The nurse is caring for an older client with asthma that has a respiratory rate of 28 breaths per minute and audible wheezes on inspiration. Which nursing diagnosis is most important for this client?

Question

1. Activity intolerance
2. Altered peripheral tissue perfusion
3. Ineffective airway clearance
4. Ineffective breathing pattern

Answer 1

4. Ineffective breathing pattern

Explanation: 1. Activity intolerance or diminished activity is appropriate if the client experiences fatigue or shortness of breath. Inability to perform activities is not a priority, though.
2. Altered tissue perfusion, whether peripheral or specific to a central organ, is important, but circulation is a concern after issues of airway and breathing.
3. Ineffective airway clearance would be appropriate if the client has a cough or if the client appears to have excessive or thick mucus. This is always a risk for the client with COPD or asthma. If mucus is not a current concern, the nurse does promote secretion thinning and continual clearance by encouraging fluid intake and deep breathing.
4. Ineffective breathing pattern is appropriate since this diagnosis is used if the client is experiencing wheezing and tachypnea. A high respiratory rate is not a sustainable breathing pattern and can lead to respiratory fatigue and failure.