INEFFECTIVE BREATHING PATTERN Nursing Care Plan

Stuart, 23 years old, diagnosed with pneumonia 3 months ago. Because of having not enough money for hospitalization. His state got worse day by day, until he experience painful feeling by just breathing. One day his Uncle Bob visit them and saw Stuart having difficulty of breathing. He accompanied Stuart to the hospital to cure his suffering. Below is a sample of nursing care plan for Stuart with ineffective breathing pattern.

ASSESSMENT

Subjective:

"I can't breath well because of my chest pain," as verbalized by the patient.

Objectives:

I clearly observed to the patient his/her difficulty of breathing and shortness of breath in response to his/her altered breath depth and altered chest excursion. As I observe the timing ratio, there is a prolonged expiration phases. Nasal flaring and grunting also observe.

Vital signs are taken and noted as follows: Body temperature is 35.7 degrees Celcius, blood pressure is 120/80 mmHg, respiratory rate is 23 cycles per minute and pulse rate is 110 beats per minute. Only body temperature is normal, but his/her blood pressure is considered as pre-hypertension, respiratory rate is above normal also his/her pulse rate is above normal.

DIAGNOSIS

Ineffective breathing pattern related to difficulty of breathing as manifested by prolonged expiration phases than inspiration. (Remember that expiration, also called exhalation is breathing out while inspiration, also known as inhalation is breathing in.

PLANNING

After an 30 minutes of nursing intervention, the patient will able to do coping mechanisms to improve his breathing pattern. (When it comes to difficulty of breathing, nursing intervention must done in a short period of time).

INTERVENTION

- You must determine if there are presence of factors and physical conditions that would cause breathing impairments of Stuart. Start by auscultating his chest to evaluate the type of breathing pattern such as tachypnea, grunting, Cheyne-Stokes, and other irregular patterns. Cheyne-Stokes breathing is an abnormal pattern of very shallow breaths to alternating apnea and deep, rapid breathing which is also called as periodic respiration.

- Ineffective breathing pattern may also occur when Stuart is experiencing pain located in his chest, so you must assess for concomitant pain and discomfort that may restrict his limit respiratory effort. Positioning Stuart may help or prevent this situation, so encourage him, the patient, to position of comfort of by elevating the head of the bed or have Stuart to sit up in chair, as appropriate to promote physiologic ease of maximal inspiration. Note: if immobility is a factor, you need to reposition the patient atleast every two hours.

- Encourage slower/deeper respirations, use purse lip technique, to assist Stuart in taking control of the situation and if symptoms persist administer oxygen at lowest concentration in indicated and prescribed respiratory medication for management of underlying pulmonary condition. If obstruction of secretions is the cause, suction airway as needed to clear the secretions. 

- Just remember to maintain calm attitude while dealing with Stuart to limit his level of anxiety. Monitor pulse oximetry, as indicated to verify maintenance in oxygen saturation and maintain emergency equipment in readily accessible location and include age and size appropriate ET tubes when ventilatory support might be needed.

EVALUATION

After 30 minutes of nursing intervention, the patient did the coping mechanisms to improve his breathing pattern.

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