Actual Nursing Care Plan example from Nursing for Life Organization

1. Nursing Care Plan
"Ineffective Breathing Pattern"
Patient
Problem
( Actual )
Nursing diagnosis Ineffective breathing pattern related to (contributing factor
according to the patient’s condition)
Subjective
Data
 According to the nurse’s observation.
Objective
Data
 According to the patient description.
Objectives
Short
term
In 2 days, the patient will…
 Patient reports feeling rested each day.
 Patient performs diaphragmatic pursed-lip breathing.
 Patient demonstrates maximum lung expansion with adequate
ventilation.
Long
term
In 2 weeks, the patient will
 Patient maintains an effective breathing pattern, as evidenced by relaxed
breathing at normal rate and depth and absence of dyspnea.
 When patient carries out ADLs, breathing pattern remains normal.
Nursing
intervention
Assessment
- Assess and record respiratory rate and depth at least every 4 hours.
- Rationale: The average rate of respiration for adults is 10 to 20 breaths per
minute. It is important to take action when there is an alteration in the
pattern of breathing to detect early signs of respiratory compromise.
 Assess ABG levels, according to facility policy.
- Rationale: This monitors oxygenation and ventilation status.
 Observe for breathing patterns.
- Rationale: Unusual breathing patterns may imply an underlying disease
process or dysfunction. Cheyne-Stokes respiration signifies bilateral
dysfunction in the deep cerebral or diencephalon related with brain injury
or metabolic abnormalities. Apneusis and ataxic breathing are related
with failure of the respiratory centers in the pons and medulla.

2.  Auscultate breath sounds at least every 4 hours.
- Rationale: This is to detect decreased or adventitious breath sounds.
 Ask if they are “short of breath” and note any dyspnea.
- Rationale: Sometimes anxiety can cause dyspnea, so watch the patient
for “air hunger” which is a sign that the cause of shortness of breath is
physical.
 Assess for use of accessory muscle.
- Rationale: Work of breathing increases greatly as lung compliance
decreases.
 Monitor for diaphragmatic muscle fatigue or weakness (paradoxical
motion).
- Rationale: Paradoxical movement of the abdomen (an inward versus
outward movement during inspiration) is indicative of respiratory muscle
fatigue and weakness.
 Observe for retractions or flaring of nostrils.
- Rationale: These signs signify an increase in respiratory effort.
 Assess the position that the patient assumes for breathing.
- Rationale: Orthopnea is associated with breathing difficulty.
 Utilize pulse oximetry to check oxygen saturation and pulse rate.
- Rationale: Pulse oximetry is a helpful tool to detect alterations in
oxygenation initially; but, for CO2 levels, end tidal CO2 monitoring or
arterial blood gases (ABGs) would require being obtained.
 Assess ability to mobilize secretions.
- Rationale: The incapability to mobilize secretions may contribute to
change in breathing pattern.
 Evaluate skin color, temperature, capillary refill; observe central versus
peripheral cyanosis.
- Rationale: Lack of oxygen will cause blue/cyanosis coloring to the lips,
tongue, and fingers. Cyanosis to the inside of the mouth is a medical
emergency!

3.  Assess for thoracic or upper abdominal pain.
- Rationale: Pain can result shallow breathing.
Interventions
 Place patient with proper body alignment for maximum breathing
pattern.
- Rationale: A sitting position permits maximum lung excursion and chest
expansion.
 Encourage sustained deep breaths by:
 Using demonstration: highlighting slow inhalation, holding end
inspiration for a few seconds, and passive exhalation
 Utilizing incentive spirometer
 Requiring the patient to yawn
- Rationale: These techniques promotes deep inspiration, which increases
oxygenation and prevents atelectasis. Controlled breathing methods may
also aid slow respirations in patients who are tachypneic. Prolonged
expiration prevents air trapping
 Encourage diaphragmatic breathing for patients with chronic disease.
- Rationale: This method relaxes muscles and increases the patient’s
oxygen level.
 Evaluate the appropriateness of inspiratory muscle training.
- Rationale: Thistraining improvesconscious control of respiratory muscles
and inspiratory muscle strength.
 Provide respiratory medications and oxygen, per doctor’s orders.
- Rationale: Beta-adrenergic agonist medications relax airway smooth
muscles and cause bronchodilation to open air passages.
 Avoid high concentration of oxygen in patients with COPD.
- Rationale: Hypoxia triggers the drive to breathe in the chronic CO2
retainer patient. When administering oxygen, close monitoring is very
important to avoid uncertain risings in the patient’s PaO2, which could
lead to apnea.
 Maintain a clear airway by encouraging patient to mobilize own secretions
with successful coughing.
- Rationale: This facilitates adequate clearance of secretions.
 Encourage small frequent meals.
- Rationale: This prevents crowding of the diaphragm.

4. Health
Teaching
 Educate patient or significant other proper breathing, coughing, and
splinting methods.
- Rationale: These allow sufficient mobilization of secretions.
 Educate patient about medications: indications, dosage, frequency, and
possible side effects. Incorporate review of metered-dose inhaler and
nebulizer treatments, as needed.
- Rationale: This information promotes safe and effective medication
administration.
 Teach patient about:
 pursed-lip breathing
 abdominal breathing
 performing relaxation techniques
 performing relaxation techniques
 taking prescribed medications (ensuring accuracy of dose and frequency
and monitoring adverse effects)
 scheduling activities to avoid fatigue and provide for rest periods
- Rationale: These measures allow patient to participate in maintaining
health status and improve ventilation.
Evaluation
Achieved ( ) Partially achieved ( ) Not achieved ( )
Evidence by:
Important Note
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