This is to detect decreased or adventitious breath sounds. Abnormal breath sounds may include:. Assess for the use of accessory muscle. Work of breathing increases greatly as lung compliance decreases. Monitor for diaphragmatic muscle fatigue or weakness paradoxical motion.
Paradoxical movement of the abdomen an inward versus outward movement during inspiration is indicative of respiratory muscle fatigue and weakness. Observe for retractions or flaring of nostrils. These signs signify an increase in respiratory effort. Assess the position that the patient assumes for breathing. Orthopnea is associated with breathing difficulty. Utilize pulse oximetry to check oxygen saturation and pulse rate. Pulse oximetry is a helpful tool to detect alterations in oxygenation initially; but, for CO2 levels, end-tidal CO2 monitoring or arterial blood gases ABGs would require obtaining.
Inquire about precipitating and alleviating factors. Knowledge of these factors is useful in planning interventions to prevent or manage future episodes of breathing problems.
Assess ability to mobilize secretions. The incapability to mobilize secretions may contribute to a change in breathing patterns. Observe the presence of sputum for amount, color, consistency. These may be indicative of a cause for the alteration in breathing patterns. Send specimen for culture and sensitivity testing if sputum appears to be discolored. This may signify infection.
Evaluate the level of anxiety. Note for changes in the level of consciousness. Evaluate skin color, temperature, capillary refill; observe central versus peripheral cyanosis. Cyanosis to the inside of the mouth is a medical emergency! Assess for thoracic or upper abdominal pain. Pain can result from shallow breathing. Keep away from a high oxygen concentration in patients with chronic obstructive pulmonary disease COPD. Hypoxia triggers the drive to breathe in the chronic CO2 retainer patient.
Evaluate nutritional status e. Malnutrition may result in premature development of respiratory failure because it reduces respiratory mass and strength. Place patient with proper body alignment for maximum breathing pattern.
A sitting position permits maximum lung excursion and chest expansion. An increased anterior-posterior chest diameter, resulting from air trapping in the alveoli, that occurs in chronic respiratory disease. Difficulty in breathing that occurs when lying down and is relieved upon changing to an upright position. Skip to content Now that we have discussed various concepts related to oxygenation and hypoxia, we will explain how a nurse uses the nursing process to care for patients with alterations in oxygenation.
Subjective Assessment The primary symptom to assess when a patient is experiencing decreased oxygenation is their level of dyspnea, the medical term for the subjective feeling of shortness of breath or difficulty breathing. Figure 8. Registered Nurses' Association of Ontario. Nursing care of dyspnea: The 6th vital sign in individuals with chronic obstructive pulmonary disease. What is a sputum culture test? Medical Encyclopedia [Internet]. Atlanta GA : A. Chest Pain; [updated , August 4].
Chest x-ray. Chest x-ray; [updated , August 4]. Routine sputum culture; [updated , Aug 4]. Comprimised host. Nursing diagnoses: Definitions and classification, Thieme Publishers New York, p. Elsevier, pp. Nursing interventions classification NIC. Mucus and other secretions that are coughed up from the mouth. Yellow or green sputum that often indicates a respiratory infection. Enlargement of the fingertips that occurs with chronic hypoxia. Previous: 8. The final model, given the information of the related factors, allows to estimate the probability of a patient to present IBP.
The related factors of the nursing diagnosis IBP in the studied ICU were fatigue, age, and group of diseases cardiocirculatory diseases, trauma and other diagnoses. Besides previous co-morbidities, several factors may contribute to fatigue, including systemic inflammation, use of some medications such as corticoids, sedatives and neuromuscular blockers, malnutrition, hyperosmolarity, parenteral nutrition, cardiopathies and prolonged immobility, common conditions in the ICU 25 - Fatigue can be present in patients with diverse pathologies, such as heart, lung, hematological, and oncological diseases, as well as in patients presenting pain, malnutrition and psychological manifestations such as anxiety and depression, which also corroborates the other RF found in this study, that is, group of diseases Other factors that may contribute to the onset of fatigue are age and number of comorbidities Regarding the number of morbidities, studies have shown an association between greater number of morbidities and greater perception of fatigue 28 - In the elderly, fatigue occurs due to changes in the body as a whole and in the cardiopulmonary system, in which reduction of oxygen uptake, reduction of respiratory muscle strength, and increase of vascular resistance are observed.
