Ineffective Breathing Pattern
INTRODUCTION:
Ineffective Breathing Pattern, which is defined as
inspiration and/or expiration that does not provide adequate
ventilation.
Children are more susceptible to severe respiratory problems and it is observed that in these cases, Ineffective Breathing Pattern is of the ten present. Furthermore, respiratory diseases are present the first cause of hospitalizations in the Unified Health System and contribute to a high morbidity and mortality rate in under-five children, becoming a public health problem (Prato et al., 2014; Melo et al., 2014; Oliveira et al., 2013). Based on the characteristics found for this diagnosis, nurses should analyze and choose the most appropriate intervention for each patient. In this opportunity, the taxonomy of interventions that subsidize the elaboration of nursing care plans
of nursing professionals.
Nursing Care Plan For Ineffective Breathing Pattern
Respiratory Monitoring
- Listen to respiratory sounds, observe areas of diminished/absent ventilation and adventitious noise.
- And then monitor respiratory patterns like bradypnea, tachypnea, hyperventilation, Kussmaul respiration, Cheyne-Stokes respiration etc.
- Monitor frequency, rhythm, depth, and effort in breathing.
- Listen to the anterior and posterior thorax, from apex to base, bilaterally.
- Palpation in search of equal pulmonary expansion.
- Record thoracic movements observing the existence of symmetry, use of accessory muscles and retractions of supraclavicular and intercostal muscles.
- Clear airways using the chin lift or mandibular maneuver technique, as appropriate.
- Record changes in SO2, SvO2, CO2 terminal current, and change in arterial blood gas values, as appropriate.
- Monitor the occurrence of increased restlessness, anxiety, and shortness of breath.
Airway Control
- Perform endotracheal or nasotracheal aspiration as appropriate.
- Insert artificial nasopharyngeal or oral airway device, as appropriate.
- Remove secretions by stimulating coughing or vacuuming.
- Put the patient in a position to relieve dyspnea.
- Administer treatment with an ultrasonic nebulizer, as appropriate.
- Monitor the respiratory condition and oxygenation, as appropriate.
- Identify if the patient has a real/potential need for an
artificial airway device.
Oxygen Therapy
- Provide the oxygen equipment and use it by means of a heated and humidified system.
- Monitor the effectiveness of oxygen therapy (e.g., pulse oximetry, arterial blood gas analysis), as appropriate.
- Observe signs of oxygen-induced hypoperfusion.
- Periodically check the oxygen delivery device to ensure that the prescribed concentration is being administered.
- To monitor the flow of liters of oxygen.
- Monitor the position of the oxygen delivery device.
Drug Administration
- Give the medicines using appropriate technique and route.
- Prepare the medicines using techniques and equipment suitable for the route of administration.
- Observe patient allergies before offering each drug and suspend it as appropriate.
Drug Administration: inhalation
- Helping the patient to use the inhaler, according to the prescription.
Ventilation Control
- Remove condensed water from water collector.
Mechanics: invasive
- Check regularly all fan connections.
- Ensure fan circuit replacement every 24 hours.
- Monitor ventilatory parameters routinely, including temperature and humidification of inspired air.
Monitoring of Vital Signs
- Monitor blood pressure, pulse, temperature, and respiratory pattern, as appropriate.
- Monitor the occurrence of central and peripheral cyanosis.
- Surveillance To monitor the neurological status.
- Reduction of Anxiety to identify changes in anxiety level.
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