Ineffective breathing patterns, clinically referred to as an alteration in respiratory function, signify inspiration and/or expiration cycles that fail to deliver adequate oxygenation to the body’s tissues. This critical nursing diagnosis stems from observable irregularities in breathing rate and depth, compromised chest expansion, and the recruitment of accessory muscles, all culminating in a breathing mechanism insufficient for proper bodily ventilation.
In patient care, the ABCs – airway, breathing, and circulation – remain the utmost priority for nurses. An alteration in respiratory function can be triggered by a multitude of factors, often manifesting abruptly. Vigilance is paramount for nurses to promptly identify acute changes and avert patient deterioration, including the potential onset of severe respiratory compromise or respiratory failure.
Common Causes of Altered Respiratory Function
Several conditions and factors can contribute to an alteration in respiratory function. These related causes are crucial for healthcare professionals to consider:
- Pain Syndromes: Both Chronic pain and Acute Pain can significantly impact respiratory mechanics and efficiency.
- Anxiety Disorders: High levels of Anxiety can lead to rapid, shallow breathing, disrupting normal respiratory patterns.
- Thoracic Trauma: Physical trauma to the chest area can directly impair the respiratory system’s ability to function effectively.
- Neurological Insults: Injuries to the Brain or spinal cord injury can disrupt neurological control of respiration.
- Airway Obstruction: Blockages in the respiratory passages, whether partial or complete, directly impede airflow (Airway obstruction).
- Chronic Lung Diseases: Conditions like COPD fundamentally alter lung structure and function, leading to compromised breathing patterns.
- Infectious Processes: Respiratory Infection can cause inflammation and fluid buildup, impairing gas exchange.
- Obesity: Excess body weight, particularly Obesity, can restrict chest wall movement and increase the work of breathing.
- Structural Deformities: Abnormalities of the chest wall or diaphragm can mechanically hinder respiratory function.
- Body Positioning: Posture and body positioning can either facilitate or restrict optimal lung expansion.
- Respiratory Muscle Fatigue: Weakness or exhaustion of respiratory muscles can lead to ineffective breathing.
- Cognitive Impairment: Altered cognitive states can affect a patient’s ability to manage their breathing or communicate respiratory distress.
Signs and Symptoms of Altered Respiratory Function
Identifying an alteration in respiratory function involves recognizing a combination of subjective patient reports and objective clinical assessments. These signs and symptoms can be categorized as follows:
Subjective Indicators (Patient-Reported)
- Dyspnea: Patients may report shortness of breath or dyspnea or difficulty breathing.
- Respiratory-Related Anxiety: Feelings of apprehension or panic associated with breathing difficulties are common.
Objective Indicators (Nurse-Assessed)
- Dyspnea (Observed): Observable signs of labored breathing.
- Abnormal Respiratory Rate: Deviations from the normal range, including tachypnea (rapid breathing) or bradypnea (slow breathing).
- Compromised Oxygen Saturation: Pulse oximetry readings indicating lower than normal blood oxygen levels.
- Abnormal Arterial Blood Gas (ABG) Results: Deviations in blood pH, PaO2, and PaCO2 levels indicating respiratory imbalance.
- Shallow Breathing: Reduced depth of respiration, resulting in minimal chest excursion.
- Pursed-Lip Breathing: Exhaling through pursed lips, often a compensatory mechanism in obstructive lung diseases.
- Accessory Muscle Use: Visible use of neck and shoulder muscles to assist breathing, indicating increased respiratory effort.
- Nasal Flaring: Widening of the nostrils during inspiration, a sign of respiratory distress, particularly in infants and children.
- Cough: May be present, but can be ineffective in clearing secretions.
- Restlessness and Anxiety (Observed): Agitation and unease related to hypoxia and breathing difficulty.
- Decreased Level of Consciousness: Confusion, lethargy, or unresponsiveness due to inadequate oxygenation of the brain.
- Diaphoresis: Excessive sweating, often associated with increased respiratory effort and anxiety.
- Abnormal Chest X-Ray Findings: Radiological evidence of underlying respiratory pathology.
Expected Outcomes for Patients with Altered Respiratory Function
Nursing care planning for patients with an alteration in respiratory function focuses on achieving specific, measurable outcomes. Common goals and expected outcomes include:
- Resolution of Dyspnea: The patient reports a subjective improvement in breathing and denies shortness of breath.
- Effective Breathing Pattern Restoration: The patient demonstrates a regular and effective breathing pattern characterized by a normal respiratory rate, appropriate depth of respiration, and satisfactory oxygen saturation levels.
