Respiratory health is fundamental to overall well-being, and nurses play a crucial role in managing patients experiencing oxygenation issues. Utilizing the nursing process is essential for providing effective care, and a critical component of this process is the accurate application of NANDA-I nursing diagnoses. This article provides a comprehensive guide to understanding and utilizing Nanda Nursing Diagnosis Respiratory in clinical practice, ensuring nurses are well-equipped to assess, diagnose, and intervene for patients with respiratory compromise. This resource will delve into the key aspects of respiratory assessment, the application of relevant NANDA diagnoses, and evidence-based interventions to optimize patient outcomes.
Assessing Respiratory Status: A Foundation for NANDA Diagnosis
A thorough respiratory assessment is the cornerstone of identifying and addressing oxygenation alterations. This assessment encompasses both subjective reports from the patient and objective clinical findings, providing a holistic picture of their respiratory status. This detailed evaluation is crucial for selecting the most appropriate nanda nursing diagnosis respiratory.
Subjective Assessment: Patient’s Perspective
Understanding the patient’s experience is paramount in respiratory assessment. Subjective data, gathered through patient interviews, offers valuable insights into their symptoms and their impact on daily life.
Dyspnea: Dyspnea, or shortness of breath, is a primary subjective symptom of decreased oxygenation. It is crucial to quantify the patient’s experience of dyspnea. Using a 0-10 dyspnea scale, similar to pain scales, allows patients to articulate the severity of their breathlessness. This subjective feeling can be profoundly disabling, affecting quality of life significantly. Nurses must prioritize interventions that alleviate dyspnea, thereby enhancing the patient’s overall well-being.
Cough and Sputum: Inquiring about the presence and characteristics of a cough is vital. If a cough is reported, determine if sputum production is present. Sputum, the mucus expelled from the respiratory tract, can provide significant diagnostic clues. Note the color and amount of sputum. While mucus is naturally produced to protect the respiratory lining, excessive production, especially during infection, leads to sputum. The color of sputum can indicate underlying conditions. For instance, purulent sputum, often yellow, green, or brown, commonly signals a respiratory infection.
Figure 8.7 Purulent Sputum: Yellowish-green sputum on tissue, indicative of a potential respiratory infection and relevant to respiratory nursing diagnosis.
Chest Pain: Chest pain associated with respiratory issues requires careful evaluation. While chest pain can stem from various cardiac and respiratory conditions, some are medical emergencies. When a patient reports chest pain, immediately assess for emergent symptoms. Ask questions to rule out cardiac chest pain, such as: “Does it feel like pressure or tightness on your chest?”, “Does the pain radiate to your jaw or arm?”, and “Are you experiencing shortness of breath, dizziness, or nausea?” If any of these symptoms are present, immediate emergency medical assistance is necessary. If emergent cardiac issues are ruled out, conduct a focused assessment of the chest pain, including onset, location, duration, characteristics (sharp, dull, etc.), alleviating or aggravating factors (coughing, deep breathing), radiation, and any treatments used. Noncardiac chest pain often worsens with coughing and deep inspiration, which can be a differentiating factor.
Objective Assessment: Clinical Observations
Objective assessments provide tangible data about the patient’s respiratory status. These observations, combined with subjective reports, inform the selection of an accurate nanda nursing diagnosis respiratory.
Airway, Breathing, and Circulation (ABCs): Begin with assessing the airway for patency. Evaluate respiratory rate, effort, and quality. Observe for signs of labored breathing, such as nasal flaring or use of accessory muscles. Pulse oximetry provides a non-invasive measure of oxygen saturation (SpO2). Auscultate lung sounds to identify any adventitious sounds like wheezing, crackles, or rhonchi, which can indicate underlying respiratory problems. Assess heart rate for tachycardia, which can be a compensatory mechanism for hypoxia.
Cyanosis and Clubbing: Observe for cyanosis, a bluish discoloration of the skin and mucous membranes, indicating hypoxemia. Note the presence of clubbing, an enlargement of the fingertips, which is a sign of chronic hypoxia often seen in conditions like COPD or congenital heart defects.
Figure 8.8 Clubbing of Fingertips: Enlarged and rounded fingertips, a clinical sign of chronic hypoxia often associated with respiratory and cardiac conditions, relevant for nanda nursing diagnosis respiratory.
Barrel Chest: In patients with chronic respiratory diseases like COPD, observe for barrel chest, an increased anterior-posterior chest diameter. This results from chronic air trapping in the alveoli.
Figure 8.9 Comparison of Chest with Normal Anterior/Posterior Diameter (A) to a Barrel Chest (B): Illustrating the difference between a normal chest shape and a barrel chest, a visual cue for chronic respiratory conditions influencing nanda nursing diagnosis respiratory.
Diagnostic Tests and Lab Work: Supporting the Diagnosis
Diagnostic tests and laboratory work provide objective data to confirm suspected respiratory issues and guide medical management. These tests are crucial for supporting and refining the nanda nursing diagnosis respiratory.
