Question

CASE STUDY

After a week the shortness of breath has returned. Her son notices that she seems mildly confused. He takes her to the emergency department. The triage nurse takes her vital signs and performs a focused assessment. (Clinical Hint: When a client is experiencing a new onset of confusion, first, rule out hypoxia as the cause).

BP (MAP) HR RR SpO2 Mar. 10 1039 100/58 (72) 108 26 89% RA

Brought in by son per private vehicle. Oriented to name and place only. Crackles in the right lower lobe, inspiratory/expiratory wheezes. Moist cough. Some use of accessory muscles. States having a hard time breathing.

THIN Thinking Time! Reflect on the events that have occurred since Luanne Yazzie came to the emergency department and apply THIN Thinking.

(T - Top 3 H - Help Quick I - Identify Risk to Safety N - Nursing Process)

T –

H –

I –

N –

Answer 1

ANSWER

T –patient shows the signs of hypoxia spo2 89 % tachy cardia,oxygen administration to be considered as per physician order,plan for nebulization therapy as needed to relieve hard time breathing,adminsteration of steroids as per physicians advice,provide safe environment to prevent falls and risk.

H –help quick to relieve shortness of breath .the nurse should immediately administer oxygen to treat hypoxia status.

I –patient has the risk of Brain cells damage .Brain cells are extremely sensitive to oxygen deprivation and can begin to die within five minutes after oxygen supply has been cut off. When hypoxia lasts for longer periods of time, it can cause coma, seizures, and even brain death

N – Nursing Assessment

Continuous assessment is necessary in order to know possible problems that may have lead to Ineffective Breathing Pattern as well as name any concerns that may occur during nursing care.

Assessment	Rationales
Assess and record respiratory rate and depth at least every 4 hours.	The average rate of respiration for adults is 10 to 20 breaths per minute. It is important to take action when there is an alteration in the pattern of breathing to detect early signs of respiratory compromise.
Assess ABG levels, according to facility policy.	This monitors oxygenation and ventilation status.
Analyzing Blood Gas
1. Note the pH.	Determine if it is acidosis or alkalosis.
2. Note the PaCO2.	Is it normal, increased, or decreased?
3. Note the HCO3.	Is it normal, increased, or decreased?
4. Note the base.	Excess or deficit?
5. Note the PaO2.	To determine if there is hypoxia.
Normal Blood Gas Values
pH	7.35 – 7.45
PaCO2	35 – 45
PaO2	Adults: 80 – 100 Infants: 60 – 80
HCO3	20 – 26
Observe for breathing patterns.	Unusual breathing patterns may imply an underlying disease process or dysfunction. Cheyne-Stokes respiration signifies bilateral dysfunction in the deep cerebral or diencephalon related with brain injury or metabolic abnormalities. Apneusis and ataxic breathing are related with failure of the respiratory centers in the pons and medulla.
Rates and Depths of Respiration
· Apnea	Temporary cessation of breathing, especially during sleep
· Apneusis	Deep, gasping inspiration with a pause at full inspiration followed by a brief, insufficient release
· Ataxic patterns	Complete irregularity of breathing with irregular pauses and increasing periods of apnea
· Biot’s respiration	Groups of quick, shallow inspirations followed by regular or irregular periods of apnea (10 to 60 seconds).
· Bradypnea	Respirations fall below 12 breaths per minute depending on the age of patient
· Cheyne-Stokes respiration	Progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in apnea. The pattern repeats, with each cycle usually taking 30 seconds to 2 minutes.
· Eupnea	Normal, good, unlabored ventilation, sometimes known as quiet breathing or resting, respiratory rate
· Hyperventilation	Increased rate and depth of breathing
· Kussmaul’s respirations	Deep respirations with fast, normal, or slow rate associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) but also kidney failure
· Tachypnea	Rapid, shallow breathing, with more than 24 breaths per minute
Auscultate breath sounds at least every 4 hours.	This is to detect decreased or adventitious breath sounds.
Abnormal Breath Sounds
· Wheeze	High-pitched, whistling sound when air moves through narrowed breathing tubes in the lungs. This is heard most commonly in asthmatics and CHF
Ask if they are “short of breath” and note any dyspnea.	Sometimes anxiety can cause dyspnea, so watch the patient for “air hunger” which is a sign that the cause of shortness of breath is physical.
Assess for use of accessory muscle.	Work of breathing increases greatly as lung compliance decreases.
Monitor for diaphragmatic muscle fatigue or weakness (paradoxical motion).	Paradoxical movement of the abdomen (an inward versus outward movement during inspiration) is indicative of respiratory muscle fatigue and weakness.
Observe for retractions or flaring of nostrils.	These signs signify an increase in respiratory effort.
Assess the position that the patient assumes for breathing.	Orthopnea is associated with breathing difficulty.
Utilize pulse oximetry to check oxygen saturation and pulse rate.	Pulse oximetry is a helpful tool to detect alterations in oxygenation initially; but, for CO2 levels, end tidal CO2 monitoring or arterial blood gases (ABGs) would require being obtained.
Inquire about precipitating and alleviating factors.	Knowledge of these factors is useful in planning interventions to prevent or manage future episodes of breathing problems.
Assess ability to mobilize secretions.	The incapability to mobilize secretions may contribute to change in breathing pattern.
Observe presence of sputum for amount, color, consistency.	These may be indicative of a cause for the alteration in breathing pattern.
Send specimen for culture and sensitivity testing if sputum appears to be discolored.	This may signify infection.
Evaluate level of anxiety.	Hypoxia and sensation of “not being able to breathe” are frightening and may worsen hypoxia.
Note for changes in level of consciousness.	Restlessness, confusion, and/or irritability can be early indicators of insufficient oxygen to the brain.
Evaluate skin color, temperature, capillary refill; observe central versus peripheral cyanosis.	Lack of oxygen will cause blue/cyanosis coloring to the lips, tongue, and fingers. Cyanosis to the inside of the mouth is a medical emergency!
Assess for thoracic or upper abdominal pain.	Pain can result shallow breathing.
Keep away from high concentration of oxygen in patients with chronic obstructive pulmonary disease (COPD).	Hypoxia triggers the drive to breathe in the chronic CO2 retainer patient. When administering oxygen, close monitoring is very important to avoid hazardous risings in the patient’s PaO2, which could lead to apnea.
Evaluate nutritional status (e.g., weight, albumin level, electrolyte level).	Malnutrition may result in premature development of respiratory failure because it reduces respiratory mass and strength.

