NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
* Respiratory Status: Ventilation
* Vital Sign Status
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
* Airway Management
* Respiratory Monitoring
NANDA Definition: Inspiration and/or expiration that does not provide adequate ventilation
Respiratory pattern monitoring addresses the patient’s ventilatory pattern, rate, and depth. Most acute pulmonary deterioration is preceded by a change in breathing pattern. Respiratory failure can be seen with a change in respiratory rate, change in normal abdominal and thoracic patterns for inspiration and expiration, change in depth of ventilation (Vt), and respiratory alternans. Breathing pattern changes may occur in a multitude of cases from hypoxia, heart failure, diaphragmatic paralysis, airway obstruction, infection, neuromuscular impairment, trauma or surgery resulting in musculoskeletal impairment and/or pain, cognitive impairment and anxiety, metabolic abnormalities (e.g., diabetic ketoacidosis [DKA], uremia, or thyroid dysfunction), peritonitis, drug overdose, and pleural inflammation.
* Defining Characteristics: Dyspnea
* Nasal flaring
* Respiratory depth changes
* Altered chest excursion
* Use of accessory muscles
* Pursed-lip breathing or prolonged expiratory phase
* Increased anteroposterior chest diameter
* Related Factors: Inflammatory process: viral or bacterial
* Neuromuscular impairment
* Musculoskeletal impairment
* Tracheobronchial obstruction
* Perception or cognitive impairment
* Decreased energy and fatigue
* Decreased lung expansion
* Expected Outcomes Patient’s breathing pattern is maintained as evidenced by eupnea, normal skin color, and regular respiratory rate/pattern.
* Assess respiratory rate and depth by listening to lung sounds. Respiratory rate and rhythm changes are early warning signs of impending respiratory difficulties.
* Assess for dyspnea and quantify (e.g., note how many words per breath patient can say); relate dyspnea to precipitating factors.
o Assess for dyspnea at rest versus activity and note changes. Dyspnea that occurs with activity may indicate activity intolerance.
* Monitor breathing patterns:
o Bradypnea (slow respirations)
o Tachypnea (increase in respiratory rate)
o Hyperventilation (increase in respiratory rate or tidal volume, or both)
o Kussmaul’s respirations (deep respirations with fast, normal, or slow rate)
o Cheyne-Stokes respiration (waxing and waning with periods of apnea between a repetitive pattern)
o Apneusis (sustained maximal inhalation with pause)
o Biot’s respiration (irregular periods of apnea alternating with periods in which four or five breaths of identical depth are taken)
o Ataxic patterns (irregular and unpredictable pattern with periods of apnea)
Specific breathing patterns may indicate an underlying disease process or dysfunction. Cheyne-Stokes respiration represents bilateral dysfunction in the deep cerebral or diencephalon associated with brain injury or metabolic abnormalities. Apneusis and ataxic breathing are associated with failure of the respiratory centers in the pons and medulla.
* Note muscles used for breathing (e.g., sternocleido-mastoid, abdominal, diaphragmatic). The accessory muscles of inspiration are not usually involved in quiet breathing. These include the scalenes (attach to the first two ribs) and the sternocleidomastoid (elevates the sternum).
* Monitor for diaphragmatic muscle fatigue (paradoxical motion). Paradoxical movement of the diaphragm indicates a reversal of the normal pattern and is indicative of ventilatory muscle fatigue and/or respiratory failure. The diaphragm is the most important muscle of ventilation, normally responsible for 80% to 85% of ventilation during restful breathing.
* Note retractions or flaring of nostrils. These signify an increase in work of breathing.
* Assess position patient assumes for normal or easy breathing.
* Use pulse oximetry to monitor oxygen saturation and pulse rate. Pulse oximetry is a useful tool to detect changes in oxygenation early on; however, for CO2 levels, end tidal CO2 monitoring or arterial blood gases (ABGs) would need to be obtained.
* Monitor ABGs as appropriate; note changes. Increasing PaCO2 and decreasing PaO2 are signs of respiratory failure. As the patient begins to fail, the respiratory rate decreases and PaCO2 begins to rise.
* Monitor for changes in orientation, increased restlessness, anxiety, and air hunger. Restlessness is an early sign of hypoxia.
