DIAGNOSIS

Ineffective breathing pattern related to chest pain as evidenced by use of accessory muscles
to breathe, nasal flaring, respiratory rate of 22 cpm, oxygen saturation at room temperature
of 92%, wheezing upon auscultation of the anterior and posterior thorax, audible respiratory
grunting and a verbalization of the patient "nagrigat iti umanges nurse"

NURSING INTERVENTION RATIONALE

Position the client in high fowler’s and This position permits maximum lung
change the position every 2 hours. excursion and chest expansion.
Promote bed rest and provide rest periods To decrease oxygen demand and to
before and after activities. conserve energy, decreasing episodes of
respiratory distress.
Encourage sustained deep breaths by: These techniques promote deep
 Using demonstration: highlighting inspiration, which increases oxygenation
slow inhalation, holding end and prevents atelectasis. Controlled
inspiration for a few seconds, and breathing methods may also aid slow
passive exhalation respirations in patients who are tachypneic.
 Utilizing incentive spirometer Prolonged expiration prevents air trapping.
 Requiring the patient to yawn
Provide respiratory medications and Beta-adrenergic agonist medications relax
oxygen, per doctor’s orders. airway smooth muscles and cause
bronchodilation to open air passages.
Provide reassurance and allay anxiety by The presence of a trusted person may be
staying with the client during acute helpful during periods of anxiety.
episodes of respiratory distress.
Ambulate patient as tolerated with doctor’s Ambulation can further break up and move
order secretions that block the airways.
Encourage small frequent meals. This prevents crowding of the diaphragm.
Anticipate the need for intubation and To provide partial or total ventilatory
mechanical ventilation  support in case of respiratory failure
Administer oxygen as indicated. Supplemental oxygen maintains adequate
oxygenation, decreases the work of
breathing, relieves dyspnea, and promotes
comfort. The appropriate amount of
oxygen needs to be continuously delivered
so the client does not become desaturated.
Educate patient about medications: This information promotes safe and
indications, dosage, frequency, and effective medication administration.
possible side effects. Incorporate review of
metered-dose inhaler and nebulizer
treatments, as needed.
Teach patient about: These measures allow patient to participate
in maintaining health status and improve
 pursed-lip breathing ventilation.
  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
Provide referrals as appropriate. May include a wide variety of services and
providers, including support groups, a
comprehensive rehabilitation program,
occupational nurse, oxygen and durable
medical equipment companies for supplies,
home health services, occupational and
physical therapy, transportation, assisted or
alternate living facilities, local and national
Lung Association chapters, and Web sites
for educational materials.