00033 Deterioration Of Spontaneous Ventilation

Domain 4: activity/rest
Class 4: cardiovascular/pulmonary responses
Diagnostic Code: 00033
Nanda label: deterioration of spontaneous ventilation
Diagnostic focus: spontaneous ventilation
approved 1992 • Revised 2017

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « deterioration of spontaneous ventilation is defined as: inability to initiate and/or maintain independent breathing for the maintenance of life.

Definite characteristics

  • apprehension
  • Decreased oxygen arterial saturation
  • Decrease in cooperation
  • Decrease in partial oxygen pressure
  • Current volume decrease
  • Increased use of accessory muscles
  • Increase in heart rate
  • Increase in the metabolic rate
  • Increased partial pressure of carbon dioxide (PCO2)
  • Psychomotor agitation

Related factors

  • Fatigue of respiratory muscles

Associated problems

  • Metabolism deterioration

Suggestions of use

  • The deterioration of gaseous exchange is one of the defining characteristics of this label. When blood gases are altered but the patient is able to breathe without assistance, a diagnosis of deterioration of gas exchange instead of the deterioration of spontaneous ventilation should be established.
  • The authors do not recommend the use of this label as a nursing diagnosis. When breathing is “inadequate to keep life”, it is an emergency; Doctors determine interventions, including resuscitation and assisted breathing. The nursing professional is responsible for controlling changes in the patient’s state and performing interventions according to the protocols of the institution. The objectives and interventions are included in this text only because the standardized language of Noc and Nic includes them.

Suggested alternative diagnostics

  • Weaning, dysfunctional ventilatory response to
  • Gaseous exchange, deterioration of
  • Respiratory pattern, ineffective
  • Respiratory routes, ineffective cleaning of the

NOC Results

  • Respiratory status: Gaseous exchange: Alveolar exchange of C02 and 0 2 to maintain gase concentrations in blood pressure
  • Respiratory status: ventilation: input and output of the lungs
  • Response to assisted breathing: Adult: Alveolar exchange and tissue perfusion are supported by assisted breathing
  • Vital signs: degree to temperature, pulse, breathing and blood pressure are within normal limits

Evaluation objectives and criteria

  • • Demonstrates vital signs, as manifested by the following indicators (specify from 1 to 5: severely, substantially, moderately, slightly or without deviation from the normal range): temperature, pulse, breathing and blood pressure.
  • Other examples

    The patient will be able to:

    • • Have an adequate level of energy and muscle function to maintain spontaneous breathing
    • • Receive adequate nutrition before, during and after the weaning process.
    • • Have arterial gases and oxygen saturation within an acceptable range.
    • • Demonstrate an adequate neurological state to maintain spontaneous breathing

    NIC Interventions

    • Medication administration: preparation, administration and evaluation of the effectiveness of prescribed and non -prescribed drugs
    • Ventilation assistance: promotion of a spontaneous respiratory pattern
    • optimal that maximizes oxygen exchange and carbon dioxide in the lungs
    • Emergency care: Administration of life support measures in situations that put life at risk
    • Assisted breathing management: Invasive: Help the patient receiving artificial breathing support through a device inserted in the trachea
    • Management of respiratory tract: facilitation of the permeability of the respiratory tract
    • Management of artificial respiratory tract: maintenance of endotracheal and tracheostomy catheters, and prevention of complications associated with their use
    • Monitoring of vital signs: Collection and analysis of cardiovascular, respiratory and body temperature data, to determine and prevent complications
    • Oxygen therapy: Oxygen administration and efficiency control
    • Precautions to avoid bronchoaspiration: prevention or minimization of risk factors in a patient with possibilities of bronchaspiration
    • Respiratory surveillance: Collection and analysis of patient data to guarantee the permeability of the respiratory tract and the appropriate gas exchange