* Avoid high concentration of oxygen in patients with chronic obstructive pulmonary disease (COPD). Hypoxia stimulates the drive to breathe in the chronic CO2 retainer patient. When applying oxygen, close monitoring is imperative to prevent unsafe increases in the patient’s PaO2 , which could result in apnea.
* Assess skin color, temperature, capillary refill; note central versus peripheral cyanosis.
* Monitor vital capacity in patients with neuromuscular weakness and observe trends. Monitoring detects changes early.
* Assess presence of sputum for quantity, color, consistency.
* If the sputum is discolored (no longer clear or white), send sputum specimen for culture and sensitivity, as appropriate. An infection may be present. Respiratory infections increase the work of breathing; antibiotic treatment may be indicated.
* Assess ability to clear secretions. The inability to clear secretions may add to a change in breathing pattern.
* Assess for pain. Postoperative pain can result in shallow breathing.
* Position patient with proper body alignment for optimal breathing pattern. If not contraindicated, a sitting position allows for good lung excursion and chest expansion.
* Ensure that oxygen delivery system is applied to the patient. The appropriate amount of oxygen is continuously delivered so that the patient does not desaturate.
An oxygen saturation of 90% or greater should be maintained. This provides for adequate oxygenation.
* Encourage sustained deep breaths by:
o Using demonstration (emphasizing slow inhalation, holding end inspiration for a few seconds, and passive exhalation)
o Using incentive spirometer (place close for convenient patient use)
o Asking patient to yawn This simple technique promotes deep inspiration.
* Evaluate appropriateness of inspiratory muscle training. This improves conscious control of respiratory muscles.
* Maintain a clear airway by encouraging patient to clear own secretions with effective coughing. If secretions cannot be cleared, suction as needed to clear secretions.
* Use universal precautions (e.g., gloves, goggles, and mask) as appropriate. If secretions are purulent, precautions should be instituted before receiving the culture and sensitivity final report. Institute appropriate isolation procedures for positive cultures (e.g., methicillin-resistant Staphylococcus aureus, tuberculosis [TB]).
* Pace and schedule activities providing adequate rest periods. This prevents dyspnea resulting from fatigue.
* Provide reassurance and allay anxiety by staying with patient during acute episodes of respiratory distress. Air hunger can produce an extremely anxious state.
* Provide relaxation training as appropriate (e.g., biofeedback, imagery, progressive muscle relaxation).
* Encourage diaphragmatic breathing for patient with chronic disease.
* Use pain management as appropriate. This allows for pain relief and the ability to deep breathe.
* Anticipate the need for intubation and mechanical ventilation if patient is unable to maintain adequate gas exchange with the present breathing pattern.
Education/Continuity of Care
* Explain all procedures before performing. This decreases patient’s anxiety.
* Explain effects of wearing restrictive clothing. Respiratory excursion is not compromised.
* Explain use of oxygen therapy, including the type and use of equipment and why its maintenance is important. ratioIssues related to home oxygen use, storage, and precautions need to be addressed.
* Instruct about medications: indications, dosage, frequency, and potential side effects. Include review of metered-dose inhaler and nebulizer treatments, as appropriate.
* Review the use of at-home monitoring capabilities and refer to home health nursing, oxygen vendors, and other resources for rental equipment as appropriate.
* Explain environmental factors that may worsen patient’s pulmonary condition (e.g., pollen, second-hand smoke) and discuss possible precipitating factors (e.g., allergens and emotional stress).
* Explain symptoms of a "cold" and impending problems. A respiratory infection would increase the work of breathing.
* Teach patient or caregivers appropriate breathing, coughing, and splinting techniques. These facilitate adequate clearance of secretions.
* Teach patient how to count own respirations and relate respiratory rate to activity tolerance. Patient will then know when to limit activities in terms of his or her own limitations.
* Teach patient when to inhale and exhale while doing strenuous activities. Appropriate breathing techniques during exercise are important in maintaining adequate gas exchange.
* Assist patient or caregiver in learning signs of respiratory compromise. Refer significant other/caregiver to participate in basic life support class for CPR, as appropriate.
* Refer to social services for further counseling related to patient’s condition and give list of support groups or a contact person from the support group for the patient to talk with.