An altered respiratory function, also known as ineffective breathing pattern, is a critical nursing diagnosis defined as inadequate ventilation and oxygenation to meet the body’s metabolic demands. This condition arises when the patient’s breathing pattern, encompassing rate, depth, and mechanics, fails to provide sufficient oxygen intake or carbon dioxide removal. Nurses, especially in critical care settings and for patients with chronic conditions, must be acutely aware of this diagnosis and its implications.
The principles of Airway, Breathing, and Circulation (ABCs) are paramount in nursing practice. Recognizing and addressing altered respiratory function is a cornerstone of patient care. This condition can manifest suddenly due to acute events or develop gradually as a result of chronic illnesses. Prompt identification and intervention are vital to prevent patient deterioration and the potential onset of respiratory failure.
Common Causes of Altered Respiratory Function
Several factors can contribute to altered respiratory function. Understanding these causes is crucial for accurate diagnosis and targeted interventions:
- Pain (Acute or Chronic): Pain, whether sudden or persistent, can significantly restrict respiratory effort. Patients may consciously or unconsciously limit chest expansion to minimize pain, leading to shallow and ineffective breathing.
- Anxiety: Elevated anxiety levels can trigger rapid, shallow breathing (hyperventilation), disrupting the normal respiratory rhythm and potentially leading to an imbalance in oxygen and carbon dioxide levels.
- Chest Trauma: Injuries to the chest wall, such as fractures or contusions, directly impair the mechanics of breathing. Pain, structural damage, and potential lung injury all contribute to altered respiratory function.
- Neurological Injuries (Brain or Spinal Cord): The respiratory drive is controlled by the brainstem, and the muscles of respiration are innervated by nerves originating from the spinal cord. Brain injuries or spinal cord injuries, particularly those affecting the cervical region, can disrupt these neural pathways, leading to ineffective breathing patterns.
- Airway Obstruction: Blockage of the airway, whether by foreign objects, secretions, or swelling, directly impedes airflow and gas exchange, resulting in altered respiratory function.
- Chronic Lung Diseases (e.g., COPD): Conditions like Chronic Obstructive Pulmonary Disease (COPD), emphysema, and chronic bronchitis progressively damage the lungs, impairing their ability to effectively exchange gases. This leads to chronic altered respiratory function.
- Infections (e.g., Pneumonia): Respiratory infections, such as pneumonia, cause inflammation and fluid accumulation in the lungs, reducing lung capacity and impairing gas exchange.
- Obesity: Excess body weight, especially around the chest and abdomen, can restrict lung expansion and increase the work of breathing, contributing to altered respiratory function.
- Chest Wall Deformities: Skeletal abnormalities of the chest wall, such as scoliosis or kyphosis, can limit lung expansion and compromise respiratory mechanics.
- Body Positioning: Certain body positions, especially those that compress the chest or abdomen, can restrict breathing. For instance, lying flat (supine) can be more challenging for breathing than an upright position.
- Respiratory Muscle Fatigue: Prolonged or labored breathing can lead to fatigue of the respiratory muscles (diaphragm and intercostals), weakening their ability to effectively ventilate the lungs.
- Cognitive Impairment: Patients with cognitive impairments may not be able to effectively communicate their breathing difficulties or follow instructions for breathing techniques, potentially worsening altered respiratory function.
Recognizing Altered Respiratory Function: Signs and Symptoms
Identifying altered respiratory function involves recognizing both subjective reports from the patient and objective signs observed by the nurse.
Subjective Symptoms (Patient-Reported)
- Dyspnea (Shortness of Breath): Patients may describe a feeling of breathlessness, air hunger, or difficulty getting enough air. The severity can range from mild discomfort to severe distress.
- Anxiety Related to Breathing: The sensation of not being able to breathe adequately can be profoundly anxiety-provoking. Patients may express fear, panic, or unease about their breathing.
Objective Signs (Nurse-Observed)
- Dyspnea: Observable difficulty in breathing, manifested as labored breathing, gasping, or struggling to breathe.
- Abnormal Respiratory Rate:
- Tachypnea: An abnormally rapid respiratory rate (typically >20 breaths per minute in adults).
- Bradypnea: An abnormally slow respiratory rate (typically <12 breaths per minute in adults).
- Poor Oxygen Saturation (SpO2): A pulse oximeter reading below the normal range (usually <95% on room air) indicates inadequate oxygenation of the blood.
- Abnormal Arterial Blood Gas (ABG) Results: ABGs provide a direct measurement of oxygen and carbon dioxide levels in the blood. Abnormal results, such as low PaO2 (partial pressure of oxygen) or high PaCO2 (partial pressure of carbon dioxide), confirm impaired gas exchange.
