Actions/Interventions

Nursing Priority No. 1.

To identify etiology/precipitating factors:
 Determine the presence of factors/conditions as noted in Defining Characteristics that would demonstrate
breathing impairments.
 Ascertain if client has history of underlying respiratory disorder, or if this is a new condition with potential for
breathing problems, or exacerbation of preexisting problems (e.g., asthma, other acute upper respiratory
infection, lung cancer, neuromuscular disorders, heart disease, sepsis, burns, acute chest or brain trauma).
 Note current symptoms and how they relate to past history.
 Note emotional state. Emotional changes can accompany a condition or precipitate or aggravate ineffective
breathing patterns.
 Assess client’s awareness and cognition. Affects ability to manage own airway and cooperate with
interventions such as controlling breathing and managing secretions.
 Assess for concomitant pain/discomfort that may restrict respiratory effort.
 Evaluate client’s respiratory status:
 Note rate and depth of respirations, counting for 1 full minute, if rate is irregular. Rate may be faster or
slower than usual. In infants and younger children, rate increases dramatically relative to anxiety, crying,
fever, or disease.
 Note client’s reports and perceptions of breathing ease. Client may report a range of symptoms (e.g., air
hunger, shortness of breath with speaking, activity, or at rest) and demonstrate a wide range of signs (e.g.,
tachypnea, gasping, wheezing, coughing).
 Observe characteristics of breathing pattern. May see use of accessory muscles for breathing, sternal
retractions (infants and young children), nasal flaring, or pursed lip breathing. Irregular patterns (e.g.,
prolonged expiration, periods of apnea, obvious agonal breathing) may be pathological.
 Auscultate and percuss chest, describing presence, absence, and character of breath sounds. Abnormal
breath sounds are indicative of numerous problems and must be evaluated further.
 Note color of skin and mucous membranes. If pallor, duskiness, and/or cyanosis are present, supplemental
oxygen and/or other interventions may be required.
 Assist in treatment of underlying conditions, administering medications and therapies as ordered
 Elevate the head of the bed and/or have the client sit up in a chair, as appropriate, to promote physiological
and psychological ease of maximal inspiration.
 Direct client in breathing efforts as needed. Encourage slower and deeper respirations and use of the
pursed-lip technique to assist client in “taking control” of the situation, especially when condition is
associated with anxiety and air hunger.
 Monitor pulse oximetry, as indicated, to verify maintenance/ improvement in O 2 saturation.
 Maintain a calm attitude while dealing with the client and significant other(s) to limit the level of anxiety.
 Assist the client in the use of relaxation techniques.
 Deal with fear/anxiety that may be present. (Refer to NDs Fear; Anxiety.)
 Encourage a position of comfort. Reposition the client frequently if immobility is a factor.
 Encourage ambulation/exercise, as individually indicated, to prevent onset or reduce severity of respiratory
complications and to improve respiratory muscle strength.
 Review the etiology of respiratory distress, treatment options, and possible coping behaviors.
 Emphasize the importance of good posture and effective use of accessory muscles to maximize respiratory
effort.
 Instruct and reinforce breathing retraining. Education may include many measures, such as conscious
control of breathing rate, breathing exercises (diaphragmatic, abdominal breathing, inspiratory resistive,
pursed-lip), and assistive devices such as rocking bed.
 Encourage adequate rest periods between activities to limit fatigue.
 Review environmental factors (e.g., exposure to dust, high pollen counts, severe weather, perfumes, animal
dander, household chemicals, fumes, secondhand smoke; insufficient home support for safe care) that may
require avoidance of triggers or modification of lifestyle or environment to limit the impact on the client’s
breathing.
 Encourage self-assessment and symptom management:
 Medication regimen, including actions, side effects, and potential interactions of medications, over-the-
counter (OTC) drugs, vitamins, and herbal supplements
 Dietary patterns and needs; access to foods and nutrients supportive of health and breathing
 Management of personal environment, including stress reduction, rest and sleep, social events, travel, and
recreation issues
 Avoidance of known irritants, allergens, and sick persons
 Early intervention when respiratory symptoms occur, knowing
 what symptoms require reporting to medical providers, and seeking emergency care

 Provide referrals as appropriate. May include a wide variety of services and providers, including support
groups, a comprehensive rehabilitation program, occupational nurse, oxygen and durable medical
equipment companies for supplies, home health services, occupational and physical therapy, transportation,
assisted or alternate living facilities, local and national Lung Association chapters, and Web sites for
educational materials.