Nursing Diagnosis :
Ineffective breathing pattern
Definition: The exchange of air inspired and / or inadequate expiratory
Defining characteristics:
Related factors:
NANDA NOC:
Criteria Results:
NANDA NIC:
Airway Management
Oxygen therapy
Vital sign monitoring
Ineffective breathing pattern
Definition: The exchange of air inspired and / or inadequate expiratory
Defining characteristics:
- The pressure drop of inspiration / expiration
- Decreased air exchange per minute
- Using the additional respiratory muscles
- Nasal flaring
- Dyspnea
- Orthopnea
- Changes in breast irregularities
- Shortness of breath
- Assumption of the 3-point position
- Respiratory pursed-lip
- Expiratory phase lasts very long
- Increased anterior-posterior diameter
- Respiratory rata-rata/minimal
- Infants: less than 25 or more than 60
- Ages 1-4: less than 20 or more than 30
- Age 5-14: less than 14 or more than 25
- Age over 14: less than 11 or more than 24
- The depth of breathing
- Adult 500 ml tidal volume at rest
- Baby tidal volume 6-8 ml / kg
- Timing ratio
- Decrease in vital capacity
Related factors:
- Hyperventilation
- Bone deformities
- Chest wall deformity
- Reduction of energy / fatigue
- Destruction / musculoskeletal impairment
- Obesity
- The position of the body
- Fatigue of respiratory muscles
- Hypoventilation syndrome
- Pain
- Anxiety
- Neuromuscular Dysfunction
- Damage to perceptual / cognitive
- Injury to the spinal cord
- Immaturity of Neurological
NANDA NOC:
- Respiratory status: Ventilation
- Respiratory status: Airway patency
- Vital sign Status
Criteria Results:
- Demonstrate effective cough and breath sounds are clean, no cyanosis and dyspneu (capable of removing sputum, able to breathe easily, no pursed lips)
- Indicates a patent airway (the client does not feel suffocated, breath rhythm, respiratory frequency in the normal range, there is no abnormal breath sounds)
- Vital signs are within normal range (blood pressure, pulse, respiration)
NANDA NIC:
Airway Management
- Open the airway, using chin lift technique or jaw thrust if necessary
- Position the patient to maximize ventilation
- Identify the patient's need for the installation of an artificial airway devices
- Place the mayo if needed
- Perform chest physiotherapy if necessary
- Remove secretions by coughing or suction
- Auscultation of breath sounds, record the presence of additional noise
- Perform suction on the mayo
- Give bronchodilators if necessary
- Adjust intake to optimize fluid balance.
- Monitor respiration and oxygenation status
Oxygen therapy
- Clean the mouth, nose and trachea secret
- Maintain a patent airway
- Set oxygenation equipment
- Monitor the flow of oxygen
- Maintain the position of the patient
- Observe for signs of hypoventilation
- Monitor the patient's anxiety to oxygenation
Vital sign monitoring
- Monitor blood pressure, pulse, temperature, and respiratory rate
- Note the presence of fluctuations in blood pressure
- Monitor vital signs while the patient is lying down, sitting, or standing
- Auscultation of blood pressure in both arms and compare
- Monitor blood pressure, pulse, respiratory rate, before, during, and after activity
- Monitor the quality of the pulse
- Monitor respiratory rate and rhythm
- Monitor lung sounds
- Monitor abnormal breathing pattern
- Monitor the temperature, color, and skin moisture
- Monitor peripheral cyanosis
- Monitor the existence of Cushing's triad (a widened pulse pressure, bradycardia, increased systolic)
- Identify the causes of changes in vital signs
0 Komentar untuk "Ineffective Breathing Pattern NANDA NIC NOC"