Which of the following actions should the nurse take for alterations in breathing pattern?

After reading the skill overview, watching the video, following up some of the references/web sites and completing the self-test quiz you should be ready to be assessed in practice in the skill of assessing the patient’s breathing.

The overall function of the respiratory system is to transport air into the lungs and to allow the diffusion of oxygen into the blood. The waste product of carbon dioxide is received from the blood and exhaled via the respiratory system. Breathing is a vital physiological function and is involved in homeostasis, or maintenance of the equilibrium of the body (Marieb 2014).

The four stages in respiration are:

1. inspiration (breathing in)
2. gas exchange within the lungs
3. respiration at cellular level
4. expiration (breathing out) (Marieb 2014).

The assessment of breathing, and counting and recording the respiratory rate, is a crucial part of the overall assessment of the patient’s vital signs (Smith & Rushton 2015). It is important that close and accurate observation of breathing and respiratory rate is not restricted to those patients with conditions known to affect breathing such as asthma or other respiratory or cardiovascular conditions, but that careful observation is carried out for all patients (The Royal College of Physicians (RCP) 2012).

It has been noted that measuring and recording the respiratory rate is frequently overlooked, not carried out accurately, or in up to 50% of cases is not carried out at all. Failure to carry out observation and monitoring of breathing and the respiratory rate represents poor practice which may adversely affect patient safety (NHS National Institute for Health and Care Excellence (NICE) 2017.

The accurate identification of any alteration in the respiratory function is key to early detection of a change in the patient’s condition. The respiratory rate is considered to be a sensitive predictor of clinical deterioration (RCP 2015, Smith & Rushton 2015). Changes may occur in breathing and the respiratory rate long before other changes in the vital signs. Impending adverse clinical events which may be preceded by changes in respiratory function include sepsis, cardiac arrest, metabolic disturbance, and neurological deterioration (Clarke & Malecki-Ketchell 2016). The Royal College of Physicians advises that a raised respiratory rate is a good indicator of serious illness as well as general pain and distress. Accurate reporting of any change in the respiratory function allows for early intervention and treatment, and prevention of further deterioration in the patient’s condition (Massey & Merdith 2011, Clarke & Malecki-Ketchell 2016).

Recording of the respiratory rate forms an integral part of current evidence-based clinical early warning scoring systems and is the first parameter documented in the National Early Warning Score (NEWS). The respiratory rate is often recorded at the same time as other vital signs such as temperature, pulse, blood pressure, and oxygen saturation levels. According to NICE (2007), the respiratory rate should be recorded a minimum of 12 hourly and more frequently as the patient’s condition dictates or as indicated by the NEWS score (The Royal College of Physicians 2012).

It is imperative that the nurse ensures that measurement and recording of breathing and the respiratory rate is carried out carefully and accurately, and that any change is reported immediately to the nurse or clinician in charge (RCP 2012, Rushton 2015).

No special equipment is required to measure and record the respiratory rate; however, good clinical observation skills and a sound underpinning knowledge of the importance of measuring this vital sign are crucial.

Respiratory rate must not be taken in isolation but forms a part of the whole assessment (RCP 2012).  If the patient looks unwell the nurse or clinician in charge must be informed as certain medications such as opiate (i.e. morphine or codeine) and sedatives may affect the respiratory rate (Clarke & Malecki-Ketchell 2016).  In patients who are in pain and or anxious, their respiratory rate may be higher than their normal and again, this needs to be reported to the nurse or clinician in charge.

Dyspnea often called shortness of breath (SOB), is used to describe difficult or labored breathing often with an increased respiratory rate. Shortness of breath is not a disease but a symptom. Dyspnea can be acute or chronic depending on the causative factor. Related factors include:

• Body positions that prevent lung expansion
• Presence of bronchial secretions
• Generalized weakness
• Respiratory muscle fatigue
• Hyperventilation
• Obesity
• Age
• History of smoking
• Conditions that may obstruct the airway or impair the gas exchange
• Excess fluid buildup in the heart or lungs

Shortness of breath (SOB) is the feeling of running out of breath and not being able to breathe in and out deeply or quickly enough. This is due to multiple interactions of signals and receptors in the upper airway, lungs, and chest wall.

The following conditions may cause dyspnea:

• Respiratory: asthma, acute or chronic obstructive pulmonary disorder (COPD), pneumonia, pulmonary embolism, lung cancer, pneumothorax (collapsed lung), or aspiration.
• Cardiovascular: congestive heart failure, pulmonary edema, acute coronary syndrome, heart diseases, pulmonary hypertension, cardiac arrhythmia.
• Neuromuscular: chest trauma, obesity, spinal deformity, central nervous system (CNS) or spinal cord dysfunction, phrenic (diaphragm) nerve paralysis, myopathy, and neuropathy.
• Psychogenic: hyperventilation syndrome, psychogenic dyspnea, vocal cord dysfunction syndrome, and foreign body aspiration.
• Other systemic illnesses: anemia, acute renal failure, metabolic acidosis, thyrotoxicosis (severe thyroid hormone level elevation), cirrhosis of the liver, anaphylaxis, sepsis (a life-threatening condition in response to severe infection), allergic reaction, epiglottitis (inflammation of the epiglottis), and anxiety.

The Nursing Process

Dyspnea can be quite distressing for patients. It may increase their levels of anxiety which makes them feel even more dyspneic. Vital signs including oxygen saturation should be obtained immediately and frequently. A thorough history and physical examination may reveal any ongoing psychiatric, cardiovascular, pulmonary, or musculoskeletal conditions that can cause dyspnea. Treatment depends on the underlying cause.

Nursing Care Plans Related to Shortness of Breath (Dyspnea)

Ineffective Airway Clearance Care Plan

Ineffective airway clearance associated with shortness of breath (dyspnea) can be caused by obstruction or narrowing of the airway.