- Normalization of ABG Values: Arterial blood gas results return to within normal physiological limits, indicating improved gas exchange.
- Adoption of Breathing Techniques: The patient effectively utilizes learned breathing techniques to enhance their respiratory pattern and manage dyspnea.
- Functional Capacity Improvement: The patient is able to perform Activities of Daily Living (ADLs) without experiencing dyspnea, indicating improved respiratory function and endurance.
Nursing Assessment for Altered Respiratory Function
A thorough nursing assessment is the cornerstone of effective care for patients with altered respiratory function. This assessment encompasses gathering comprehensive physical, psychosocial, emotional, and diagnostic data.
1. Review Medical History for Respiratory Risk Factors: Inquire about pre-existing conditions such as Emphysema, COPD, bronchitis, asthma, and pneumonia as these conditions are directly linked to disrupted breathing patterns. Also, assess for a history of smoking as it significantly impacts long-term respiratory health.
2. Auscultate Breath Sounds and Monitor Vital Signs: Regularly assess breath sounds for abnormalities (wheezing, crackles, diminished sounds) and closely monitor vital signs, particularly respiratory rate, depth, and oxygen saturation. Track trends to identify worsening or improving respiratory status.
3. Evaluate Mental Status and Anxiety Levels: Assess for signs of anxiety, restlessness, or changes in mental status. Shortness of breath can induce panic and exacerbate hyperventilation. Hypoxia can lead to confusion, disorientation, and decreased level of consciousness. Monitor for behavioral changes and cognitive function.
4. Analyze Arterial Blood Gas (ABG) Results: Review ABG values to assess oxygenation and carbon dioxide removal efficiency. ABGs provide critical information about lung function and acid-base balance, identifying respiratory acidosis or alkalosis. Blood Gas Test analysis is crucial in understanding the severity of respiratory compromise.
5. Pain Assessment: Evaluate the presence and severity of pain. Pain can lead to shallow breathing as patients attempt to minimize chest movement, resulting in inadequate oxygenation. Assess both verbal and nonverbal cues of pain.
6. Medication Review for Oversedation Risk: Assess for medications that can cause respiratory depression, such as narcotics, tranquilizers, and benzodiazepines. Monitor patients receiving these medications for signs of oversedation and respiratory compromise.
7. Assess Secretions and Cough Effectiveness: Evaluate the presence, amount, and consistency of respiratory secretions. Determine the patient’s ability to cough effectively to clear these secretions, as ineffective cough can impede breathing.
8. Sputum Specimen Collection: If indicated by the presence of productive cough and suspected infection, obtain a sputum specimen for culture and sensitivity testing to identify causative pathogens and guide appropriate antibiotic therapy.
Nursing Interventions for Altered Respiratory Function
Targeted nursing interventions are vital in managing and improving altered respiratory function.
1. Oxygen Administration: Administer supplemental oxygen therapy, initiating with the lowest necessary concentration to maintain adequate oxygenation.
2. Respiratory Therapy Consultation: Collaborate with Respiratory Therapists for expert guidance in managing complex respiratory issues and optimizing oxygen delivery methods. Respiratory therapists possess specialized knowledge in selecting and adjusting oxygen therapy modalities.
3. Patient Repositioning: Regularly reposition patients, particularly those with mobility limitations. Elevate the head of the bed to a Semi-Fowler’s or High-Fowler’s position as tolerated to facilitate lung expansion and improve ventilation. Avoid slumped positions that restrict chest movement.
4. Pursed-Lip Breathing Instruction: Teach patients pursed-lip breathing techniques to promote controlled ventilation. This technique involves inhaling through the nose and exhaling slowly through pursed lips, prolonging expiration and preventing air trapping, particularly beneficial for patients with COPD (Pursed-lip Breathing).
5. Incentive Spirometry Encouragement: Promote the use of incentive spirometry to encourage deep, sustained inhalations, maximizing lung expansion and preventing pulmonary complications like pneumonia.
6. Create a Calm and Cool Environment: Maintain a cool, calm, and relaxing environment. A fan blowing gently on the patient’s face can reduce the sensation of dyspnea. Cooler room temperatures are generally preferred to minimize breathlessness. Utilize relaxation techniques, such as a soothing voice and calming music, to alleviate anxiety.
7. Pain and Anxiety Management with Medications: Administer prescribed pain and anti-anxiety medications. Narcotics, particularly morphine, can reduce the work of breathing and effectively treat dyspnea. Anxiolytics can help prevent hyperventilation and promote relaxation.