Chest X-ray: A chest X-ray is a rapid, painless imaging technique that visualizes the structures within and around the chest. It aids in diagnosing and monitoring conditions like pneumonia, heart failure, lung cancer, and tuberculosis. Chest X-rays are also used to assess treatment effectiveness and post-procedure complications. However, chest X-rays are contraindicated during pregnancy.
Figure 8.10 Chest X-ray: A medical image of a chest X-ray, a key diagnostic tool for respiratory conditions and integral to informing nanda nursing diagnosis respiratory.
Sputum Culture: A sputum culture identifies the type and quantity of bacteria or other microorganisms in sputum. Patients are instructed to cough deeply and expectorate sputum into a sterile container. The sample is then cultured in the lab to promote microbial growth and identify pathogens, guiding appropriate antimicrobial therapy.
Figure 8.11 Sputum Culture: A petri dish showing bacterial growth from a sputum sample, demonstrating a sputum culture used to diagnose respiratory infections and influence nanda nursing diagnosis respiratory.
Arterial Blood Gases (ABGs): For patients experiencing respiratory distress, ABG tests are frequently ordered. ABGs provide crucial information about oxygenation (PaO2), carbon dioxide levels (PaCO2), pH, and bicarbonate (HCO3), offering a detailed assessment of respiratory and metabolic acid-base balance.
Table 8.3a Normal Ranges of ABG Values in Adults
| Value | Description | Normal Range |
|---|---|---|
| pH | Acid-base balance of blood | 7.35-7.45 |
| PaO2 | Partial pressure of oxygen | 80-100 mmHg |
| PaCO2 | Partial pressure of carbon dioxide | 35-45 mmHg |
| HCO3 | Bicarbonate level | 22-26 mEq/L |
| SaO2 | Calculated oxygen saturation | 95-100% |
NANDA Nursing Diagnoses for Respiratory Issues
Based on the comprehensive assessment, nurses select appropriate NANDA-I nursing diagnoses to guide care planning. For patients with decreased oxygenation and dyspnea, common nanda nursing diagnosis respiratory include: Impaired Gas Exchange, Ineffective Breathing Pattern, Ineffective Airway Clearance, Decreased Cardiac Output, and Decreased Activity Tolerance.
Table 8.3b NANDA-I Nursing Diagnoses Related to Decreased Oxygenation and Dyspnea
| NANDA-I Nursing Diagnoses | Definition | Selected Defining Characteristics |
|---|---|---|
| Impaired Gas Exchange | Excess or deficit in oxygenation and/or carbon dioxide elimination | – Abnormal arterial pH – Abnormal skin color – Altered respiratory depth or rhythm – Bradypnea – Confusion – Hypercapnia – Hypoxia or hypoxemia – Irritable mood – Nasal flaring – Psychomotor agitation – Tachycardia – Tachypnea – Somnolence |
| Ineffective Breathing Pattern | Inspiration and/or expiration that does not provide adequate ventilation. | – Abnormal breathing pattern – Bradypnea – Cyanosis – Dyspnea – Hypercapnia – Hyperventilation – Hypoventilation – Increased anterior-posterior chest diameter – Nasal flaring – Orthopnea – Pursed-lip breathing – Tachypnea – Uses accessory muscles to breathe – Uses three-point positioning |
| Ineffective Airway Clearance | Reduced ability to clear secretions or obstructions from the respiratory tract to maintain a clear airway. | – Absence of cough – Adventitious breath sounds – Altered respiratory rhythm – Bradypnea – Excessive sputum – Ineffective sputum elimination – Orthopnea – Psychomotor agitation – Uses accessory muscles to breath |
| Decreased Cardiac Output | Inadequate volume of blood pumped by the heart to meet the metabolic demands of the body. | – Anxiety – Bradycardia – Adventitious breath sounds – Abnormal skin color – Tachycardia – Psychomotor agitation – Fatigue – Edema – Weight gain – Decreased peripheral pulses |
| Decreased Activity Tolerance | Insufficient endurance to complete required or desired daily activities. | – Exertional dyspnea – Expresses fatigue – Abnormal heart rate or blood pressure response to activity – Generalized weakness |
For instance, in a patient with COPD, the nurse would compare assessment findings with the defining characteristics of these diagnoses. If the patient exhibits dyspnea, barrel chest, nasal flaring, orthopnea, pursed-lip breathing, tachypnea, and use of accessory muscles, Ineffective Breathing Pattern would be a fitting nanda nursing diagnosis respiratory. Accurate diagnosis is crucial for targeted interventions.
Outcome Identification: Setting SMART Goals
Once a nanda nursing diagnosis respiratory is established, the next step is to define patient-centered goals and expected outcomes. A broad goal for patients with oxygenation alterations is: The client will have adequate movement of air into and out of the lungs.
A SMART (Specific, Measurable, Achievable, Relevant, Time-bound) outcome example for a patient experiencing dyspnea could be: The client’s reported level of dyspnea will be within their stated desired range of 1-2 throughout their hospital stay. SMART outcomes provide clear targets for nursing interventions and evaluation.