Nursing Interventions

The following are the therapeutic nursing interventions for ineffective breathing pattern:

Interventions	Rationales
Place patient with proper body alignment for maximum breathing pattern.	A sitting position permits maximum lung excursion and chest expansion.
Encourage sustained deep breaths by: · Using demonstration: highlighting slow inhalation, holding end inspiration for a few seconds, and passive exhalation · Utilizing incentive spirometer · Requiring the patient to yawn	These techniques promotes deep inspiration, which increases oxygenation and prevents atelectasis. Controlled breathing methods may also aid slow respirations in patients who are tachypneic. Prolonged expiration prevents air trapping.
Encourage diaphragmatic breathing for patients with chronic disease.	This method relaxes muscles and increases the patient’s oxygen level.
Evaluate the appropriateness of inspiratory muscle training.	This training improves conscious control of respiratory muscles and inspiratory muscle strength.
Provide respiratory medications and oxygen, per doctor’s orders.	Beta-adrenergic agonist medications relax airway smooth muscles and cause bronchodilation to open air passages.
Avoid high concentration of oxygen in patients with COPD.	Hypoxia triggers the drive to breathe in the chronic CO2 retainer patient. When administering oxygen, close monitoring is very important to avoid uncertain risings in the patient’s PaO2, which could lead to apnea.
Maintain a clear airway by encouraging patient to mobilize own secretions with successful coughing.	This facilitates adequate clearance of secretions.
Suction secretions, as necessary.	This is to clear blockage in airway.
Stay with the patient during acute episodes of respiratory distress.	This will reduce the patient’s anxiety, thereby reducing oxygen demand.
Ambulate patient as tolerated with doctor’s order three times daily.	Ambulation can further break up and move secretions that block the airways.
Encourage frequent rest periods and teach patient to pace activity.	Extra activity can worsen shortness of breath. Ensure the patient rests between strenuous activities.
Consult dietitian for dietary modifications.	COPD may cause malnutrition which can affect breathing pattern. Good nutrition can strengthen the functionality of respiratory muscles.
Encourage small frequent meals.	This prevents crowding of the diaphragm.
Help patient with ADLs, as necessary.	This conserves energy and avoids overexertion and fatigue.
Avail a fan in the room.	Moving air can decrease feelings of air hunger.
Encourage social interactions with others that have medical diagnoses of ineffective breathing pattern.	Talking to others with similar conditions can help to ease anxiety and increase coping skills.
Educate patient or significant other proper breathing, coughing, and splinting methods.	These allow sufficient mobilization of secretions.
Educate patient about medications: indications, dosage, frequency, and possible side effects. Incorporate review of metered-dose inhaler and nebulizer treatments, as needed.	This information promotes safe and effective medication administration.
Teach patient about: · pursed-lip breathing · abdominal breathing · performing relaxation techniques · performing relaxation techniques · taking prescribed medications (ensuring accuracy of dose and frequency and monitoring adverse effects) · scheduling activities to avoid fatigue and provide for rest periods	These measures allow patient to participate in maintaining health status and improve ventilation.
Refer patient for evaluation of exercise potential and development of individualized exercise program.	Exercise promotes conditioning of respiratory muscles and patient’s sense of well-being.