In the muscular system, there is a decrease in muscle strength and flexibility, resulting in fatigue, which affects simple activities of daily life of the elderly The authors emphasize that IBP patients present DC related to ventilatory dysfunction and, if not treated adequately, this diagnosis may evolve to the diagnosis of impaired spontaneous ventilation ISV , characterizing a worse prognosis of the patient Old age was the second predictor of IBP in this study.
Ageing is characterized by a chronic decrease in the functions of the organic system, leaving the elderly susceptible to diseases, with risk to trigger the IBP diagnosis 2. In this sense, it is up to nurses to recognize these peculiarities and alterations during the physical examination and to select interventions that improve the respiratory state within the expected for the age. A cross-sectional study conducted in Rio Grande do Sul, Brazil, identified that almost half of the elderly In this study, It is also worth mentioning that this group of patients is more vulnerable to influenza due to the higher prevalence of chronic degenerative diseases and immunological deterioration, which may cause breathing changes and the manifestation of IBP 31 - The third related factor of IBP was group of diseases trauma, cardiocirculatory diseases, and other diagnoses.
External causes, as an important cause of traumas, represented by traffic accidents, represent a serious public health problem in Brazil and are responsible for high morbidity and mortality, disability rates, and sequelae, not to mention considerable economic cost Another study performed in the urgency and emergency unit of a large public hospital in southern Brazil identified a prevalence of The presence of these clinical indicators occurs due to the changes in pulmonary expansion following the alteration of the chest cavity, besides hypovolemia following hemorrhage and hypoxia caused by traumatic lesions.
Thus, the control of cerebral oxygenation and the supply of oxygen to the other organs of the body are fundamental in the care of these patients, besides the control of bleeding. The lack of attention to respiratory care may lead patients to develop IBP 36 - In relation to the group of diseases related to the cardiocirculatory system, it is known that patients with these comorbidities may present cardiac decompensation with consequent hemodynamic changes, giving rise to the IBP diagnosis.
Patients with left heart failure, for example, may present signs and symptoms of pulmonary congestion due to left ventricular failure, evidencing the nursing diagnosis IBP.
Moreover, patients with acute coronary syndrome have chest pain as their main symptom. Anginal pain triggers manifestations of the sympathetic system that cause an increase in heart rate and breathing, altering the breathing mechanics regarding depth, number of incursions per minute.
Without intervention, this will lead to respiratory muscle fatigue and consequent IBP diagnosis Thus, in the analysis of the final logistic regression model of the related factors of IBP, the curve presented a good related capacity of the probability of occurrence of IBP ROC curve 0. Other related factors obesity and bronchial secretion , although not identified as predictors of IBP in our study, have been also associated with this diagnosis.
It was also observed that the DC changes in respiratory depth, auscultation with adventitious sounds, dyspnea, reduced vesicular murmurs, tachypnea, cough and use of accessory respiratory muscles were also associated with IBP 12 - 14 , In obese individuals, IBP diagnosis is detected by the reduced lung volume and capacity in these patients.
Excessive adipose tissue also causes mechanical compression of the diaphragm, resulting in restrictive respiratory insufficiency, decreased pulmonary compliance and increased pulmonary resistance, which consequently increases respiratory work and oxygen, resulting in the IBP diagnosis 38 - The RF bronchial secretion possibly related to the Nursing diagnosis IBP due to the narrowing of the lumen as consequence of the exacerbated production of secretions and also due to the inability of intensive care patients to expel secretions spontaneously from the respiratory tract, leading to respiratory difficulty and to the IBP diagnosis The DC dyspnea, tachypnea, changes in respiratory depth and use of accessory muscles to breathe are very common alterations among patients with IBP.
