Ineffective Breathing Patterns

Ineffective
Breathing Patterns

(_)Actual (_)
Potential

Related
To:
[Check
those that apply]
(_)
Allergic response
(_) Anesthesia
(_) Aspiration

(_) COPD
(_) Decreased lung compliance
(_) Fatigue
(_) History of smoking

(_)
Immobility

(_) Medications (narcotics, sedatives, analgesics)
(_) Neuromuscular impairment (eg. MS, Guillain-Barre)
(_) Surgery or trauma
(_) Pain
(_) Other:_____________________________
____________________________________

____________________________________

 

As
evidenced by:
[Check
those that apply]
Major:

(
Must be
present
)
(_)
Changes is respiratory rate or pattern from baseline.
(_) Changes in pulse (rate, rythm).
Minor:

(
May be
present
)
(_)
Orthopnea (_) Tachypnea (_) Hyperpnea
(_) Splinted, guarded respirations.

 

Date &
Sign.
Plan and Outcome
[Check
those that apply]
Target
Date:
Nursing Interventions
[Check
those that apply]
Date

Achieved:

  The
patient will:

(_)
Demonstrate an effective respiratory rate, depth, and
pattern A.E.B.:

  • Color pink/
    absence of cyanosis.
  • Absence of
    diminished breath sounds.

(_) Other:

  (_)
Assess color, respiratory rate, depth, effort, rythm and
breath sounds q ___ hours.

(_) Position to facilitate optimum
breathing patterns:

  • HOB elevated ___
    degrees.
  • Turn q ___ hours.

(_) Cough and deep
breath q ___ hours.

(_) Increase activity
as tolerated to promote maximum diaphragmatic excursion:
_______________
________________________

________________________
________________________

(_)
Other:________________
________________________
________________________
________________________

 

 

__________________________
Patient/Significant other signature

 

__________________________
RN signature