00032 Ineffective Respiratory Pattern

Domain 4: activity/rest
Class 4: cardiovascular/pulmonary responses
Diagnostic Code: <00032
Nanda label: ineffective respiratory pattern
Diagnostic focus: respiratory pattern
Approved 1980 • Revised 1996, 1998, 2010, 2017, 2020 • Evidence level 3.3

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « ineffective respiratory pattern is defined as: inspiration and/or expiration that does not provide adequate ventilation.

Definite characteristics

  • Paradoxical abdominal respiratory pattern
  • Alteration of chest movements
  • Tidal volume alteration
  • Bradypnea
  • Cianosis
  • Decrease in expiratory pressure
  • Decrease in inspiratory pressure
  • Decreased ventilation per minute
  • Decrease in vital capacity
  • Hypercapnia
  • Hyperventilation
  • Hypoventilation
  • hypoxemia
  • Hypoxia
  • Increase in the anteroposterior diameter of the thorax
  • Nasal flutter
  • Orthopnea
  • Prolonged expiratory phase
  • Breathing with pursed lips
  • Subcostal retraction
  • Tachypnea
  • Use of breathing accessory muscles
  • Adoption of the tripod posture

Related factors

  • Anxiety
  • Body position that inhibits pulmonary expansion
  • Fatigue
  • Increase in physical exercise
  • Obesity
  • Pain

Risk population

  • Young women

Associated problems

  • Bone deformity
  • Deformity of the chest wall
  • Chronic obstructive pulmonary disease
  • Severe condition
  • heart disease
  • Hyperventilation syndrome
  • Hypoventilation syndrome
  • Increased airway resistance
  • Increased concentration of serum hydrogen
  • Musculoskeletic deterioration
  • Neurological immaturity
  • Neurological deterioration
  • Neuromuscular diseases
  • Decrease in pulmonary complacency
  • Sleep apnea syndromes
  • Spinal cord injuries

Suggestions of use

This diagnosis can be used for different disorders such as hyperventilation, surface breathing secondary to pain, or physiological dyspnea such as that produced by side effects of some medications or in certain diseases (asthma, allergic reaction). Do not use this diagnosis if the disorder cannot be treated through nursing actions only. Also consider that the ineffective respiratory pattern can be a symptom of another more useful diagnosis, such as anxiety, or it could be the etiology of another diagnosis, such as intolerance to activity. Differentiate carefully between this and the other alternative diagnoses. See also the suggestions of use for ineffective cleaning of the respiratory tract.

Suggested alternative diagnostics

  • Activity, intolerance to
  • Gaseous exchange, deterioration of
  • disuse syndrome, risk of
  • Respiratory routes, ineffective cleaning of the

NOC Results

  • Respiratory status: permeability of the respiratory tract: open and clear tracheobronchial tree to perform the gas exchange
  • Respiratory status: ventilation: input and output of the lungs
  • Reaction to assisted breathing: adult: assisted breathing maintains alveolar exchange and tissue perfusion
  • Reaction to the weaning of assisted breathing: adult: respiratory and psychological adaptation to the progressive suppression of assisted breathing
  • Allergic reaction: Systemic: Severity of the systemic immune response of hypersensitivity to an environmental antigen (exogenous) specific
  • Vital signs: To what extent the temperature, pulse, breathing and blood pressure are within normal values ??

Evaluation objectives and criteria

  • Demonstrates effective breathing, which is evidence
  • Demonstrates respiratory state: ventilation not affected, as the following indicators reveal (specify from 1 to 5: severely, substantially, moderately, slightly or nothing)
    • Symmetric chest expansion
    • Depth of inspiration and ease of breathing
  • Demonstrate respiratory state: ventilation not affected, as the following indicators show (specify from 1 to 5: serious, substantial, moderate, mild or absent):
    • Orthopnea
    • Anomalous respiratory noises
    • Use of accessory muscles
  • Other examples

    The patient will be able to:

    • Demonstrate optimal breathing when it is in assisted breathing
    • Have respiratory frequency and rhythm in normal limits
    • Present pulmonary function tests within normal limits
    • Request respiratory assistance when you need it
    • Describe a home care plan
    • Identify those factors (for example, allergens) that trigger ineffective respiratory patterns and take measures to avoid them