- Shallow Breathing: Reduced depth of respiration, characterized by minimal chest rise and fall.
- Pursed-Lip Breathing: Exhaling through pursed lips creates resistance, which helps to keep airways open longer, particularly in patients with COPD, but it is also a sign of respiratory distress.
- Accessory Muscle Use: Visible contraction of muscles in the neck (sternocleidomastoid, scalenes) or between the ribs (intercostals) to assist with breathing. This indicates increased effort and respiratory distress.
- Nasal Flaring: Widening of the nostrils during inhalation, especially in infants and children, is a sign of increased work of breathing.
- Cough: May be present as the body attempts to clear the airways, but can also be ineffective or weak in patients with altered respiratory function.
- Restlessness and Anxiety: Hypoxia (low oxygen levels) can cause restlessness, agitation, and anxiety.
- Decreased Level of Consciousness: As oxygen levels decline, patients may become confused, lethargic, or lose consciousness.
- Diaphoresis: Excessive sweating, often associated with increased effort and anxiety related to breathing difficulties.
- Abnormal Chest X-ray Results: Chest X-rays can reveal underlying pulmonary conditions such as pneumonia, pneumothorax, or pulmonary edema that are contributing to altered respiratory function.
Expected Outcomes for Patients with Altered Respiratory Function
Nursing care planning for altered respiratory function focuses on achieving specific, measurable outcomes. These expected outcomes guide interventions and evaluate the effectiveness of care.
- Patient will report reduced or absent shortness of breath. The patient’s subjective experience of breathing comfort is a key indicator of improvement.
- Patient will maintain an effective breathing pattern characterized by a normal respiratory rate, depth, and oxygen saturation. Objective measures of respiratory function should return to within normal limits.
- Patient will achieve ABG results within normal limits. Blood gas analysis provides objective evidence of improved gas exchange.
- Patient will demonstrate and utilize breathing techniques to enhance breathing pattern. Patients should actively participate in their care by learning and applying techniques like pursed-lip breathing or diaphragmatic breathing.
- Patient will be able to perform Activities of Daily Living (ADLs) without experiencing dyspnea. Functional improvement, allowing patients to engage in daily activities without undue breathlessness, is a crucial goal.
Nursing Assessment for Altered Respiratory Function
A thorough nursing assessment is the foundation of effective care for patients with altered respiratory function. This assessment involves gathering both subjective and objective data.
1. Review Medical History for Predisposing Conditions: A detailed medical history can identify potential underlying causes of altered respiratory function. Conditions such as emphysema, COPD, bronchitis, asthma, and pneumonia are significant risk factors. A history of smoking should also be noted as it strongly correlates with respiratory health.
2. Auscultate Breath Sounds and Monitor Vital Signs: Regularly assess breath sounds for abnormalities such as wheezing, crackles, rhonchi, or diminished sounds. Closely monitor respiratory rate, depth, and oxygen saturation using pulse oximetry. Track trends and report any worsening or improvement promptly.
3. Assess Mental Status and Anxiety Levels: Changes in mental status, such as confusion, disorientation, or restlessness, can be early indicators of hypoxia. Assess the patient’s anxiety level, as anxiety can exacerbate breathing difficulties and vice versa.
4. Analyze Arterial Blood Gas (ABG) Results: Review ABG results to evaluate the patient’s oxygenation and carbon dioxide levels, as well as blood pH. ABGs provide crucial information about the severity of respiratory compromise and the effectiveness of interventions.
5. Evaluate Pain Levels: Assess the presence, location, and intensity of pain. Pain can significantly impact breathing patterns, causing shallow respirations and reduced ventilation. Utilize pain assessment scales and consider both verbal and nonverbal cues.
6. Consider Medication Effects (Oversedation): Be mindful of medications that can depress respiratory drive, such as narcotics, tranquilizers, and benzodiazepines. Assess for signs of oversedation, including decreased respiratory rate and depth, and reduced level of consciousness.
7. Assess Secretions and Cough Effectiveness: Evaluate the presence, amount, color, and consistency of respiratory secretions. Assess the patient’s ability to cough effectively to clear secretions. A weak or ineffective cough can contribute to airway obstruction and altered respiratory function.
8. Obtain Sputum Specimen if Indicated: If secretions are present and suspected to be infectious, obtain a sputum specimen for culture and sensitivity testing as ordered. This helps identify the causative organism and guide appropriate antibiotic therapy.
