Nursing diagnosis: risk for ineffective Breathing Pattern
Risk factors may include
Intra-abdominal fluid collection (ascites)
Decreased lung expansion, accumulated secretions
Decreased energy, fatigue
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Respiratory Status: Ventilation
Maintain effective respiratory pattern and be free of dyspnea and cyanosis, with arterial blood gases (ABGs) and vital capacity within acceptable range.
Nursing intervention with rationale:
1. Monitor respiratory rate, depth, and effort.
Rationale: Rapid, shallow respirations or dyspnea may be present because of hypoxia or fluid accumulation in abdomen.
2. Auscultate breath sounds, noting crackles, wheezes, and rhonchi.
Rationale: Indicates developing complications—presence of adventitious sounds reflects accumulation of fluid while diminished sounds suggest atelectasis—increasing risk of pulmonary infection.
3. Investigate changes in level of consciousness (LOC).
Rationale: Changes in mentation may reflect hypoxemia and respiratory failure, which often accompany hepatic coma.
4. Keep head of bed elevated. Position client on side.
Rationale: Facilitates breathing by reducing pressure on the diaphragm and minimizes risk of aspiration of secretions.
5. Encourage frequent repositioning, deep-breathing exercises, and coughing, as appropriate.
Rationale: Aids in lung expansion and mobilizing secretions.
6. Monitor temperature. Note presence of chills, increased coughing, and changes in color or character of sputum.
Rationale: Indicative of onset of infection, such as pneumonia.
7. Monitor serial ABGs, pulse oximetry, vital capacity measurements, and chest x-rays.
Rationale: Reveals changes in respiratory status and developing pulmonary complications.
8. Provide supplemental oxygen (O2) as indicated.
Rationale: May be necessary to treat or prevent hypoxia. If respirations or oxygenation are inadequate, mechanical ventilation may be required.
9. Demonstrate and assist with respiratory adjuncts, such as incentive spirometer.
Rationale: Reduces incidence of atelectasis and enhances mobilization of secretions.
10. Prepare for and assist with acute care procedures, such as: Paracentesis
Rationale: Occasionally done to remove ascites fluid to relieve abdominal pressure when respiratory embarrassment is not corrected by other measures.