Planning and Implementing Nursing Interventions
Nursing interventions are planned to address the identified nanda nursing diagnosis respiratory and achieve the desired patient outcomes. Common independent nursing interventions for patients with dyspnea and oxygenation issues fall under categories like Anxiety Reduction and Respiratory Monitoring. Anxiety Reduction aims to minimize feelings of apprehension and unease related to respiratory distress. Respiratory Monitoring involves the systematic collection and analysis of patient data to ensure airway patency and adequate gas exchange.
Selected Nursing Interventions to Reduce Anxiety and Perform Respiratory Monitoring
Anxiety Reduction
- Use a calm, reassuring approach to instill confidence and reduce patient anxiety.
- Thoroughly explain all procedures, including expected sensations, to alleviate fear of the unknown.
- Seek to understand the patient’s perspective on their stressful situation to provide empathetic care.
- Provide clear and accurate information regarding diagnosis, treatment plan, and prognosis to empower the patient.
- Stay with the patient during periods of acute anxiety to promote safety and provide immediate reassurance.
- Encourage family presence, as appropriate, to provide additional emotional support and comfort.
- Practice active listening to fully understand and validate patient concerns and fears.
- Create a trusting environment where the patient feels safe to express their anxieties.
- Encourage verbalization of feelings, perceptions, and fears as a healthy coping mechanism.
- Continuously monitor and document changes in the patient’s anxiety level to tailor interventions.
- Offer diversional activities like reading or puzzles to distract from tension and promote relaxation.
- Instruct the patient in relaxation techniques such as guided imagery, music therapy, or deep breathing exercises to manage anxiety.
- Administer prescribed anxiolytic medications as appropriate, carefully monitoring for effectiveness and side effects.
Respiratory Monitoring
- Regularly monitor respiratory rate, rhythm, depth, and effort to detect early signs of respiratory compromise.
- Observe chest movement for symmetry, accessory muscle use, and retractions, indicating breathing difficulty.
- Monitor for adventitious breath sounds such as snoring, wheezing, or crackles, which may indicate airway obstruction or fluid accumulation.
- Analyze breathing patterns for abnormalities like bradypnea, tachypnea, hyperventilation, or Cheyne-Stokes respirations, which can signal underlying conditions.
- Continuously monitor oxygen saturation levels, especially in sedated or high-risk patients, to ensure adequate oxygenation.
- Utilize noninvasive continuous oxygen sensors with appropriate alarms for patients at risk of desaturation.
- Auscultate lung sounds in all fields, noting areas of decreased or absent ventilation and presence of abnormal sounds.
- Assess the patient’s ability to cough effectively to clear secretions and maintain airway patency.
- Document the onset, characteristics (productive vs. nonproductive), and duration of cough to track changes.
- Monitor the quantity, color, consistency, and odor of respiratory secretions for signs of infection or other issues.
- Determine the need for suctioning based on assessment findings of retained secretions and ineffective cough.
- Provide frequent intermittent monitoring of respiratory status in at-risk patients to proactively manage potential problems.
- Monitor for dyspnea and identify factors that exacerbate or alleviate it to tailor interventions.
- Review chest X-ray reports for relevant findings and correlate with clinical assessment.
- Note changes in ABG values and promptly notify the provider of significant deviations from baseline.
- Be prepared to initiate resuscitation efforts, including CPR and airway management, in emergency situations.
- Implement respiratory therapy treatments like nebulized bronchodilators or chest physiotherapy as prescribed.
Beyond these independent interventions, managing hypoxia involves techniques like teaching enhanced breathing and coughing exercises, proper positioning, oxygen therapy administration, medication management, and suctioning. Health promotion teaching is also crucial, including annual influenza and pneumococcal vaccinations, smoking cessation, adequate hydration, and appropriate physical activity.
Evaluation: Measuring the Effectiveness of Interventions
Evaluation is the final step of the nursing process, assessing the effectiveness of implemented interventions and the overall care plan. For respiratory care, focused reassessments include monitoring heart rate, respiratory rate, pulse oximetry, and lung sounds. Crucially, reassess the patient’s subjective experience of dyspnea using the 0-10 scale. Documenting the effectiveness of interventions and evaluating the overall plan ensures patient-centered and evidence-based care for respiratory conditions guided by the nanda nursing diagnosis respiratory.
Definitions of Terms:
Sputum: Mucus and other secretions coughed up from the mouth.
Purulent Sputum: Yellow, green, or brown sputum, often indicating infection.
Clubbing: Enlargement of fingertips due to chronic hypoxia.
Barrel Chest: Increased anterior-posterior chest diameter from air trapping in chronic respiratory disease.
Bradypnea: Abnormally slow respiratory rate.
Tachypnea: Abnormally fast respiratory rate.
Orthopnea: Shortness of breath when lying down, relieved by sitting upright.
