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 Nursing Resources

Nursing Careplan: Ineffective breathing pattern
By Ronda Phillips, CCNS
University of Alabama
Capstone College of Nursing
Tuscaloosa, Alabama

Nursing Diagnosis
Ineffective breathing pattern RT physiologic changes in alveoli
elasticity secondary to emphysema/COPD

Goal #1
The client will perform modified breathing techniques that facilitate
ventilatory capacity.

Nursing Rx
1a. Assess client's ventilation (S/S weakness, breathing pattern,
use of accessory muscles)
SR: Information is gained about effectiveness of the treatment
plan and the need for modification. (Ignativicius, 1991)
1b. Instruct client in modified breathing techniques, such as pursed
lip breathing.
SR: Modified breathing techniques facilitate exhalation of
stagnant or trapped air in airways or lungs and are
beneficial during dyspneic episodes. (Ignativivius, 1991)
1c. Assist client in maintaining proper body positioning during
dyspneic episodes.
SR: Use of accessory muscles is facilitated by supporting arms
and shoulders and thoracic cavity is enlarged for increased
lung expansion. (Ignativicius, 1991)

Goal #2
Absence of adventitious breath sounds.

2a. Auscultate client's lungs q4h for adventitious breath sounds
(wheezes, crackles, rhonchi, and decreased or absent air flow).
SR: Early detection promotes early treatment. (Doenges, 165)
2b. Monitor client for signs of cyanosis.
SR: Cyanosis is detected by decreased 02 levels in tissues.
(Potter, 522)
2c. Suction client prn.
SR: Excess moisture and mucus in airways may cause adventitious
sounds to be auscultated. (NUR 256 lecture, Univ. of AL)

Goal #3
Client identifies importance of fluid intake of at least 1-2
liters/day.

Nursing Rx
3a. Explain to client the importance of adequate fluid intake and
its effect on COPD clients.
SR: Consuming adequate fluids helps to liquify secretions.
(Sparks, 502)
3b. Provide client water access via pitcher at bedside.
SR: (See 3a.)
3c. Encourage fluid intake by client and observe for compliance.
SR: Older adults may have a diminished sense of thirst,which
may lead to dry mucus membranes. (Sparks, 502)

Goal #4
Client demonstrates controlled coughing techniques.

Nursing Rx
4a. Explain to client the importance of coughing in improving
respiratory status.
SR: Coughing permits client to remove secretions from
airways. (Potter, 1252)
4b. Assist Respiratory Therapist to use nebulizer and ventolin to
help elicit cough.
SR: Nurses act in collaboration with other health care team
members to deliver health care.
4c. Teach client controlled coughing techniques ("huff" and
"cascade" coughing).
SR: Teaching coughing exercises is part of healthcare regimen
for pulmonary clients. (NUR 256 lecture, Univ of AL)

Goal #5
Client modifies behavior to conserve energy.

Nursing Rx
5a. Encourage client to utilize energy conserving techniques while
performing ADL's (sitting while dressing or showering, or
opting for baths).
SR: Encourages client to do as much as possible while
conserving limited energy and preventing fatigue.
(Doenges, 579)
5b. Teach client to alternate periods of activity with periods of
rest.
SR: Scheduling regular rest periods helps decrease fatigue and
increase stamina. (Sparks, 97)
5c. Teach the client to always breathe during an activity and never
hold breath during activity.
SR: Pacing and controlled breathing rate conserves energy
required for breathing. (Ignativicius, 1991)

References

Doenges, M.E., Moorhouse, M.F., & Geissler, A.C. (1993).
Nursing care plans (3rd ed.). Philadelphia: F.A. Davis.

Ignativicius, D.D. & Bayne, M.V. (1991). Medical surgical
nursing. Philadelphia: W.B. Saunders.

Potter, P.A. & Perry, A.G. (1993). Fundamentals of nursing:
Concepts, process, and practice (3rd ed.). St. Louis: Mosby.

Sparks, S.M. & Taylor, C.M. (1993). Nursing diagnosis reference
manual (2nd ed.). Springhouse, PA: Springhouse, Corporation.

NUR 256 Oxygenation Lecture, Fall 1994, Lynn Stover, RNC, MSN.
University of Alabama, Capstone College of Nursing.

Originally posted at: http://listserv.buffalo.edu/cgi-bin/wa?A2=ind9412&L=CAREPL-L&P=R562&I=-3&X=56F44742ECE921FDBA&Y

 

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