Nursing Care Plan Impaired Breathing Pattern.docx

NURSING CARE PLAN: Ineffective Breathing Pattern Related to Excessive Mucus and Retained Secretions ASSESSMENT

DIAGNOSIS

Subjective data: No verbal cues

Ineffective Breathing Pattern related excessive mucus and retained secretions

Objective data: (+) Tachypnea (+) Wheezes (+) Abnormal breathing pattern ; RR=25

SCIENTIFIC Inspiration and/or expiration that does not provide adequate ventilation

PLANNING After 8 hours of nursing intervention the client will be able to: Exhibit breathing without difficulty

Vital signs as follows: T: 36.5 C BP 147/85 RR:25 HR: 87

Will have patent airway

Patient is under tracheostomy to mechanical ventilator

Will have Normal respiratory rate

Will have clear breathing sounds

INTERVENTION

RATIONALE

EVALUATION

Assess rate and depth of respirations and chest movement. Monitor for signs of respiratory failure, for example, cyanosis and severe tachypnea.

When pneumonia is severe, the client may require endotracheal intubation and mechanical ventilation to keep airways clear.

After 8 hours of nursing intervention the client is able to:

Auscultate lung fields, noting areas of decreased or absent airflow and adventitious breath sounds, such as crackles and wheezes.

Decreased airflow occurs in areas consolidated with fluid. Bronchial breath sounds (normal over bronchus) can also occur in consolidated areas. Crackles, rhonchi, and wheezes are heard on inspiration and expiration in response to fluid accumulation, thick secretions, and airway spasm or obstruction.

Elevate head of bed; change position frequently.

Suction, as indicated, for example, oxygen desaturation related to

Exhibit breathing without difficulty have patent airway

Keeping the head elevated lowers diaphragm, promoting chest expansion, aeration of lung segments, and mobilization and expectoration of secretions to keep the airway clear.

Stimulates cough or mechanically clears airway in client who is unable to do so because of ineffective cough

have clear breathing sounds RR=19 (within normal respiratory rate)

airway secretions.

or decreased level of consciousness.

Collaborative: Assist with and monitor effects of nebulizer treatments and other respiratory physiotherapy, percussion, and postural drainage. Perform treatments between meals and limit fluids when appropriate.

Administer medications, as indicated. Provide supplemental fluids such as IV, humidified oxygen, and room humidification.

Monitor ABGs, and pulse oximetry readings.

Facilitates liquefaction and removal of secretions. Postural drainage may not be effective in interstitial pneumonias or those causing alveolar exudates or destruction. Coordination of treatments, schedules, and oral intake reduces likelihood of vomiting with coughing and expectorations.

Aids in reduction of bronchospasm and mobilization of secretions. Fluids are required to replace losses, including insensible losses, and aid in mobilization of secretions. Note: Some studies indicate that room humidification has been found to provide minimal benefit and is thought to increase the risk of transmitting infection. Follows progress and effects of disease process and therapeutic regimen and facilitates necessary

alterations in therapy.