ineffective Breathing Pattern
Taxonomy II: Activity/Rest—Class 4
Cardiovascular/Pulmonary Responses (00032)
[Diagnostic Division: Respiration]
Submitted 1980; Revised 1996, and Nursing Diagnosis
Extension and Classification (NDEC) 1998
Definition: Inspiration and/or expiration that does not provide adequate ventilation
Cardiovascular/Pulmonary Responses (00032)
[Diagnostic Division: Respiration]
Submitted 1980; Revised 1996, and Nursing Diagnosis
Extension and Classification (NDEC) 1998
Definition: Inspiration and/or expiration that does not provide adequate ventilation
Related Factors
Neuromuscular dysfunction; SCI; neurological immaturity
Musculoskeletal impairment; bony/chest wall deformity
Anxiety
Pain
Perception/cognitive impairment
Decreased energy/fatigue; respiratory muscle fatigue
Body position; obesity
Hyperventilation; hypoventilation syndrome; [alteration of client’s normal O2:CO2 ratio (e.g., O2 therapy in COPD)]
Neuromuscular dysfunction; SCI; neurological immaturity
Musculoskeletal impairment; bony/chest wall deformity
Anxiety
Pain
Perception/cognitive impairment
Decreased energy/fatigue; respiratory muscle fatigue
Body position; obesity
Hyperventilation; hypoventilation syndrome; [alteration of client’s normal O2:CO2 ratio (e.g., O2 therapy in COPD)]
Defining Characteristics
SUBJECTIVE
Shortness of breath
OBJECTIVE
Dyspnea; orthopnea
Respiratory rate:
Adults >14 yr: <=11 or [>]24
Children 1 to 4 yr, <20 or >30
5 to 14 yr, <14 or >25
Infants [0 to 12 mo], <25 or >60
Depth of breathing:
Adult tidal volume: 500 mL at rest
Infant tidal volume: 6 to 8 mL/kg
Timing ratio; prolonged expiration phases; pursed-lip breathing
Decreased minute ventilation; vital capacity
Decreased inspiratory/expiratory pressure
Use of accessory muscles to breathe; assumption of three-point position
Altered chest excursion; [paradoxical breathing patterns]
Nasal flaring; [grunting]
Increased anterior-posterior diameter
SUBJECTIVE
Shortness of breath
OBJECTIVE
Dyspnea; orthopnea
Respiratory rate:
Adults >14 yr: <=11 or [>]24
Children 1 to 4 yr, <20 or >30
5 to 14 yr, <14 or >25
Infants [0 to 12 mo], <25 or >60
Depth of breathing:
Adult tidal volume: 500 mL at rest
Infant tidal volume: 6 to 8 mL/kg
Timing ratio; prolonged expiration phases; pursed-lip breathing
Decreased minute ventilation; vital capacity
Decreased inspiratory/expiratory pressure
Use of accessory muscles to breathe; assumption of three-point position
Altered chest excursion; [paradoxical breathing patterns]
Nasal flaring; [grunting]
Increased anterior-posterior diameter
Desired Outcomes/Evaluation
Criteria—Client Will:
• Establish a normal/effective respiratory pattern.
• Be free of cyanosis and other signs/symptoms of hypoxia with ABGs within client’s normal/acceptable range.
• Verbalize awareness of causative factors and initiate needed lifestyle changes.
• Demonstrate appropriate coping behaviors.
Criteria—Client Will:
• Establish a normal/effective respiratory pattern.
• Be free of cyanosis and other signs/symptoms of hypoxia with ABGs within client’s normal/acceptable range.
• Verbalize awareness of causative factors and initiate needed lifestyle changes.
• Demonstrate appropriate coping behaviors.
Tags: Activity/ Rest, Cardiovascular, ineffective Breathing Pattern, Pulmonary
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