related to diminished lung/chest wall expansion associated with:
weakness and decreased mobility;
pressure on the diaphragm as a result of ascites;
pleural effusion (hepatic hydrothorax) resulting from fluid volume excess and passage of ascitic fluid into the pleural space through a probable pressure-related defect in the diaphragm.
The client will have an improved breathing pattern as evidenced by:
normal rate and depth of respirations
symmetrical chest excursion.
Nursing Actions and Selected Purposes/Rationales
Assess for signs and symptoms of an ineffective breathing pattern (e.g. shallow respirations, dyspnea, tachypnea, use of accessory muscles when breathing, limited chest excursion).
Implement measures to improve breathing pattern:
perform actions to increase strength and activity tolerance (see Diagnosis 7, action b) in order to increase client's willingness and ability to move, deep breathe, and use incentive spirometer
perform actions to restore fluid balance (see Diagnosis 2, action a.2) in order to reduce fluid accumulation in the peritoneal cavity and pleural space
place client in a semi-Fowler's position (a high Fowler's position is uncomfortable if ascites is severe)
instruct client to deep breathe or use incentive spirometer every 1-2 hours
instruct client to avoid intake of gas-forming foods (e.g. beans, cauliflower, cabbage, onions), carbonated beverages, and large meals in order to prevent gastric distention and additional pressure on the diaphragm