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
