Ineffective Breathing Pattern NIC NOC

Nursing Diagnosis for Ineffective Breathing Pattern

Definition: The exchange of air inspiration and / or expiration inadequate.

Ineffective breathing pattern related to

• Hyperventilation
• Hypoventilation syndrome
• Damage muskuloskletal
• Neuromuscular Dysfunction
• Fatigue muscles of respiration

Data:

• Changes in chest movement
• Bradipnea, tachypnea
• Decrease in inspiratory and expiratory pressures
• Breath nostril
• The use of auxiliary respiratory muscles
• Increased vital signs

Nursing Interventions for Ineffective Breathing Pattern
a. Airway Management:

• Open the airway with headtilt, chinlift, jaw thrust
• Set the position to maximize ventilation
• Use tools airway
• Perform chest physiotherapy
• Teach breath deeply and cough effectively
• Auscultation of breath sounds
• Give bronchodilators (Collaboration)

b. Oxygen therapy

• Provide humidification system of oxygen equipment
• Monitor the flow of oxygen and the amount given
• Monitor signs of oxygen toxicity

c. Monitoring of respiration

• Monitor the frequency, rhythm and depth of breathing
• Monitor the use of auxiliary respiratory muscles

d. Monitoring of vital signs

• Monitor blood pressure, pulse, respiratory rate, temperature
• Monitor blood pressure during sleep, sit, stand up if indicated
• Monitor signs and symptoms of hypothermia or hyperthermia
• Monitor rhythm and breath sounds

Ineffective Breathing Pattern related to Cardiac Tamponade

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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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