Nursing Diagnosis
- Risk for Ineffective Breathing Pattern
Risk factors may include
- Abdominal pressure/restricted diaphragmatic excursion; rapid infusion of dialysate; pain
- Inflammatory process (e.g., atelectasis/pneumonia)
Desired Outcomes
- Display an effective respiratory pattern with clear breath sounds, ABGs within patient’s normal range.
- Experience no signs of dyspnea/cyanosis
| Interventions | Rationale |
| Monitor respiratory rate/effort. Reduce infusion rate if dyspnea is present. | Tachypnea, dyspnea, shortness of breath, and shallow breathing during dialysis suggest diaphragmatic pressure from distended peritoneal cavity or may indicate developing complications. |
| Auscultate lungs, noting decreased, absent, or adventitious breath sounds, e.g., crackles/wheezes/rhonchi. | Decreased areas of ventilation suggest presence of atelectasis, whereas adventitious sounds may suggest fluid overload, retained secretions, or infection. |
| Note character, amount, and color of secretions. | Patient is susceptible to pulmonary infections as a result of depressed cough reflex and respiratory effort, increased viscosity of secretions, as well as altered immune response and chronic/debilitating disease. |
| Elevate head of bed or have patient sit up in chair. Promote deep-breathing exercises and coughing | Facilitates chest expansion/ventilation and mobilization of secretions. |
| Review ABGs/pulse oximetry and serial chest x-rays. | Changes in Pao2 and Paco2 and appearance of infiltrates/congestion on chest x-ray suggest developing pulmonary problems. |
| Administer supplemental O2 as indicated. | Maximizes oxygen for vascular uptake, preventing/lessening hypoxia. |
| Administer analgesics as indicated. | Alleviates pain, promotes comfortable breathing, maximal cough effort. |
Facebook
Twitter
Google Plus
RSS Feed
Email Newsletter
Nurseslabs.org
