NURSING DIAGNOSIS: Breathing Pattern, risk for ineffective
Risk factors may include
- Intra-abdominal fluid collection (ascites)
- Decreased lung expansion, accumulated secretions
- Decreased energy, fatigue
- Maintain effective respiratory pattern; be free of dyspnea and cyanosis, with ABGs and vital capacity within acceptable range.
Nursing Interventions & Rationale
|Monitor respiratory rate, depth, and effort.||Rapid shallow respirations/dyspnea may be present because of hypoxia and/or fluid accumulation in abdomen.|
|Auscultate breath sounds, noting crackles, wheezes, rhonchi.||Indicates developing complications (e.g., presence of adventitious sounds reflects accumulation of fluid/secretions; absent/diminished sounds suggest atelectasis), increasing risk of infection.|
|Investigate changes in level of consciousness.||Changes in mentation may reflect hypoxemia and respiratory failure, which often accompany hepatic coma.|
|Keep head of bed elevated. Position on sides.||Facilitates breathing by reducing pressure on the diaphragm, and minimizes risk of aspiration of secretions.|
|Encourage frequent repositioning and deep-breathing exercises/coughing as appropriate.||Aids in lung expansion and mobilizing secretions.|
|Monitor temperature. Note presence of chills, increased coughing, changes in color/character of sputum.||Indicative of onset of infection, e.g., pneumonia.|
|Monitor serial ABGs, pulse oximetry, vital capacity measurements, chest x-rays.||Reveals changes in respiratory status, developing pulmonary complications.|
|Provide supplemental O2 as indicated.||May be necessary to treat/prevent hypoxia. If respirations/oxygenation inadequate, mechanical ventilation may be required.|
|Demonstrate/assist with respiratory adjuncts, e.g., incentive spirometer.||Reduces incidence of atelectasis, enhances mobilization of secretions.|
|Prepare for/assist with acute care procedures, e.g.:
|Occasionally done to remove ascites fluid to relieve abdominal pressure when respiratory embarrassment is not corrected by other measures.
Surgical implant of a catheter to return accumulated fluid in the abdominal cavity to systemic circulation via the vena cava; provides long-term relief of ascites and improvement in respiratory function.