8. Energy Conservation Strategies: Educate patients on energy conservation techniques. Advise prioritizing essential activities, such as bathing, for times when energy levels are highest. Encourage frequent rest periods and breaks between tasks to minimize fatigue.
9. Smoking Cessation Promotion: Strongly encourage smoking cessation and educate patients about the detrimental effects of smoking on respiratory function. Assist in developing a quit plan and setting realistic goals.
10. Secretion Management: Implement strategies to manage respiratory secretions. For patients with an effective cough, administer expectorants to loosen mucus. For those with ineffective coughs, frequent suctioning may be necessary to prevent aspiration and maintain airway patency. Anticholinergic medications may be used to reduce excessive secretions.
11. Chest Splinting for Coughing and Deep Breathing: Instruct patients, especially those post-thoracic or abdominal surgery, on chest splinting techniques using a pillow to support the incision during deep breathing and coughing. This reduces pain and improves comfort, facilitating effective respiratory mechanics.
Nursing Care Plans for Altered Respiratory Function
Nursing care plans provide structured frameworks for prioritizing assessments and interventions, guiding both short-term and long-term care goals. Here are examples of nursing care plans addressing alteration in respiratory function:
Care Plan #1: Altered Respiratory Function related to Excessive Secretions in COPD
Diagnostic Statement:
Alteration in respiratory function related to excessive secretions secondary to COPD, as evidenced by pursed-lip breathing and patient report of dyspnea.
Expected Outcomes:
- Patient will exhibit clear breath sounds upon auscultation.
- Patient will maintain a respiratory rate within the normal range of 12 to 20 breaths per minute.
- Patient will demonstrate the ability to effectively cough up and clear secretions.
- Patient will exhibit a normal depth of respiration.
- Patient will remain comfortable and free from respiratory distress.
Assessment:
1. Auscultate Breath Sounds: COPD often leads to increased mucus production and impaired secretion clearance. Decreased or absent breath sounds may indicate mucus plugging.
2. Assess Respiratory Parameters: Monitor respiratory rate, depth, accessory muscle use, and body positioning (tripod position). Tachypnea, increased respiratory effort, and tripod positioning are indicative of respiratory distress.
3. Evaluate Lung Function (Spirometry): Review spirometry results to understand the severity of COPD.
- Stage I (mild): FEV1 > 80% predicted
- Stage II (moderate): FEV1 50-79% predicted
- Stage III (severe): FEV1 30-49% predicted
- Stage IV (very severe): FEV1 < 30% predicted
4. Review Arterial Blood Gases (ABGs): ABGs reflect the chronicity and severity of COPD exacerbations. Mild COPD may show mild hypoxemia. Severe stages may present with hypercapnia and worsening hypoxemia.
Interventions:
1. Optimize Patient Positioning: Position the patient in a high-Fowler’s position to maximize diaphragmatic descent and lung expansion.
2. Administer Low-Flow Oxygen Therapy: Initiate low-flow oxygen at 2L/min via nasal cannula as indicated. In COPD patients, hypoxic drive may be the primary respiratory stimulus; high oxygen concentrations can suppress this drive and lead to apnea. Consult with a respiratory therapist regarding appropriate oxygen delivery.
3. Medication Administration: Administer bronchodilators, expectorants, anti-inflammatories, and antibiotics as prescribed to reduce airway resistance, manage infection, and facilitate secretion removal.
4. Implement Effective Coughing Techniques:
- Teach chest splinting.
- Encourage use of abdominal muscles.
- Instruct in huff coughing techniques.
- Guide the patient to take two slow, deep breaths, hold briefly, and perform 2-3 consecutive coughs without inhaling between.
Controlled coughing mobilizes secretions from smaller to larger airways for easier expectoration.
Care Plan #2: Altered Respiratory Function related to Pulmonary Congestion in Heart Failure
Diagnostic Statement:
Alteration in respiratory function related to pulmonary congestion secondary to heart failure, as evidenced by orthopnea.
Expected Outcomes:
- Patient will demonstrate an effective breathing pattern with:
- Respiratory rate of 12-20 breaths per minute
- Regular respiratory rhythm and normal respiratory depth
- Patient will maintain an oxygen saturation level of 90% or greater.
- Patient will report a decrease in orthopnea.
