Page 11 - PNEUMONIA NURSING CARE PLAN
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Unusual breathing patterns may imply an
underlying disease process or dysfunction. Cheyne-
Stokes respiration signifies bilateral dysfunction in
Observe for breathing patterns. 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.
Auscultate breath sounds at least every four This is to detect decreased or adventitious breath
(4) hours. sounds.
Work of breathing increases greatly as lung
Assess for use of accessory muscle.
compliance decreases.
Paradoxical movement of the abdomen (an inward
Monitor for diaphragmatic muscle fatigue or versus outward movement during inspiration) is
weakness (paradoxical motion). indicative of respiratory muscle fatigue and
weakness.
Observe for retractions or flaring of nostrils. These signs signify an increase in respiratory effort.
Therapeutic Interventions
Place patient with proper body alignment for
maximum breathing pattern.
Positioning the client to facilitate A sitting position permits maximum lung excursion
effective breathing (raising head of bed and chest expansion.
to 45 degrees), teaching how to splint
chest wall with a pillow.
Encourage sustained deep breaths by:
These techniques promotes deep inspiration, which
• Using demonstration: highlighting
slow inhalation, holding end increases oxygenation and prevents atelectasis.
Controlled breathing methods may also aid slow
inspiration for a few seconds, and
passive exhalation respirations in patients who are tachypneic.
• Utilizing incentive spirometer Prolonged expiration prevents air trapping.
• Requiring the patient to yawn
Encourage diaphragmatic breathing for This method relaxes muscles and increases the
patients with chronic disease. patient’s oxygen level.
Maintain a clear airway by
encouraging patient to mobilize own This facilitates adequate clearance of secretions.
secretions with successful coughing.
Suction secretions, as necessary. This is to clear blockage in airway.
Stay with the patient during acute episodes This will reduce the patient’s anxiety, thereby
of respiratory distress. reducing oxygen demand.
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