Spontaneous ventilation refers to the process of breathing that is controlled by the body’s natural mechanisms. When these mechanisms are compromised, it can lead to a decline in respiratory function, which is known as deterioration of spontaneous ventilation. In the nursing field, this is referred to as a “Deterioration of Spontaneous Ventilation” and is classified as a NANDA nursing diagnosis.
NANDA Nursing Diagnosis Definition
According to NANDA International, the official definition of “Deterioration of Spontaneous Ventilation” is: “A decline in the patient’s ability to initiate and maintain spontaneous ventilation as evidenced by changes in respiratory rate, depth, and pattern.”
Defining Characteristics
- Changes in respiratory rate
- Changes in respiratory depth
- Changes in respiratory pattern
- Shortness of breath
- Restlessness
- Decreased lung expansion
Related Factors
- Chronic obstructive pulmonary disease (COPD)
- Pneumonia
- Asthma
- Chest injury
- Neuromuscular disorders
- Medications
- Fatigue
- Anxiety
Risk Population
Individuals who are at a higher risk for developing “Deterioration of Spontaneous Ventilation” include:
- Elderly adults
- Individuals with chronic lung disease
- Individuals with asthma
- Individuals with chest injury
- Individuals with neuromuscular disorders
- Individuals taking sedatives or opioids
- Individuals with high levels of stress or anxiety
Associated Problems
- Acute respiratory failure
- Hypoxia
- Infections
- Pneumonia
- Atelectasis
- Decreased lung expansion
Suggestions for Use
- Assess patient’s respiratory rate, depth, and pattern and monitor for changes.
- Administer bronchodilators, mucolytics, or other medications as ordered
- Instruct patient in techniques such as deep breathing, coughing, and use of incentive spirometer to improve spontaneous ventilation
- Implement measures to prevent infections, such as proper hand hygiene and aseptic technique
- Monitor patient for signs of respiratory distress and take appropriate action as necessary.
- Provide a calming and comfortable environment to reduce stress and anxiety levels.
- Regularly assess the patient’s medications and their potential impact on spontaneous ventilation.
- Encourage and assist the patient with mobility and physical activity to prevent fatigue and improve lung function.
Suggested Alternative NANDA Diagnoses
- Ineffective Airway Clearance
- Impaired Gas Exchange
- Ineffective Respiratory Pattern
- Risk for Injury related to impaired physical mobility
- Impaired Spontaneous Ventilation
Usage Tips
- This diagnosis should be used in conjunction with other diagnoses that may be contributing to the deterioration of spontaneous ventilation, such as pneumonia or COPD.
- It is important to monitor the patient’s response to interventions and adjust as necessary.
- It is also important to consider the patient’s overall respiratory history and any previous respiratory events they may have experienced.
- In cases where the patient is experiencing severe deterioration of spontaneous ventilation, referral to a respiratory therapist or pulmonologist may be necessary.
NOC Results
- Respiratory Pattern: This outcome measures the patient’s breathing pattern, which can indicate changes in overall respiratory function and effectiveness of interventions.
- Oxygenation Status: This outcome measures the patient’s oxygenation status, which can be affected by deterioration of spontaneous ventilation.
- Breathing Effort: This outcome measures the patient’s breathing effort, which can indicate changes in overall respiratory function and effectiveness of interventions.
- Tissue Perfusion: This outcome measures the patient’s tissue perfusion, which can be affected by deterioration of spontaneous ventilation.
NIC Interventions
- Breathing Techniques: This intervention involves techniques such as deep breathing, coughing, and use of an incentive spirometer to improve the patient’s spontaneous ventilation and overall respiratory function.
- Medications Management: This intervention involves administering medications such as bronchodilators, mucolytics, or other as ordered to improve the patient’s spontaneous ventilation and overall respiratory function.
- Chest Physical Therapy: This intervention involves techniques to mobilize secretions and improve lung expansion to enhance the patient’s spontaneous ventilation and overall respiratory function.
- Infection Control: This intervention involves implementing measures to prevent infections, such as proper hand hygiene, to protect the patient’s overall health and respiratory function.
- Relaxation Techniques: This intervention involves techniques such as meditation, yoga or deep breathing exercises to reduce stress and anxiety levels which may affect the patient’s spontaneous ventilation.
- Medication Management: This intervention involves monitoring and adjusting the patient’s medications to minimize their negative impact on spontaneous ventilation.
- Physical Activity: This intervention involves encouraging and assisting the patient with mobility and physical activity to prevent fatigue and improve lung function.
Conclusion
Deterioration of Spontaneous Ventilation is a serious concern that can lead to a variety of problems and complications. By understanding the NANDA nursing diagnosis and utilizing appropriate interventions, nurses can help to promote optimal respiratory function and prevent further complications in at-risk patients.