This is due to respiratory muscle weakness and non-resolution of the underlying problem that led in the first place to respiratory decompensation.
Tachypnea is the result of pulmonary hyperventilation, which develops as an adaptive compensation attempt The failure of this compensatory mechanism and the imbalance between the demand and the supply of oxygen favor the appearance of the IBP diagnosis 40 - The use of the accessory musculature demonstrates the attempt to re-establish a normal breathing pattern.
A study carried out in the city of Fortaleza, CE, Brazil, identified that the use of the accessory musculature brings a seven-fold higher chance of having the IBP diagnosis Cough is a symptom of a wide variety of pulmonary and extra-pulmonary diseases, and is very prevalent in the population, has a negative social impact, non-tolerated at work and family contexts, besides generating a great cost in terms of exams and medications. The major causes of cough are viral infections of the upper airways common cold , lower airways acute tracheobronchitis , acute sinusitis, exposure to allergens and irritants, and exacerbations of chronic diseases such as asthma, chronic obstructive pulmonary disease COPD and rhinosinusitis 42 , which can cause changes in pulmonary ventilation, leading the individual to present the IBP diagnosis.
A cross-sectional study carried out in Fortaleza, CE, Brazil, showed that the IBP diagnosis was the most prevalent and the most common DC were adventitious respiratory sounds and cough Adventitious respiratory sounds are detected in pulmonary auscultation and are common in patients with respiratory changes in ICUs When assessing the specificity, sensitivity and positive and negative related values of DC and RF, it was observed that the DC reduced vesicular murmurs had an association and an excellent measure of accuracy, presenting sensitivity, specificity, positive related value and negative high values for the nursing diagnosis IBP.
Vesicular murmurs are normal sounds auscultated in the lungs and their decrease is pathological and may indicate the presence of atelectasis and even decreased lung expansion Atelectasis is a respiratory complication caused by the obstruction of a bronchus, or lung, by secretion or solid bodies that prevent the flow of air and lead to a decrease in the number of alveoli worked When there is complete obstruction in a bronchus that supplies air to a normally ventilated region of the lung parenchyma, the gas in the alveoli distal to the obstruction is absorbed into the pulmonary circulation.
Once all the alveolar gas is absorbed into the circulation, the alveoli, now without gas, collapse, generating a decrease in vesicular murmurs and causing changes in the respiratory ventilation and ineffective breathing pattern The results of this study showed that there are related factors for the nursing diagnosis IBP and nursing interventions and early targeting should be performed in the case of patients with fatigue, advanced age, with problems such as trauma, cardiocirculatory diseases and other diseases.
Related factors of IBP were fatigue, old age, trauma, cardiocirculatory diseases and other diseases. When analyzing the final model through the ROC curve, it was observed that the model had a good related capacity for IBP, associated to high specificity and sensitivity. The DC reduced murmurs presented high sensitivity, specificity and related and negative values for IBP, demonstrating its importance in the identification of this nursing diagnosis.
To the employees of the Intensive Care Unit of the Hospital of Emergency and Emergency of Rio Branco for the assistance and availability in its unit to carry out this research. National Center for Biotechnology Information , U. Rev Lat Am Enfermagem. Published online Oct 7. Find articles by Juliana de Lima Lopes. Author information Article notes Copyright and License information Disclaimer.
Autor correspondente: Patricia Rezende do Prado E-mail: moc. Received Oct 10; Accepted Feb This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Objective to identify the predicting factors and sensitivity, specificity, positive and negative related value of nursing diagnosis Ineffective Breathing Pattern among patients of an intensive care unit.
Method cross-sectional study. Results among the patients, Conclusion fatigue, age and patients with a group of diseases were related factors of Ineffective Breathing Pattern in this study. Method This is an observational, cross-sectional, analytical study.
Results From the patients in the sample, Table 1 Defining characteristics according to the presence or absence of the Nursing diagnosis Ineffective Breathing Pattern.
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