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Ineffective Breathing Pattern — Liver Cirrhosis

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NURSING DIAGNOSIS: Breathing Pattern, risk for ineffective

LC-Ineffective Breathing Pattern
Image: http://nurseslabs.com
Risk factors may include
  • Intra-abdominal fluid collection (ascites)
  • Decreased lung expansion, accumulated secretions
  • Decreased energy, fatigue
Desired Outcomes
  • Maintain effective respiratory pattern; be free of dyspnea and cyanosis, with ABGs and vital capacity within acceptable range.

Nursing Interventions & Rationale

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.:

Peritoneovenous shunt.
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.
 Source: http://ncplist.blogspot.com/2012/05/ineffective-breathing-pattern-liver.html