NURSING DIAGNOSIS: Ineffective breathing pattern

related to diminished lung/chest wall expansion associated with:
  1. weakness and decreased mobility;
  2. pressure on the diaphragm as a result of ascites;
  3. 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.
Desired Outcome
The client will have an improved breathing pattern as evidenced by:
  1. normal rate and depth of respirations
  2. decreased dyspnea
  3. symmetrical chest excursion.
Nursing Actions and Selected Purposes/Rationales
  1. 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).
  2. Implement measures to improve breathing pattern:
    1. 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
    2. 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
    3. place client in a semi-Fowler's position (a high Fowler's position is uncomfortable if ascites is severe)
    4. instruct client to deep breathe or use incentive spirometer every 1-2 hours
    5. 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
    6. assist with positive airway pressure techniques (e.g. IPPB, continuous positive airway pressure [CPAP], bilevel positive airway pressure [BiPAP], expiratory positive airway pressure [EPAP]) if ordered
    7. increase activity as allowed and tolerated
    8. administer central nervous system depressants judiciously; hold medication and consult physician if respiratory rate is less then 12/minute
    9. assist with thoracentesis and/or paracentesis if performed to remove pleural and/or peritoneal fluid in order to allow increased lung expansion.
  3. Consult appropriate health care provider (e.g. respiratory therapist, physician) if:
    1. ineffective breathing pattern continues
    2. signs and symptoms of impaired gas exchange (e.g. restlessness, irritability, confusion, significant decrease in oximetry results, decreased PaO2 and increased PaCO2 levels) are present.