Assessment:
1. Monitor Cardiovascular and Respiratory Vital Signs: Observe for changes in blood pressure, heart rate, respiratory rate, depth, and rhythm. Early hypoxia and hypercapnia may present with elevated BP, HR, and RR. Progressive pulmonary congestion can lead to decreased BP and HR with dysrhythmias.
2. Auscultate Lung Sounds: Assess for adventitious breath sounds such as wheezes and crackles, particularly in lung bases, indicating fluid accumulation.
3. Monitor Oxygen Saturation: Use pulse oximetry to continuously monitor oxygen saturation levels. Maintain SpO2 at 90% or above.
4. Review Laboratory and Radiological Findings:
- Chest X-ray: Evaluate for pulmonary edema, which appears as cloudy white lung fields.
- ABGs: In early pulmonary edema, ABGs may show hypoxemia and respiratory alkalosis. Worsening conditions may lead to hypoxemia, hypercapnia, and respiratory acidosis.
Interventions:
1. Administer Prescribed Medications: Administer medications as ordered to reduce pulmonary congestion and associated symptoms. Diuretics like furosemide (Lasix) reduce fluid overload. Medications to improve heart function may include antihypertensives and drugs to enhance cardiac contractility. Morphine may be used to relieve shortness of breath and anxiety.
2. Optimize Patient Positioning: Position the patient upright to increase thoracic capacity and diaphragmatic descent. Suggest sleeping in an elevated position if orthopnea is problematic.
3. Administer Supplemental Oxygen: Provide supplemental oxygen as needed to maintain adequate oxygen saturation levels.
4. Prepare for Advanced Respiratory Support: Anticipate potential need for endotracheal intubation and mechanical ventilation if the patient does not respond to initial therapies to prevent complete decompensation. Early intubation may be necessary.
Care Plan #3: Altered Respiratory Function related to Musculoskeletal Impairment from Chest Trauma
Diagnostic Statement:
Alteration in respiratory function related to musculoskeletal impairment secondary to a stab wound, as evidenced by splinted and guarded respirations.
Expected Outcomes:
- Patient will demonstrate a stable and effective breathing pattern.
- Patient will report the ability to breathe comfortably with reduced pain.
Assessment:
1. Monitor for Pneumothorax: Assess for signs and symptoms of pneumothorax, a potential complication of penetrating chest trauma:
- Acute pleuritic chest pain
- Dyspnea, tachypnea, tachycardia
- Hyperresonant percussion and diminished breath sounds on the affected side
- Tracheal deviation
2. Monitor Respiratory Rate, Depth, and Effort: Assess respiratory rate (rates >30 breaths/min indicate significant distress), depth, and ease of breathing.
3. Continuous Oxygen Saturation Monitoring: Continuously monitor oxygen saturation using pulse oximetry. Subnormal oxygen saturation (<90%) indicates hypoxemia.
Interventions:
1. Administer Analgesics: Provide prescribed analgesics to manage thoracic pain. Pain can restrict deep inspiration and compromise oxygenation.
2. Optimal Patient Positioning: Position the patient upright or in a semi-Fowler’s position. This often optimizes vital capacity, oxygenation, and reduces dyspnea. Arms supported on pillows or a bedside table can enhance comfort and breathing mechanics.
3. Oxygen Administration: Administer supplemental oxygen as ordered to correct hypoxemia and alleviate dyspnea.
4. Minimize Stimuli and Provide Emotional Support: Create a calm environment, reduce unnecessary stimuli, offer emotional support, and explain all procedures to minimize anxiety and optimize respiratory rate and depth.
References
- Ackley, B.J., Ladwig, G.B.,& Makic, M.B.F. (2017). Nursing diagnosis handbook: An evidence-based guide to planning care (11th ed.). Elsevier.
- Agarwal, A.K., Raja, A.,& Brown, B.D. (2022). Chronic obstructive pulmonary disease. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK559281/
- Carpenito, L.J. (2013). Nursing diagnosis: Application to clinical practice (14th ed.). Lippincott Williams & Wilkins.
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). F. A. Davis Company.
- Gulanick, M. & Myers, J.L. (2014). Nursing care plans Diagnoses, interventions, and outcomes (8th ed.). Elsevier.
- Herdman, T. H., Kamitsuru, S., & Lopes, C. (Eds.). (2024). NANDA-I International Nursing Diagnoses: Definitions and Classification, 2024-2026. Thieme. 10.1055/b000000928
- Nall, R. (2019, July 2). Blood Gas Test. Healthline. https://www.healthline.com/health/blood-gases
- Nguyen JD, Duong H. Pursed-lip Breathing. [Updated 2021 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK545289/