Nursing Diagnosis: Ineffective Airway Clearance

Related to:

• Obstruction in the airway 
• Narrowing of the airway
• Blood backing up in the lungs
• Fluid accumulation in the lungs
• Increased mucus production
• Inability to cough or clear secretions

As evidenced by:

• Irregular breathing pattern 
• Shallow and rapid breaths
• Chest tightness
• A feeling of choking or suffocation
• Breathlessness
• Alterations in oxygen saturation
• Alterations in respiratory rate
• Alterations in respiratory rhythm
• Alterations in respiratory depth
• Changes in arterial blood gas
• Use of accessory muscles
• Abnormal chest X-ray
• Adventitious breath sounds

Expected outcomes:

• Patient will maintain a patent airway
• Patient will be able to attain oxygen saturation of 95-100%
• Patient will demonstrate clear breath sounds
• Patient will demonstrate the ability to clear their airway

Ineffective Airway Clearance Assessment

1. Determine the causative factors.
Shortness of breath is a symptom, not a disease. Focusing on the causative factor (obstruction or narrowing of the airway) resulting in ineffective airway clearance will guide treatment.

2. Assess the patient’s respiratory status.
Closely monitor and document respiratory rate, depth, pattern, and O2 saturation as ordered.

3. Observe for other dyspnea-related symptoms.
Coughing, grabbing of the neck, skin color changes, and difficulty in speaking can signal obstruction in the airway.

4. Listen to the breath sounds.
A restriction of airflow in the trachea (windpipe) or the throat causes a wheezing-like sound. High-pitched sounds are caused by narrowed airways.

5. Review arterial blood gas (ABGs).
ABGs reflect conditions that influence the respiratory, circulatory, and metabolic systems.

Ineffective Airway Clearance Interventions

1. Place the patient on the side or elevate the head of the bed.
Place the patient on their side or raise the head of the bed for optimal breathing and to prevent obstruction caused by secretions.

2. Suction secretions from the airway as needed.
Suctioning is essential for normal breathing as it removes mucus from the airway. if secretions are left in the airway, they may become infected and cause a chest infection.

3. Administer medications as prescribed.
Bronchodilators dilate the lung passageways while mucolytics and expectorants help remove chest congestion by thinning and loosening mucus in the airways.

4. Teach coughing and deep breathing exercises.
Breathing exercises will improve gas exchange, clear the lungs, and reduce the risk of pneumonia. Teach the patient to take deep breaths and cough to mobilize and expel secretions every hour when awake.

5. Promote smoking cessation.
Smoking damages the alveoli and airways in the lungs. Encourage smoking cessation and offer resources to quit.

6. Collaborate with respiratory therapists (RT).
Respiratory therapists are knowledgeable about respiratory medications and interventions and assist the doctors in the insertion of airway tools (such as ET tubes) when required.

Ineffective Breathing Pattern Care Plan

Ineffective breathing pattern associated with dyspnea is caused by alterations in the gas exchange (inspiration and expiration mechanisms) resulting in insufficient ventilation.

Nursing Diagnosis: Ineffective Breathing Pattern

Related to:

• Anxiety
• Acute Pain
• Fatigue
• Respiratory muscle fatigue
• Hyperventilation
• Obesity
• Body positions that prevent lung expansion
• Chest wall and diaphragm deformities
• Presence of bronchial secretions
• Age
• History of smoking
• Conditions that impair inspiration and expiration mechanisms (such as spinal cord injuries)
• Pneumothorax

 As evidenced by:

• Irregular breathing pattern 
• Shallow rapid breaths
• Asymmetric respirations
• Pursed lip breathing
• Grunting
• Nasal flaring
• Mouth breathing
• Gasping for air
• Chest retractions
• Breathlessness
• Alterations in oxygen saturation
• Alterations in respiratory rate
• Alterations in respiratory rhythm
• Alterations in respiratory depth
• Changes in arterial blood gas
• Use of accessory muscles

Expected outcomes:

• Patient will demonstrate a regular respiratory rate and rhythm
• Patient will maintain an oxygen saturation of 95-100%
• Patient will demonstrate clear breath sounds
• Patient will demonstrate respirations without the use of accessory muscles, nasal flaring, or grunting

Ineffective Breathing Pattern Assessment

1. Identify the causative factors.
Decipher between a physical or emotional cause (such as anxiety, pain, infection, etc.) to effectively relieve the shortness of breath resulting in an ineffective breathing pattern.

2. Observe for other respiratory symptoms.
Irregular breathing (hyperventilating), nasal flaring, mouth breathing, gasping for air, and use of accessory muscles are symptoms of an ineffective breathing pattern that require immediate attention.

3. Obtain a chest x-ray.
An ineffective breathing pattern requires investigation for respiratory infections, lung trauma, chronic airway changes, cancer, etc., to manage effectively.

Ineffective Breathing Pattern Interventions

1. Relax the respiratory muscles.
Morphine reduces the rate of breathing and anti-anxiety drugs can promote relaxation which prevents hyperventilation.

2. Promote bronchodilation.
Bronchodilation produced by beta-adrenergic agonist drugs relaxes the smooth muscles of the airways.

3. Apply oxygen.
For oxygen saturation levels below 95% or altered ABGs, apply oxygen to improve ventilation and perfusion.

4. Educate on chronic conditions.
Asthma, COPD, emphysema, CHF, and more require specific interventions to control respiratory distress. Educate on the use of inhalers and medications, lifestyle modifications, breathing exercises, and diet changes.

Anxiety Care Plan

Anxiety associated with dyspnea can be caused by the triggered fight-or-flight response resulting in hyperventilation and shortness of breath.