Which comfort measure would the nurse plan to use for a patient who has orthopnea?

Use this ineffective breathing pattern nursing care plan guide to help you create nursing interventions for this nursing diagnosis.

When the abdominal wall excursion during inspiration, expiration or both do not maintain optimum ventilation for the individual, the nursing diagnosis Ineffective Breathing Pattern is one of the issues nurses need to focus on. It is considered the state in which the rate, depth, timing, rhythm, or pattern of breathing is altered. When the breathing pattern is ineffective, the body will likely not get enough oxygen to the cells. Respiratory failure may be correlated with variations in respiratory rate, abdominal and thoracic patterns.

Breathing pattern alteration may also transpire in several circumstances from heart failure, hypoxia, airway obstruction, diaphragmatic paralysis, infection, neuromuscular impairment, trauma or surgery resulting in musculoskeletal impairment and pain, cognitive impairment and anxiety, diabetic ketoacidosis, uremia, thyroid dysfunction, peritonitis, drug overdose, AIDS, acute alcohol withdrawal, cardiac surgery, cholecystectomy, liver cirrhosis, craniocerebral trauma, disc surgery, lymphomas, renal dialysis, seizure disorders, spinal cord injuries, mechanical ventilatory assistance, and pleural inflammation.

Having a clear and effective airway is vital in inpatient care. Appropriate management for patients with oxygenation difficulties is to sustain or enhance pulmonary ventilation and oxygenation, promote comfort and ease of breathing, improve the ability to participate in physical activities, and prevent risks associated with oxygenation problems such as skin and tissue breakdown, syncope, acid-base imbalances, and feelings of hopelessness and social isolation.

• Signs and Symptoms
• Goals and Outcomes
• Nursing Assessment and Rationales
• Nursing Interventions and Rationales
• Recommended Resources
• See also
• References and Sources

Signs and Symptoms

Common signs and symptoms related to Ineffective Breathing Pattern (Pascoal et al., 2014). Use these subjective and objective data to help guide you through nursing assessment. Alternatively, you can check out the assessment guide below.

• Abnormal rate, rhythmn, depth in breathin
• Bradypnea
• Dyspnea
• Nasal flaring
• Orthopnea
• Pursed-lip breathing
• Use of accessory muscles to breathe

Goals and Outcomes

The following are the common goals and expected outcomes.

• Patient maintains an effective breathing pattern, as evidenced by relaxed breathing at normal rate and depth and absence of dyspnea.
• Patient’s respiratory rate remains within established limits.
• Patient’s ABG levels return to and remain within established limits.
• Patient indicates, either verbally or through behavior, feeling comfortable when breathing.
• Patient reports feeling rested each day.
• Patient performs diaphragmatic pursed-lip breathing.
• Patient demonstrates maximum lung expansion with adequate ventilation.
• When patient carries out ADLs, breathing pattern remains normal.

Nursing Assessment and Rationales

Continuous assessment is necessary to know possible problems that may have led to Ineffective Breathing Pattern and name any concerns during nursing care.

1. Assess and record respiratory rate and depth at least every 4 hours.
The average rate of respiration for adults is 10 to 20 breaths per minute. It is important to take action when there is an alteration in breathing patterns to detect early signs of compromise on the respiratory system.

2. Assess ABG levels according to facility policy.
This monitors oxygenation and ventilation status. See our Tic-Tac-Toe guide on analyzing ABGs

3. Observe breathing patterns.
Unusual breathing patterns may imply an underlying disease process or dysfunction. Cheyne-Stokes respiration signifies bilateral dysfunction in the deep cerebral or diencephalon related to brain injury or metabolic abnormalities. Apneusis and ataxic breathing are related to the failure of the respiratory centers in the pons and medulla. Rates and depths of breathing patterns include:

• Apnea
  Temporary cessation of breathing, especially during sleep
• Apneusis
  Deep, gasping inspiration with a pause at full inspiration followed by a brief, insufficient release
• Ataxic patterns
  Complete irregularity of breathing with irregular pauses and increasing periods of apnea
• Biot’s respiration
  Groups of quick, shallow inspirations followed by regular or irregular periods of apnea (10 to 60 seconds).
• Bradypnea
  Respirations fall below 12 breaths per minute, depending on the age of the patient.
• Cheyne-Stokes respiration
  Progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in apnea. The pattern repeats, with each cycle usually taking 30 seconds to 2 minutes.
• Eupnea
  Normal, good, unlabored ventilation, sometimes known as quiet breathing or resting, respiratory rate
• Hyperventilation
  Increased rate and depth of breathing
• Kussmaul’s respirations
  Deep respirations with fast, normal, or slow rate associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) but also kidney failure
• Tachypnea
  Rapid, shallow breathing, with more than 24 breaths per minute

