Saturday, September 10, 2011

Ineffective Breathing Pattern Care Plan

Ineffective breathing pattern

DEFINITIONS:

Inspiration and / or expiration that does not provide adequate ventilation

PURPOSE:

Addressing the problem of ineffective breathing pattern

CRITERIA:
  • There was no increased work of breathing
  • There is no use of accessory muscles / retractions and asymmetrical chest expansion
  • No dyspnoea and cyanosis
  • Blood Gas Analysis within normal limits
  • Vital signs within normal limits
  • No additional breath sounds

NURSING DIAGNOSIS INEFFECTIVE BREATHING PATTERN CARE PLAN :

Ineffective breathing pattern related to
  • Fatigue, changes in the ratio of O2 and CO2
  • Anxiety, hyperventilation, hypoventilation syndrome
  • Pain
  • Bone deformities, spinal cord injury
  • Neuromuscular dysfunction
  • Obesity

NURSING INTERVENTIONS INEFFECTIVE BREATHING PATTERN CARE PLAN
  • Review the causes of respiratory failure
  • Observations of breathing patterns
  • Auscultation of lung sounds periodically, note the quality of breath sounds, wheezing, expiratory lengthening and observation symmetry chest movement
  • Determine the location and extent of crackles in the sternum
  • Ensure breathing in tune with vgentilator and no resistance (Fighting)
  • Attach and fill the balloon with the proper ETT fixation
  • Have resuscitation equipment close to the client, perform manual ventilation if necessary

HEALTH EDUCATION:
  • Teach the client and family relaxation techniques to increase effective breathing pattern
  • Teach how to cough effectively
  • Talk about home-care plan

Act of collaboration:
  • Ventilator settings and adjust the ventilator pattern with the client's condition
  • Observation konsintrasi O2 (Fi O2) is given
  • Encourage deep breath through the abdomen during the period of respiratory distress
  • Record the pressure and the airway pressure waveform monitor
  • Ensure humidity and air temperature of inspiration and periodically checks
  • Set and check the ventilator alarm

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