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)
- Maintain effective respiratory pattern.
- Experience no dyspnea/cyanosis, with breath sounds and chest x-ray clear/improving and ABGs within patient’s normal range.
|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.