4. Auscultate breath sounds at least every 4 hours.
This is to detect decreased or adventitious breath sounds. Abnormal breath sounds may include:

• Bronchospasm
  Constant breath sounds of both rhonchi and wheezing; normally treated with a bronchodilator.
• Expiratory grunt
  Frequently occurs in combination with nasal flaring and intercostal or subcostal retractions, associated with increased work of breathing.
• Rales
  Clicking, rattling, or crackling sounds are heard during inspiration and expiration.
• Rhonchi
  Coarse crackle sound that is wetter than a rale. Suctioning recommended.
• Stridor
  High-pitched, musical breathing sound caused by a blockage in the throat or voice box (larynx).
• Wheeze
  High-pitched, whistling sound when air moves through narrowed breathing tubes in the lungs. This is heard most commonly in asthmatics and CHF

5. Ask if they are “short of breath” and note any dyspnea.
Sometimes anxiety can cause dyspnea, so watch the patient for “air hunger,” which is a sign that the cause of shortness of breath is physical.

6. Assess for the use of accessory muscle.
Work of breathing increases greatly as lung compliance decreases.

7. Monitor for diaphragmatic muscle fatigue or weakness (paradoxical motion).
Paradoxical movement of the abdomen (an inward versus outward movement during inspiration) is indicative of respiratory muscle fatigue and weakness.

8. Observe for retractions or flaring of nostrils.
These signs signify an increase in respiratory effort.

9. Assess the position that the patient assumes for breathing.
Orthopnea is associated with breathing difficulty.

10. Utilize pulse oximetry to check oxygen saturation and pulse rate.
Pulse oximetry is a helpful tool to detect alterations in oxygenation initially; but, for CO2 levels, end-tidal CO2 monitoring or arterial blood gases (ABGs) would require obtaining.

11. Inquire about precipitating and alleviating factors.
Knowledge of these factors is useful in planning interventions to prevent or manage future episodes of breathing problems.

12. Assess ability to mobilize secretions.
The incapability to mobilize secretions may contribute to a change in breathing patterns.

13. Observe the presence of sputum for amount, color, consistency.
These may be indicative of a cause for the alteration in breathing patterns.

14. Send specimen for culture and sensitivity testing if sputum appears to be discolored.
This may signify infection.

15. Evaluate the level of anxiety.
Hypoxia and the sensation of “not being able to breathe” are frightening and may worsen hypoxia.

16. Note for changes in the level of consciousness.
Restlessness, confusion, and/or irritability can be early indicators of insufficient oxygen to the brain.

17. Evaluate skin color, temperature, capillary refill; observe central versus peripheral cyanosis.
Lack of oxygen will cause blue/cyanosis coloring to the lips, tongue, and fingers. Cyanosis to the inside of the mouth is a medical emergency!

18. Assess for thoracic or upper abdominal pain.
Pain can result from shallow breathing.

19. Keep away from a high oxygen concentration in patients with chronic obstructive pulmonary disease (COPD).
Hypoxia triggers the drive to breathe in the chronic CO2 retainer patient. When administering oxygen, close monitoring is critical to avoid hazardous risings in the patient’s PaO2, leading to apnea.

20. Evaluate nutritional status (e.g., weight, albumin level, electrolyte level).
Malnutrition may result in premature development of respiratory failure because it reduces respiratory mass and strength.

Nursing Interventions and Rationales

The following are the therapeutic nursing interventions for ineffective breathing patterns:

1. Place patient with proper body alignment for maximum breathing pattern.
A sitting position permits maximum lung excursion and chest expansion.

2. Encourage sustained deep breaths. Techniques include (1) using demonstration: highlighting slow inhalation, holding end inspiration for a few seconds, and passive exhalation; (2) utilizing incentive spirometer and (3) requiring the patient to yawn.
These techniques promote deep inspiration, which increases oxygenation and prevents atelectasis. Controlled breathing methods may also aid slow respirations in tachypneic patients. Prolonged expiration prevents air trapping.

3. Encourage diaphragmatic breathing for patients with chronic disease.
This method relaxes muscles and increases the patient’s oxygen level.

4. Evaluate the appropriateness of inspiratory muscle training.
This training improves conscious control of respiratory muscles and inspiratory muscle strength.

5. Provide respiratory medications and oxygen, per doctor’s orders.
Beta-adrenergic agonist medications relax airway smooth muscles and cause bronchodilation to open air passages.

