In which client should the nurse prioritize assessments for respiratory depression?

An ineffective breathing pattern is defined as inspiration and/or expiration that does not provide adequate oxygenation. This diagnosis is related to the observed rate and depth of breathing, as well as abnormal chest expansion, and accessory muscle use that results in a breathing pattern that does not supply adequate ventilation to the body.  

The ABCs; airway, breathing, and circulation, are the highest priority of nurses in caring for patients. An ineffective breathing pattern can arise from an array of causes and can occur suddenly. Nurses must be vigilant in observing acute changes and preventing the deterioration of patients and the possibility of respiratory failure.

Causes of Ineffective Breathing Pattern (Related to)

• Chronic pain and/or Acute Pain 
• Anxiety 
• Trauma to the chest 
• Brain or spinal cord injury 
• Airway obstruction 
• Lung diseases such as COPD 
• Infection 
• Obesity 
• Chest wall or diaphragm deformities 
• Body positioning 
• Respiratory muscle fatigue 
• Cognitive impairment 

Signs and Symptoms (As evidenced by) 

Subjective: (Patient reports) 

• Difficulty breathing; shortness of breath or dyspnea 
• Anxiety in relation to breathing 

Objective: (Nurse assesses) 

• Dyspnea
• Abnormal respiratory rate; tachypnea or bradypnea 
• Poor oxygen saturation 
• Abnormal ABG results 
• Shallow breathing 
• Pursed-lip breathing
• Accessory muscle use when breathing 
• Nasal flaring 
• Cough 
• Restlessness and anxiety 
• Decreased level of consciousness
• Diaphoresis 
• Abnormal chest x-ray results

Expected Outcomes

• Patient will deny shortness of breath
• Patient will maintain an effective breathing pattern with normal respiratory rate, depth, and oxygen saturation 
• Patient will have ABG results within normal limits 
• Patient will incorporate breathing techniques to improve breathing pattern  
• Patient demonstrates the ability to complete ADLs without dyspnea

Nursing Assessment for Ineffective Breathing Pattern

1. Assess medical history for possible causes of ineffective breathing.
Emphysema, COPD, bronchitis, asthma, and pneumonia can disrupt breathing patterns. A recent history of smoking may also give insight into respiratory health.

2. Assess breath sounds and other vital signs.
Monitor for changes in lung sounds, respiratory rate and depth, and oxygen saturation closely for worsening or improvement.

3. Monitor for anxiety or change in mental status.
Feeling short of breath can induce panic which can, in turn, worsen hyperventilation. As oxygen decreases in the brain, the patient may become confused or lose consciousness. Monitor closely for changes in behavior or incoherent responses.

4. Review ABGs.
Arterial blood gas is drawn to measure the amount of oxygen and CO2 in the blood. Blood gases determine how well the lungs are able to move O2 into the blood and remove CO2. Abnormal blood pH levels can indicate respiratory problems.

5. Assess for pain.
Pain can cause increased blood pressure, heart rate, and ineffective breathing patterns. Some patients breathe very shallowly to guard against pain. This prevents them from getting adequate oxygenation. The nurse should assess for verbal and nonverbal signs of pain.

6. Assess for oversedation.
On the opposite side of pain, is the risk of oversedation. Narcotics, tranquilizers, and benzodiazepines have a risk of decreased level of consciousness and respiratory depression. The patient should be assessed to monitor for overdoses of medications.

7. Assess for secretions or ability to cough.
If secretions cannot be expectorated effectively, this can impede breathing.

8. Obtain sputum specimen as ordered.
Patients with secretions causing an ineffective breathing pattern may need their sputum cultured to assess for the presence of infection.

Nursing Interventions for Ineffective Breathing Pattern

1. Apply oxygen.
Apply the lowest amount of oxygen required to support ventilation.

2. Request RT support.
Respiratory therapists often administer breathing treatments and respiratory medications as ordered. They are a wealth of knowledge regarding the correct oxygen therapy for each patient.

3. Reposition the patient.
Patients who cannot reposition themselves may become slumped in bed which prevents proper expansion of the lungs. Elevate the HOB and keep the patient in Semi-Fowlers or High-fowler’s position as tolerated to promote oxygenation.

4. Teach the patient pursed-lip breathing.
Pursed-lip breathing is a technique that allows for controlled ventilation. The breath is inhaled through the nose then slowly exhaled through pursed lips allowing for a prolonged expiration. Research shows this is thought to support opening the airways and preventing CO2 trapping.

5. Encourage the use of an incentive spirometer.
Incentive spirometers promote taking slow, deep breaths and expanding the lungs. This can prevent lung problems like pneumonia.

6. Keep a cool, calm, relaxing environment.
The use of a fan blowing on the patient can decrease the feeling of dyspnea. Feeling overly hot can increase breathlessness so a cool room is usually preferred. The nurse can use relaxing techniques such as a quiet voice and soothing music to help with anxiety.

7. Medicate for pain or anxiety.
Narcotics, especially morphine, decrease the work of breathing and can be an effective treatment for dyspnea. Anti-anxiety medications can also help prevent hyperventilation and promote relaxation.

8. Promote energy conservation.
Teach the patient about performing the most taxing or important activities first, such as bathing, when energy is the highest. Rest as needed and take breaks between tasks to limit fatigue.

9. Encourage smoking cessation.
Educate the patient on the correlation between smoking and respiratory function. Help the patient develop a plan and goals to quit smoking.

10. Suction secretions or administer expectorants.
For patients who can cough effectively, expectorants can loosen mucus so the patient can cough it up. If the patient cannot cough on their own, they may need secretions suctioned frequently to prevent aspirating or poor ventilation. Anticholinergic medications can also dry up saliva and secretions.

11. Teach splinting of the chest & abdomen for deep breathing and coughing.
Those with recent chest or abdominal surgery may need to splint their incision with a pillow when deep breathing or coughing. This helps support the area and provides comfort.

References and Sources

1. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). F. A. Davis Company.
2. Nall, R. (2019, July 2). Blood Gas Test. Healthline. https://www.healthline.com/health/blood-gases
3. Nguyen JD, Duong H. Pursed-lip Breathing. [Updated 2021 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK545289/

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