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NCLEX & CGFNS Practice Questions
Ineffective Breathing Pattern
  • 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: –
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Objective/Expected Outcome;The patient will:

  • 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.

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