Nurseslabs For All Your Nursing Needs 
Nursing Diagnosis: Risk for Impaired Breathing Pattern
Risk factors may include
- Muscular impairment (wasting of respiratory musculature), decreased energy/fatigue, decreased lung expansion
- Retained secretions (tracheobronchial obstruction), infectious/inflammatory process; pain
- Ventilation perfusion imbalance (PCP/other pneumonias, anemia)
Desired Outcomes
- Maintain effective respiratory pattern.
- Experience no dyspnea/cyanosis, with breath sounds and chest x-ray clear/improving and ABGs within patient’s normal range.
| Nursing Interventions | Rationale |
| Auscultate breath sounds, noting areas of decreased/absent ventilation and presence of adventitious sounds, e.g., crackles, wheezes, rhonchi. | Suggests developing pulmonary complications/infection, e.g., atelectasis/pneumonia. Note: PCP is often advanced before changes in breath sounds occur. |
| Note rate/depth of respiration, use of accessory muscles, increased work of breathing, and presence of dyspnea, anxiety, cyanosis. | Tachypnea, cyanosis, restlessness, and increased work of breathing reflect respiratory distress and need for increased surveillance/medical intervention. |
| Assess changes in level of consciousness. | Hypoxemia can result in changes ranging from anxiety and confusion to unresponsiveness. |
| Investigate reports of chest pain. | Pleuritic chest pain may reflect nonspecific pneumonitis or pleural effusions associated with malignancies. |
| Elevate head of bed. Have patient turn, cough, deep-breathe, as indicated. | Pleuritic chest pain may reflect nonspecific pneumonitis or pleural effusions associated with malignancies. |
| Suction airway as indicated, using sterile technique and observing safety precautions, e.g., mask, protective eyewear. | Promotes optimal pulmonary function and reduces incidence of aspiration or infection due to atelectasis. |
| Allow adequate rest periods between care activities. Maintain a quiet environment. | Assists in clearing the ventilatory passages, thereby facilitating gas exchange and preventing respiratory complications. |
| Monitor/graph serial ABGs or pulse oximetry. | Indicators of respiratory status, treatment needs/effectiveness. |
| Review serial chest x-rays. | Presence of diffuse infiltrates may suggest pneumonia, whereas areas of congestion/consolidation may reflect other pulmonary complications, e.g., atelectasis or KS lesions. |
| Assist with/instruct in use of incentive spirometer. Provide chest physiotherapy, e.g., percussion, vibration, and postural drainage. | Encourages proper breathing technique and improves lung expansion. Loosens secretions, dislodges mucous plugs to promote airway clearance. Note: In the event of multiple skin lesions, chest physiotherapy may be discontinued. |
| Administer medications as indicated:
Antimicrobials, e.g.: trimethoprim-sulfamethoxazole (Bactrim, Septra), pentamidine isethionate (Pentam);
Foscarnet (Foscavir), ganciclovir (Cytovene);
Clarithromycin (Biaxin), azithromycin (Zithromax), rifabutin (Mycobutin);
Bronchodilators, expectorants, cough depressants. | Choice of therapy depends on individual situation/infecting organism(s). Although Bactrim (TMP/SMX) is the drug of choice for PCP, Pentam can be used in combination or alone when treatment with Bactrim is unsuccessful or contraindicated. Note: Bactrim is also used prophylactically. Effective for treatment of pulmonary CMV infections. Note: CMV often coexists with PCP. First-line therapy for treatment of MAC, a common bacterial infection that frequently disseminates to other organ systems. May be needed to improve/maintain airway patency or help clear secretions. |
Found through:
care plans for bacterial pneumonia, pneumonitis nursing diagnosis
