positioning (client often positions self on side with knees and trunk flexed to reduce pain)
pleural effusion if present
pressure on the diaphragm resulting from accumulation of gastrointestinal gas and fluid and ascites if present.
The client will maintain an effective breathing pattern as evidenced by:
normal rate and depth of respirations
absence of dyspnea
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 reduce fear and anxiety (e.g. assure client that staff are nearby; provide a calm, restful environment; explain all tests and procedures) in order to prevent the shallow and/or rapid breathing that can occur with fear and anxiety
perform actions to reduce pain (see Diagnosis 4, action d) in order to increase the client's willingness to move and breathe more deeply
perform actions to reduce pressure on the diaphragm:
implement measures to reduce the accumulation of gas and fluid in the gastrointestinal tract (see Diagnosis 6, action b)
implement measures to prevent further third-spacing and/or promote mobilization of fluid back into vascular space (see Diagnosis 2) in order to reduce ascites
perform actions to prevent and treat pleural effusion (see Diagnosis 8, actions B and C in pleural effusion complication)
when severe pain has subsided, place client in a semi- to high Fowler's position unless contraindicated; position with pillows to prevent slumping
if client must remain flat in bed, assist with position change at least every 2 hours
instruct client to deep breathe or use incentive spirometer every 1-2 hours