Nursing Interventions to Improve Respiratory Function
Nursing interventions are aimed at optimizing respiratory function, addressing the underlying causes, and alleviating symptoms.
1. Administer Oxygen Therapy: Provide supplemental oxygen as prescribed to maintain adequate oxygen saturation levels. Use the lowest effective oxygen concentration and delivery method to meet the patient’s needs.
2. Consult Respiratory Therapy: Collaborate with respiratory therapists for expert guidance on oxygen therapy, airway management, and other respiratory interventions. Respiratory therapists possess specialized knowledge and skills in managing complex respiratory issues.
3. Optimize Patient Positioning: Reposition the patient to promote lung expansion. Elevate the head of the bed to a Semi-Fowler’s or High-Fowler’s position as tolerated. Upright positions facilitate diaphragmatic movement and improve ventilation.
4. Teach Pursed-Lip Breathing Technique: Instruct the patient in pursed-lip breathing. This technique involves inhaling through the nose and exhaling slowly through pursed lips. It helps to prolong expiration, prevent airway collapse, and reduce air trapping, particularly beneficial for COPD patients.
5. Encourage Incentive Spirometry: Promote the use of an incentive spirometer to encourage deep, slow inhalations. Incentive spirometry helps to expand the lungs, improve ventilation, and prevent complications such as pneumonia and atelectasis.
6. Create a Calm and Cool Environment: Maintain a cool, calm, and relaxing environment. A fan blowing gently across the patient’s face can reduce the sensation of dyspnea. A cool room temperature is generally preferred as excessive heat can exacerbate breathlessness. Employ relaxation techniques such as a quiet voice, soothing music, and reducing unnecessary stimuli to minimize anxiety.
7. Administer Medications for Pain and Anxiety: Provide pain relief as prescribed, as pain can restrict breathing. Narcotics, particularly morphine, can reduce the work of breathing and alleviate dyspnea. Administer anti-anxiety medications as ordered to manage anxiety-induced hyperventilation and promote relaxation.
8. Promote Energy Conservation: Educate the patient on energy conservation strategies. Advise them to prioritize activities, perform the most important tasks when energy levels are highest, and incorporate rest periods to minimize fatigue and reduce respiratory demand.
9. Encourage Smoking Cessation: If the patient is a smoker, provide education about the detrimental effects of smoking on respiratory function. Assist in developing a smoking cessation plan and set realistic goals for quitting.
10. Manage Secretions: Implement measures to manage respiratory secretions. For patients who can cough effectively, encourage expectorants to loosen mucus and facilitate expectoration. For patients with a weak cough, suctioning may be necessary to remove secretions and prevent airway obstruction. Anticholinergic medications may be prescribed to reduce excessive secretions.
11. Teach Splinting Techniques: For patients with chest or abdominal incisions (post-surgery or trauma), instruct them on splinting the incision with a pillow during deep breathing and coughing exercises. Splinting provides support, reduces pain, and allows for more effective respiratory effort.
Nursing Care Plans for Altered Respiratory Function
Nursing care plans provide a structured framework for organizing assessments and interventions to achieve patient-centered goals. Here are examples of care plan diagnoses for altered respiratory function:
Care Plan #1
Diagnostic Statement:
Altered respiratory function related to excessive secretions secondary to COPD as evidenced by pursed-lip breathing and reported 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 secretions.
- Patient will exhibit a normal depth of respiration.
- Patient will remain comfortable and free from respiratory distress.
Assessments:
1. Auscultate Breath Sounds: COPD is characterized by increased mucus production due to goblet cell hyperplasia and hypertrophy. Impaired ciliary movement and ineffective coughing lead to secretion retention. Decreased or absent breath sounds may indicate mucus plugging.
2. Assess Respiratory Rate, Depth, Accessory Muscle Use, and Positioning: Tachypnea, increased respiratory depth, and accessory muscle use are indicators of respiratory distress. Patients may adopt tripod positioning to optimize breathing and alleviate dyspnea.
3. Evaluate Lung Function Spirometry Results: Spirometry assesses the severity and prognosis 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 or FEV1 < 50% predicted with chronic respiratory failure
4. Review Arterial Blood Gases (ABGs): ABGs reflect the chronicity and severity of COPD exacerbations. Mild COPD may show mild hypoxemia without hypercapnia. Severe stages can present with hypercapnia and worsening hypoxemia.
Interventions:
1. Position Patient in High-Fowler’s Position: This position maximizes lung expansion by allowing the diaphragm to descend, promoting optimal ventilation.
