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NURSING DIAGNOSIS: Breathing Pattern, risk for ineffective
Risk factors may include
- Intra-abdominal fluid collection (ascites)
- Decreased lung expansion, accumulated secretions
- Decreased energy, fatigue
Desired Outcomes
- Maintain effective respiratory pattern; be free of dyspnea and cyanosis, with ABGs and vital capacity within acceptable range.
8 Liver Cirrhosis Nursing Care Plan (NCP)
- Imbalanced Nutrition — Liver Cirrhosis Nursing Care Plan (NCP)
- Excess Fluid Volume — Liver Cirrhosis Nursing Care Plan (NCP)
- Impaired Skin Integrity — Liver Cirrhosis Nursing Care Plan (NCP)
- Ineffective Breathing Pattern — Liver Cirrhosis Nursing Care Plan (NCP)
- Risk for Injury — Liver Cirrhosis Nursing Care Plan (NCP)
- Risk for Acute Confusion — Liver Cirrhosis Nursing Care Plan (NCP)
- Disturbed Body Image/Self-Esteem — Liver Cirrhosis Nursing Care Plan (NCP)
- Knowledge Deficit — Liver Cirrhosis Nursing Care Plan (NCP)
Ineffective Breathing Pattern — Liver Cirrhosis Nursing Care Plan (NCP): Nursing Interventions & Rationale
| Nursing Interventions | Rationale |
| Monitor respiratory rate, depth, and effort. | Rapid shallow respirations/dyspnea may be present because of hypoxia and/or fluid accumulation in abdomen. |
| Auscultate breath sounds, noting crackles, wheezes, rhonchi. | Indicates developing complications (e.g., presence of adventitious sounds reflects accumulation of fluid/secretions; absent/diminished sounds suggest atelectasis), increasing risk of infection. |
| Investigate changes in level of consciousness. | Changes in mentation may reflect hypoxemia and respiratory failure, which often accompany hepatic coma. |
| Keep head of bed elevated. Position on sides. | Facilitates breathing by reducing pressure on the diaphragm, and minimizes risk of aspiration of secretions. |
| Encourage frequent repositioning and deep-breathing exercises/coughing as appropriate. | Aids in lung expansion and mobilizing secretions. |
| Monitor temperature. Note presence of chills, increased coughing, changes in color/character of sputum. | Indicative of onset of infection, e.g., pneumonia. |
| Monitor serial ABGs, pulse oximetry, vital capacity measurements, chest x-rays. | Reveals changes in respiratory status, developing pulmonary complications. |
| Provide supplemental O2 as indicated. | May be necessary to treat/prevent hypoxia. If respirations/oxygenation inadequate, mechanical ventilation may be required. |
| Demonstrate/assist with respiratory adjuncts, e.g., incentive spirometer. | Reduces incidence of atelectasis, enhances mobilization of secretions. |
| Prepare for/assist with acute care procedures, e.g.:Paracentesis;
Peritoneovenous shunt. | Occasionally done to remove ascites fluid to relieve abdominal pressure when respiratory embarrassment is not corrected by other measures.Surgical implant of a catheter to return accumulated fluid in the abdominal cavity to systemic circulation via the vena cava; provides long-term relief of ascites and improvement in respiratory function. |
Found through:
Nursing care plan ineffective breathing pattern pneumonia, nursing care paln for ineffective breathing pattern related to decreased lung expansion, paracentesis interventions
