Breathing Pattern, Ineffective
RN, MS, CCRN
NANDA: A state in which an individual's respiratory pattern
(cycles of inhalation and exhalation) does not enable adequate ventilation
Respiratory pattern monitoring addresses the patient's
ventilatory pattern, rate, and depth. Most acute pulmonary deterioration is
preceded by a change in breathing pattern. Respiratory failure can be seen with
a change in respiratory rate, change in normal abdominal and thoracic patterns
for inspiration and expiration, change in depth or ventilation (Vt), and
respiratory alternans. Breathing pattern changes may occur in a multitude of
cases from hypoxia, heart failure, diaphragmatic paralysis, airway obstruction,
infection, neuromuscular impairment, trauma or surgery resulting in
musculoskeletal impairment and/or pain, cognitive impairment and anxiety,
metabolic abnormalities (e.g., diabetic ketoacidosis [DKA], uremia, thyroid
dysfunction), peritonitis, drug overdose, and pleural inflammation.
- Inflammatory process: viral or bacterial
- Neuromuscular impairment
- Musculoskeletal impairment
- Tracheobronchial obstruction
- Perception or cognitive impairment
- Decreased energy and fatigue
- Decreased lung expansion
- Nasal flaring
- Respiratory depth changes
- Altered chest excursion
- Use of accessory muscles
- Pursed-lip breathing or prolonged expiratory phase
- Increased anteroposterior chest diameter
Patient's breathing pattern is maintained as evidenced by: eupnea,
normal skin color, and regular respiratory rate/pattern.
- (i) independent
- (i) Assess respiratory rate and depth by
listening to lung sounds.
- Respiratory rate and rhythm changes are early warning signs
of impending respiratory difficulties.
- (i) Assess for dyspnea and quantify (i.e.,
note how many words per breath patient can say); relate dyspnea to
precipitating factors. Assess for dyspnea at rest versus with activity and note
- To determine activity tolerance.
- (i) Monitor breathing patterns:
- Bradypnea (slow respirations)
Tachypnea (increase in
Hyperventilation (increase in respiratory rate or tidal
volume, or both)
Kussmaul respirations (deep respirations with fast, normal
or slow rate)
Cheyne-Stokes (waxing and waning with periods of apnea
between a repetitive pattern)
Apneusis (sustained maximal inhalation with
Biot's respiration (irregular periods of apnea alternating with
periods in which four or five breaths of identical depth are taken)
patterns (irregular and unpredictable pattern with periods of apnea)
- (i) Note muscles used for breathing (e.g.,
sternocleidomastoid, abdominal, diaphragmatic).
- The accessory muscles of inspiration are not usually
involved in quiet breathing. These include the scalenes (attach to the first
two ribs) and the sternocleidomastoid (elevates the sternum).
- (i) Monitor for diaphragmatic muscle
fatigue (paradoxical motion).
- Paradoxical movement of the diaphragm indicates a reversal
of the normal pattern and is indicative of ventilatory muscle fatigue and/or
respiratory failure. The diaphragm is the most important muscle of ventilation
normally responsible for 80% to 85% of ventilation during restful
- (i) Note retractions, or flaring of
- Which would signify an increase in work of
- (i) Assess position patient assumes for
normal or easy breathing.
- (i) Use pulse oximetry to monitor O2 saturation and pulse rate.
- Pulse oximetry is a useful tool to detect changes in
oxygenation early on; however, for CO2 levels, end tidal CO2 monitoring or arterial blood gases (ABGs)
would need to be obtained.
- (c) Monitor ABGs as appropriate; note
- Increasing PaCO2 and decreasing PaO2 are signs of respiratory failure. As the
patient begins to fail, the respiratory rate decreases and PaCO2 begins to rise.
- (i) Monitor for changes in orientation,
increased restlessness, anxiety, and air hunger.
- Restlessness is an early sign of hypoxia.
- (c) Avoid high concentration of O2 in patients with chronic
obstructive pulmonary disease (COPD).
- Hypoxia stimulates the drive to breathe in the chronic
CO2 retainer patient. When
applying O2, close monitoring
is imperative to prevent unsafe increases in the patient's PaO2, which could result in apnea.
- (i) Assess skin color, temperature,
capillary refill; note central versus peripheral cyanosis.