2. Administer Low-Flow Oxygen Therapy (2L/min via Nasal Cannula) as Indicated: COPD patients may rely on hypoxic drive for breathing due to chronic carbon dioxide retention. High oxygen therapy can suppress this drive and lead to apnea. Consult with a respiratory therapist regarding appropriate oxygen delivery. Venturi masks may be used for more precise oxygen delivery if low flow is insufficient.
3. Administer Medications as Prescribed: Administer bronchodilators, expectorants, anti-inflammatories, and antibiotics as ordered. These medications reduce airway resistance, treat infections, and facilitate secretion removal.
4. Assist with Effective Coughing Techniques:
- Splint the chest if needed for comfort.
- Encourage the use of abdominal muscles during coughing.
- Instruct in huff coughing techniques.
- Teach controlled coughing: two slow, deep breaths, hold breath, and perform 2-3 consecutive coughs without inhaling in between.
Controlled coughing mobilizes secretions from smaller to larger airways. Forced expiratory coughing through an open airway is effective for clearing secretions from larger airways.
Care Plan #2
Diagnostic Statement:
Altered respiratory function related to pulmonary congestion secondary to heart failure as evidenced by orthopnea.
Expected Outcomes:
- Patient will demonstrate improved breathing patterns as evidenced by:
- Respiratory rate within normal limits (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.
Assessments:
1. Monitor Vital Signs (BP, HR, RR, Rhythm): Early hypoxia and hypercapnia in heart failure may present with elevated BP, HR, and RR. As pulmonary congestion worsens, BP and HR may drop, and dysrhythmias can occur.
2. Auscultate Lung Sounds: Assess for adventitious breath sounds. Wheezes and crackles (rales) in lung bases indicate fluid accumulation in the lungs.
3. Monitor Oxygen Saturation: Pulse oximetry detects changes in oxygenation. Maintain SpO2 at 90% or higher.
4. Review Laboratory and Diagnostic Findings:
- Chest X-ray: Pulmonary edema will appear as cloudy white infiltrates, particularly in the lung bases (Batwing appearance).
- ABGs: Early pulmonary edema may show hypoxemia and respiratory alkalosis. As the condition progresses, hypoxemia and hypercapnia worsen, leading to respiratory acidosis.
Interventions:
1. Administer Prescribed Medications: Administer medications to reduce pulmonary congestion and associated symptoms. Diuretics (e.g., furosemide/Lasix) reduce fluid overload. Medications to improve cardiac function may include antihypertensives and positive inotropes. Morphine may be used to relieve dyspnea and reduce anxiety associated with breathlessness.
2. Position Patient Upright: Upright positioning increases thoracic capacity and diaphragmatic descent, improving ventilation. Suggest sleeping in a recliner or with extra pillows to elevate the upper body if orthopnea is present at night.
3. Administer Oxygen as Needed: Supplemental oxygen is often required to maintain adequate oxygen saturation.
4. Prepare for Possible Intubation and Mechanical Ventilation: Early intubation and mechanical ventilation may be necessary if the patient’s condition deteriorates and they do not respond to initial therapies. This prevents full respiratory decompensation.
Care Plan #3
Diagnostic Statement:
Altered 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 breathing pattern.
- Patient will report the ability to breathe comfortably.
Assessments:
1. Monitor for Pneumothorax: Penetrating chest injuries like stab wounds increase the risk of pneumothorax. Assess for:
- Acute pleuritic chest pain.
- Dyspnea, tachypnea, tachycardia.
- Hyperresonant percussion sounds and diminished or absent breath sounds on the affected side.
- Tracheal deviation (shift away from the affected side in tension pneumothorax).
2. Monitor Respiratory Rate, Depth, and Effort: A respiratory rate exceeding 30 breaths/minute signifies significant respiratory distress.
3. Continuous Oxygen Saturation Monitoring: Maintain continuous pulse oximetry monitoring. Subnormal oxygen saturation (<90%) indicates hypoxemia.
Interventions:
1. Administer Analgesics: Provide analgesics as prescribed to manage thoracic pain. Pain restricts chest wall movement and reduces lung expansion, compromising oxygenation.
2. Position Patient Upright or Semi-Fowler’s: Upright positions typically optimize vital capacity, oxygenation, and reduce dyspnea. Support arms with pillows or an overbed table to reduce strain and improve comfort.
3. Administer Oxygen as Ordered: Oxygen administration corrects hypoxemia, which is a primary cause of dyspnea.
4. Minimize Stimuli and Provide Emotional Support: Reduce environmental stimuli and provide emotional support to minimize anxiety and optimize respiratory rate and depth. Explain all procedures clearly to alleviate anxiety.
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