    NIC Interventions

    • Breathing assistance: promotion of a spontaneous respiratory pattern
    • optimal, which achieves the maximum possible exchange of oxygen and carbon dioxide in the lungs
    • Aspiration of the respiratory tract: elimination of secretions from the respiratory tract by inserting an aspiration catheter in the mouth or in the patient’s trachea
    • Respiratory control and monitoring: Patient data collection and analysis to ensure the permeability of the respiratory tract and an adequate gas exchange
    • Allergy management: identification, treatment and prevention of allergic responses to food, medications, insect bites, contrast material, blood or other substances
    • Assisted breathing management: Invasive: Help the patient receiving artificial breathing through a device inserted in the trachea
    • Anaphylactic reactions management: Promotion of adequate tissue ventilation and perfusion in a person suffering from an allergic reaction (antigen-antibody) severe
    • Management of respiratory tract: facilitation of the permeability of the respiratory system
    • Management of artificial respiratory tract: maintenance of endotracheal and tracheostomy catheters, as well as the prevention of complications associated with their use
    • Asthma management: identification, treatment and prevention of reactions caused by inflammation or constriction of the respiratory system
    • Monitoring of vital signs: Collection and analysis of cardiovascular, respiratory and body temperature data to determine and prevent complications
    • Mechanical respirator separation: Help the patient breathe without having to use the respirator

    Nursing Activities

    In general, nursing activities in this diagnosis focus on evaluating the causes of ineffective breathing, monitoring the respiratory state, teaching the automanejo of allergies, training the patient to breathe more slowly and control their reactions, Help patients with respiratory treatments and reassure the patient in periods of dyspnea and lack of breath.

    Valuations

    • Monitor the appearance of paleness and cyanosis
    • Monitor the effect of medicines on the respiratory state
    • Determine the location and extension of crepitants in the thorax
    • Evaluate the need to insert a respiratory path
    • Observe and record the bilateral thoracic expansion of the patient in assisted breathing
    • (NIC) Respiratory control and monitoring:
      • Monitor the frequency, rhythm, depth and respiratory effort
      • Observe the thoracic movement, and especially symmetry, use of accessory muscles and supraclavicular retraction and intercostal muscles
      • Monitor possible noisy breaths, such as snoring or graznidos
      • Monitor respiratory patterns: bradypnea, tachypnea, hyperventilation, kussmaul breathing, Cheyne-Stokes, apneic breathing, biot breathing and atáxic patterns
      • Observe the location of the trachea
      • Auscultar the respiratory sounds, observing whether there are areas in which ventilation is reduced or absent, as well as anomalous noises
      • Monitor increases in the restlessness, anxiety and hunger of air
      • Observe changes in the arterial and venous saturation of 0 „C02 residual, and the values ??of arterial blood gases, as required
      • Patient teaching and family
    • Inform the patient and the family about relaxation techniques to improve respiratory pattern; Specify the techniques
    • Analyze the home care plan, including medications, auxiliary equipment, signs and symptoms of the complications that must be communicated, as well as community resources
    • Analyze how to avoid allergens, for example:
      • Check if there are fungi on the walls
      • Do not use carpets
      • Use electrostatic filters in furnaces and air conditioning
    • Teach to cough effectively
    • Inform the patient and the family that is prohibited smoking in the room
    • Teach the patient and the family to notify the nurse as soon as an ineffective respiratory pattern begins

    Collaboration activities

    • Consult the breathing therapist to ensure proper operation of the mechanical respirator
    • Communicate changes in the level of consciousness, respiratory noises, respiratory pattern, arterial gases, sputum, etc., as necessary or required by the protocol
    • Administer medications (for example, bronchodilators) according to medical orders or protocols
    • Manage ultrasound nebulization treatments and humidified or oxygen air according to medical orders or protocols of the institution
    • Give analgesics to favor an optimal respiratory pattern, specifying the frequency

    Others

    • Correlation and register all the data of the assessment (for example, level of consciousness of the patient, respiratory sounds, respiratory pattern, arterial gases, sputum, effect of medications)
    • Help the patient use the encouraged spirometer, if necessary
    • Remove the patient during periods of respiratory discomfort
    • Promote slow abdominal breathing during periods of respiratory discomfort
    • To help reduce the respiratory rate, train the patient in controlled breathing techniques and breathe with pursed lips
    • Aspire when necessary to eliminate secretions
    • Make the patient turn, take and breathe deeply every
    • Inform the patient before starting the planned procedures, to reduce anxiety and increase the feeling of control
    • Maintain oxygen with a low flow by nostrils, mask, hood or store; Specify the flow
    • Place the patient so that their breathing is optimal; Specify the posture
    • Synchronize the patient’s respiratory pattern with the frequency of the respirator

    At home

    • If respirators or electrical equipment are used, evaluate the electrical safety of the home and notify the supply company, so that it can guarantee a quick service in case of electricity cuts

    Babies and Children

    • Remember that newborns always breathe through the nose; that their normal breaths are the abdominals and that, due to their respiratory irregularity (also normal), you have to count the breaths of a complete minute. A normal frequency for newborns is 30-50 breaths/minute, and they are normal periods of apnea up to 15 seconds
    • To reduce the risk of sudden death syndrome during the baby’s dream, you have to place them upside down or side, and not on the stomach
    • Children continue to breathe with the abdomen up to five years, and the smallest diameter of their respiratory tract increases the risk of obstruction

    Older people

    • Encourage them to be active as much as possible, to increase ventilation