    Nursing Activities

    Valuations

    • • For patients who require artificial breathing: monitor the placement of the tube, check the sphygmomanometer inflation sleeve every four hours and every time it inflates and deflates.
    • • (NIC) Assisted breathing management: invasive:
      • Monitor an imminent respiratory failure
      • Monitor a decrease in expiratory volume and an increase in inspiratory pressure
      • Monitor the effectiveness of assisted breathing in the physiological and psychological state of the patient
      • Monitor the adverse effects of assisted breathing (for example, tracheal deviation, infection, barotrauma, volutrauma, under cardiac output, gastric distension, subcutaneous emphysema)
      • Monitor the effects of ventilation changes in oxygenation:
        • ABG, SA02, SV02, C02 at the end of expiration, QSP/QT, and A-AD levels and the subjective response of the patient
      • Monitor the Perfusion-Pulmonary relationship, the vital capacity, VD/VT, m W, the strength of inspirations, for FEV, and the preparation to weave the assisted breathing, based on the protocol of the institution
    • • (NIC) Respiratory control:
      • Take note of the location of the trachea
      • Auscultar the sounds of breathing, looking at the areas of decrease and absence of ventilation, as well as in the presence of abnormal noises
      • Determine the need for suction when auscultating crepitations and snoring in the most important respiratory tract
      • Monitor the increase in restlessness, anxiety and the need for air
      • Monitor the crepitations, if appropriate

    Patient and family education

    • • Instruct the patient and his family about the weaning process and their objectives, including the following:
      • How will the patient feel during the process
      • Patient participation is required
      • Reasons why weaning is necessary
    • • (NIC) Assisted breathing management: invasive: instruct the patient and their relatives about the fundamentals and sensations expected with the use of mechanical fans

    Collaboration activities

    • • (NIC) Assisted breathing management: invasive:
      • Consult other health professionals on the selection of a fan modality (usually, in the initial modality the volume is controlled with the respiratory rate, the FIIO level, and the specified current volume)
      • Manage agents that paralyze the muscles, sedatives and narcotic analgesics, as required

    Others

    • • Start relaxation techniques, as required
    • • (NIC) Assisted breathing management: invasive:
      • Start the assembly and application of the fan
      • Make sure the fan alarms are lit
      • Provide the patient for media (for example, paper and pencil or a board with the alphabet)
      • Perform the suction, based on the presence of anomalous respiratory sounds or an increase in inspiratory pressure
      • Provide routine oral care with soft, antiseptic and soft aspiration
      • For patients who need artificial airways
      • • Provide management for artificial respiratory tract, according to the procedures and protocols of the institution, which could include the following:
      • Provide oral care at least every four hours
      • Turn the endotracheal tube from one place to another every day
      • Firmly set the endotracheal tube; change bandages or ties every 24 hours
      • Sedar, use gloves or hold the dolls, if necessary, to prevent unforeseen extubation
      • Clean the stoma and tracheal cannulas every four hours (according to the institutional protocol)
      • Aspire oropharynx, if required

    Note : To obtain detailed information on the management of artificial respiratory tract, consult a medical-surgical text, a nursing technique manual or the protocols of the institution.

    for patients who require fan weaning

    • • See nursing activities for the diagnosis of dysfunctional ventilatory response to weaning.

    At home

    • • Assess the skills and commitment of caregivers to provide care to a family member who depends on a fan
    • • As part of the planning of the hospital discharge, ask a social worker or a case administrator to help the family to compare the cost of home care with the cost of care in an extensive care institution
    • • Instruct the patient and caregivers about the functioning of the fan, suction, tracheostomy care and breathing medications
    • • Notify the electricity company to include housing in a high -risk list in case of supply failure
    • • Help the family create an emergency plan, including the measures that must be taken while medical aid comes

    Babies and Children

    for newborns who require resuscitation:

    • • Consult a maternal-child nursing text and pediatrics to know all the details about the resuscitation procedure
    • • Have resuscitation equipment during childbirth
    • • To quietly explain to parents the procedures to reduce anxiety
    • • Be prepared to transfer or transport the newborn

    Older people

    • • Establish preventive interventions to favor nutrition and circulation in order to prevent rapid deterioration associated with assisted breathing in the elderly