Related To: [Check those that apply]
As evidenced by: [Check those that apply]
Patient’s Diagnosis: –
Date:-
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| 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. |