6. Avoid high concentrations of oxygen in patients with COPD.
Hypoxia triggers the drive to breathe in the chronic CO2 retainer patient. When administering oxygen, close monitoring is critical to avoid uncertain risings in the patient’s PaO2, leading to apnea.

7. Maintain a clear airway.
Encouraging the patient to mobilize their own secretions via effective coughing facilitates adequate clearance of secretions.

8. Suction secretions, as necessary.
Suctioning helps to clear the blockages in the airway.

9. Stay with the patient during acute episodes of respiratory distress.
This will reduce the patient’s anxiety, thereby reducing oxygen demand.

10. Ambulate patient as tolerated with doctor’s order three times daily.
Ambulation can further break up and move secretions that block the airways.

11. Encourage frequent rest periods and teach the patient to pace activity.
Extra activity can worsen shortness of breath. Ensure the patient rests between strenuous activities.

12. Consult a dietitian for dietary modifications.
COPD may cause malnutrition which can affect breathing patterns. Good nutrition can strengthen the functionality of respiratory muscles.

13. Encourage small frequent meals.
This prevents crowding of the diaphragm.

14. Help the patient with ADLs, as necessary.
This conserves energy and avoids overexertion and fatigue.

15. Avail a fan in the room.
Moving air can decrease feelings of air hunger.

16. Encourage social interactions with others that have medical diagnoses of ineffective breathing pattern.
Talking to others with similar conditions can help to ease anxiety and increase coping skills.

17. Educate patient or significant other on proper breathing, coughing, and splinting methods.
These allow sufficient mobilization of secretions.

18. Educate patient about medications: indications, dosage, frequency, and possible side effects. Incorporate review of the metered-dose inhaler and nebulizer treatments, as needed.
This information promotes safe and effective medication administration.

19. Teach the patient about pursed-lip breathing, abdominal breathing, performing relaxation techniques, performing relaxation techniques, taking prescribed medications (ensuring the accuracy of dose and frequency and monitoring adverse effects), scheduling activities to avoid fatigue, and provide for rest periods.
These measures allow the patient to participate in maintaining health status and improve ventilation.

20. Refer the patient for evaluation of exercise potential and development of individualized exercise program.
Exercise promotes conditioning of respiratory muscles and the patient’s sense
of well-being.

Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources.

Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy.

• Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
  An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use.
• Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
  A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively.
• NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
  The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales.
• Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
  Another great nursing care plan resource that is updated to include the recent NANDA-I updates.
• Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
  Useful for creating nursing care plans related to mental health and psychiatric nursing.
• Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
  Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans.
• Maternal Newborn Nursing Care Plans (3rd Edition)
  If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you.
• Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
  An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023.
• All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
  Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.

See also

Other recommended site resources for this nursing care plan:

• Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
  Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
• Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
  Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.

References and Sources

Recommended sources, interesting articles, and references about Ineffective Breathing Pattern to further your reading.

• Amorim Beltrão, B., da Silva, V. M., de Araujo, T. L., & de Oliveira Lopes, M. V. (2011). Clinical indicators of ineffective breathing pattern in children with congenital heart diseases. International Journal of Nursing Terminologies and Classifications, 22(1), 4-12.
• Cavalcante, J. C. B., Mendes, L. C., de Oliveira Lopes, M. V., & de Oliveira Lima, L. H. (2010). Clinical indicators of ineffective breathing pattern in children with asthma. Rev Rene, 11(1).
• Gouna, G., Rakza, T., Kuissi, E., Pennaforte, T., Mur, S., & Storme, L. (2013). Positioning effects on lung function and breathing pattern in premature newborns. The Journal of pediatrics, 162(6), 1133-1137.
• Lopes, M. V. O., Silva, V. M. D., & VEC, S. F. (2020). A Content Analysis of Clinical Indicators of the Nursing Diagnosis Ineffective Breathing Pattern. International Journal of Nursing Knowledge.
• Pascoal, L. M., Lopes, M. V. D. O., da Silva, V. M., Beltrão, B. A., Chaves, D. B. R., de Santiago, J. M. V., & Herdman, T. H. (2014). Ineffective breathing pattern: defining characteristics in children with acute respiratory infection. International journal of nursing knowledge, 25(1), 54-61.
• Silveira, U. A., de Oliveira Lima, L. H., & de Oliveira Lopes, M. V. (2008). Defined characteristics of the nursing diagnoses ineffective airway clearanceand ineffective breathing pattern in asthmatic children. Rev Rene, 9(4).

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