- (i) Monitor vital capacity in patients
with neuromuscular weakness and observe trends
- To detect changes early.
- (i) Assess presence of sputum for
quantity, color, consistency.
If the sputum is discolored (no longer clear
- An infection may be present.
- (c) Send sputum specimen for culture and
sensitivity, as appropriate.
- Respiratory infections increase the work of breathing;
antibiotic treatment may be indicated.
- (i) Assess ability to clear
- The inability to clear secretions may add to a change in
- (i) Assess for pain.
- Postoperative pain can result in shallow breathing.
- (i) independent
- (i) Position patient with proper body
alignment for optimal breathing pattern.
- If not contraindicated, a sitting position allows for good
lung excursion and chest expansion.
- (c) Ensure that O2 delivery system is applied to the
- So that the appropriate amount of oxygen is continuously
delivered and the patient does not desaturate.
- An O2
saturation of 90% or greatershould be maintained
- To provide for adequate oxygenation.
- (i) Encourage sustained deep breaths using
- Demonstration (emphasizing slow inhalation, holding end
inspiration for a few seconds, and passive exhalation)
- Use of incentive spirometer (place close for convenient patient
- Asking patient to yawn
- To promote deep inspiration
- (i) Evaluate appropriateness of inspiratory
- To improve conscious control of respiratory
- (i) Maintain a clear airway by encouraging
patient to clear own secretions with effective coughing. If secretions cannot
be cleared, suction as needed to clear secretions.
- (i) Use universal precautions: gloves,
goggles, and mask, as appropriate. If secretions are purulent, precautions
should be instituted before receiving the culture and sensitivity final report.
Institute appropriate isolation procedures for positive cultures (e.g.,
methicillin resistant Staphylococcus aureus, tuberculosis [TB]).
- (i) Pace and schedule activities providing
adequate rest periods.
- To prevent dyspnea resulting from fatigue.
- (i) Provide reassurance and allay anxiety
by staying with patient during acute episodes of respiratory distress.
- Air hunger can produce an extremely anxious
- (i) Provide relaxation training as
appropriate (e.g., biofeedback, imagery, progressive muscle relaxation).
- (i) Encourage diaphragmatic breathing for
patient with chronic disease.
- (c) Use pain management as
- To allow for pain relief and the ability to deep
- (i) Anticipate the need for intubation and
mechanical ventilation if patient is unable to maintain adequate gas exchange
with the present breathing pattern.
Education/Continuity of Care
- (i) independent
- (i) Explain all procedures before
- To decrease patient's anxiety.
- (i) Explain effects of wearing restrictive
- So that respiratory excursion is not compromised.
- (i) Explain use of O2 therapy, including the type and use of
equipment and why its maintenance is important.
- Issues related to home oxygen use, storage, or precautions
need to be addressed.
- (i) Instruct about medications:
indications, dosage, frequency, and potential side effects. Include review of
metered-dose inhaler and nebulizer treatments, as appropriate.
- (i) Review the use of at-home monitoring
capabilities and refer to home health nursing, O2 vendors, and other resources for rental
equipment as appropriate.
- (i) Explain environmental factors that may
worsen patient's pulmonary condition (e.g., pollen, second-hand smoke), and
discuss possible precipitating factors (e.g., allergens and emotional
- (i) Explain symptoms of a "cold" and
- A respiratory infection would increase the work of
- (i) Teach patient or caregivers
appropriate breathing, coughing, and splinting techniques.
- To facilitate adequate clearance of secretions.
- (i) Teach patient how to count own
respirations and relate respiratory rate to activity tolerance.
- Patient will then know when to limit activities in terms of
his or her own limitations.
- (i) Teach patient when to inhale and
exhale while doing strenuous activities.
- Appropriate breathing techniques during exercise are
important in maintaining adequate gas exchange.
- (i) Assist patient or caregiver in
learning signs of respiratory compromise. Refer significant other/caregiver to
participate in basic life support class for CPR, as appropriate
- (c) Refer to Social Services for further
counseling related to patient's condition and give list of support groups or a
contact person from the support group for the patient to talk with.
Airway Management; Respiratory Monitoring
- See also:
~ Care Plan Index ~
Outcomes Index ~
~ Care Plan Constructor Home ~