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Respiratory pattern monitoring addresses the patient’s ventilatory pattern, rate, and depth. Most
acute pulmonary deterioration is preceded by a change in breathing pattern. Respiratory failure can be
seen with a change in respiratory rate, change in normal abdominal and thoracic patterns for
inspiration and expiration, change in depth of ventilation (Vt), and respiratory alternans. Breathing
pattern changes may occur in a multitude of cases from hypoxia, heart failure, diaphragmatic
paralysis, airway obstruction, infection, neuromuscular impairment, trauma or surgery resulting in
musculoskeletal impairment and/or pain, cognitive impairment and anxiety, metabolic abnormalities
(e.g., diabetic ketoacidosis [DKA], uremia, or thyroid dysfunction), peritonitis, drug overdose, and
pleural inflammation.
Defining Characteristics:
Dyspnea
Tachypnea
Fremitus
Cyanosis
Cough
Nasal flaring
Respiratory depth changes
Altered chest excursion
Use of accessory muscles
Pursed-lip breathing or prolonged expiratory phase
Increased anteroposterior chest diameter
Related Factors:
Inflammatory process: viral or bacterial
Hypoxia
Neuromuscular impairment
Pain
Musculoskeletal impairment
Tracheobronchial obstruction
Perception or cognitive impairment
Anxiety
Decreased energy and fatigue
Decreased lung expansion
Expected Outcomes
Patient’s breathing pattern is maintained as evidenced by eupnea, normal skin color, and
regular respiratory rate/pattern.
Ongoing Assessment
• Assess respiratory rate and depth by listening to lung sounds. Respiratory rate and
rhythm changes are early warning signs of impending respiratory difficulties.
• Assess for dyspnea and quantify (e.g., note how many words per breath patient can say);
relate dyspnea to precipitating factors.
Assess for dyspnea at rest versus activity and note changes. Dyspnea that occurs
with activity may indicate activity intolerance.
• Use pulse oximetry to monitor oxygen saturation and pulse rate. Pulse oximetry is a
useful tool to detect changes in oxygenation early on; however, for CO2 levels, end
tidal CO2 monitoring or arterial blood gases (ABGs) would need to be obtained.
• Avoid high concentration of oxygen in patients with chronic obstructive pulmonary disease
(COPD). Hypoxia stimulates the drive to breathe in the chronic CO2 retainer patient.
When applying oxygen, close monitoring is imperative to prevent unsafe increases in
the patient’s PaO2 , which could result in apnea.
• Assess skin color, temperature, capillary refill; note central versus peripheral cyanosis.
• If the sputum is discolored (no longer clear or white), send sputum specimen for culture
and sensitivity, as appropriate. An infection may be present. Respiratory infections
increase the work of breathing; antibiotic treatment may be indicated.
• Assess ability to clear secretions. The inability to clear secretions may add to a
change in breathing pattern.
• Position patient with proper body alignment for optimal breathing pattern. If not
contraindicated, a sitting position allows for good lung excursion and chest
expansion.
• Ensure that oxygen delivery system is applied to the patient. The appropriate amount
of oxygen is continuously delivered so that the patient does not desaturate.
An oxygen saturation of 90% or greater should be maintained. This provides for adequate
oxygenation.
• Maintain a clear airway by encouraging patient to clear own secretions with effective
coughing. If secretions cannot be cleared, suction as needed to clear secretions.
• Use universal precautions (e.g., gloves, goggles, and mask) as appropriate. If secretions
are purulent, precautions should be instituted before receiving the culture and sensitivity final
report. Institute appropriate isolation procedures for positive cultures (e.g., methicillin-
resistant Staphylococcus aureus, tuberculosis [TB]).
• Pace and schedule activities providing adequate rest periods. This prevents dyspnea
resulting from fatigue.
• Provide reassurance and allay anxiety by staying with patient during acute episodes of
respiratory distress. Air hunger can produce an extremely anxious state.
• Use pain management as appropriate. This allows for pain relief and the ability to
deep breathe.
• Anticipate the need for intubation and mechanical ventilation if patient is unable to
maintain adequate gas exchange with the present breathing pattern.
Education/Continuity of Care
• Explain use of oxygen therapy, including the type and use of equipment and why its
maintenance is important. ratioIssues related to home oxygen use, storage, and
precautions need to be addressed.
• Instruct about medications: indications, dosage, frequency, and potential side effects.
Include review of metered-dose inhaler and nebulizer treatments, as appropriate.
• Review the use of at-home monitoring capabilities and refer to home health nursing,
oxygen vendors, and other resources for rental equipment as appropriate.
• Explain environmental factors that may worsen patient’s pulmonary condition (e.g.,
pollen, second-hand smoke) and discuss possible precipitating factors (e.g., allergens and
emotional stress).
• Teach patient how to count own respirations and relate respiratory rate to activity
tolerance. Patient will then know when to limit activities in terms of his or her own
limitations.
• Teach patient when to inhale and exhale while doing strenuous activities. Appropriate
breathing techniques during exercise are important in maintaining adequate gas
exchange.
• Refer to social services for further counseling related to patient’s condition and give list of
support groups or a contact person from the support group for the patient to talk with.