Nasal flaring
- Respiratory depth changes
- Altered chest excursion
- Use of accessory muscles
- Pursed-lip breathing or prolonged expiratory phase diameter
- Increased anteroposterior chest
Patient’s Diagnosis: –
Date:-
CLICK HERE for Free NCLEX –RN & CGFNS Practice Questions
- Demonstrate an effective respiratory rate, depth, and pattern (evidenced by: eupnea, normal skin colour). .
- Others
Note: you need to indicate time frame/target as objective must be measurable.
| Nursing Interventions | Scientific Rationale |
|---|---|
| Assess respiratory rate and depth by listening to lung sounds. | Respiratory rate and rhythm changes are early warning signs of impending respiratory difficulties. |
| Assess for dyspnea at rest versus with activity and note changes. | To determine activity tolerance. |
| Note muscles used for breathing (e.g., sternocleidomastoid, abdominal, diaphragmatic). | The accessory muscles of inspiration are not usually involved in quiet breathing. |
| Monitor for diaphragmatic muscle fatigue (paradoxical motion). | Paradoxical movement of the diaphragm indicates a reversal of the normal pattern and is indicative of ventilatory muscle fatigue and/or respiratory failure. |
| Note retractions, or flaring of nostrils. | Which would signify an increase in work of breathing. |
| Use pulse oximetry to monitor O2 saturation and pulse rate. | Pulse oximetry is a useful tool to detect changes in oxygenation early on; however, for CO2 levels, end tidal CO2 monitoring or arterial blood gases (ABGs) would need to be obtained. |
| Monitor ABGs as appropriate; note changes. | Increasing PaCO2 and decreasing PaO2 are signs of respiratory failure. As the patient begins to fail, the respiratory rate decreases and PaCO2 begins to rise. |
| Monitor for changes in orientation, increased restlessness, anxiety, and air hunger. | Restlessness is an early sign of hypoxia. |
| Monitor vital capacity in patients with neuromuscular weakness and observe trends. | To detect changes early. |
| Assess ability to clear secretions. | The inability to clear secretions may add to a change in breathing pattern. |
| Assess for pain. | Postoperative pain can result in shallow breathing. |
| Position patient with proper body alignment for optimal breathing pattern. | If not contraindicated, a sitting position allows for good lung excursion and chest expansion. |
| Ensure that O2 delivery system is applied to the patient | So that the appropriate amount of oxygen is continuously delivered and the patient does not desaturate. |
| Encourage sustained deep breaths | To promote deep inspiration. |
| Evaluate appropriateness of inspiratory muscle training. | To improve conscious control of respiratory muscles. |
| Teach patient when to inhale and exhale while doing strenuous activities. | Appropriate breathing techniques during exercise are important in maintaining adequate gas exchange. |
CLICK HERE for more Free Nursing Care Plans
___________________________________
Patient/Significant other signature
___________________________________
RN Signature
