Domain 4. Activity-rest
Class 4. Cardiovascular-pulmonary responses
Diagnostic Code: 00033
Nanda label: Impaired spontaneous ventilation
Diagnostic focus: Spontaneous ventilation
Spontaneous ventilation is the act of breathing without being artificially supported, or without the need for a machine. A nursing diagnosis of impaired spontaneous ventilation outlines situations in which the natural respiratory process has become compromised and requires medical attention.
NANDA Nursing Diagnosis Definition
The official definition of this nursing diagnosis is the “inability to initiate or sustain spontaneous breaths, due to an alteration in the central or peripheral components of respiratory control”. In other words, it means that the individual has difficulty breathing on their own, as the respiratory mechanisms responsible for automatic breathing are not functioning correctly.
This condition of impaired spontaneous ventilation can present with many different subject symptoms. These typically include a feeling of shortness of breath, dizziness, fatigue, confusion and anxiety. Other related physical symptoms may consist of chest pain, labored breathing, tachypnea (rapid breathing) and cyanosis (blue discoloration of the skin or mucous membranes).
The most common observable symptoms associated with this diagnosis will include a decrease in oxygen levels as well as changes in respiratory rate and pattern. The individual may also present with possible signs of increased effort in order to breathe, such as retractions of the chest and use of accessory muscles. Additionally, an increase in heart rate and blood pressure may also be seen.
There can be a range of factors that lead to impaired spontaneous ventilation. Depending upon the root cause of the disorder, one or more of the following conditions can be attributed to the diagnosis: disruption of impulse formation, interruption of impulse conduction, alveolar/ventilatory compromise, fatigue, a decrease in respiratory muscle strength and inactivity, anatomical/structural defect, hypoxemia, pulmonary embolism and infection.
Disruption of the impulse formation relates to the generation of nervous signals within the body (such as a nerve compression) that prevent respiration from commencing or continuing normally. Interruption of impulse conduction relates to a disruption to the travel of the nerve signals once they have been generated, generally as a result of damage to the nervous system. Alveolar/ventilatory compromise is due to a decrease in the ability of the lungs to intake and exhale air as required. This can be caused by diseases such as asthma, COPD or even obesity hypoventilation syndrome. Symptoms of fatigue and weakness can result in the recoil of the respiratory muscles, leading to increased difficulty in breathing. Anatomical/structural defects may hinder the process of respiration, and infections can either directly or indirectly impact the organs that facilitate respiration, such as the pleura, bronchi and trachea. Finally, hypoxemia is the occurrence of low oxygen levels in the bloodstream, which can lead to respiratory and circulatory failure if untreated.
A range of other disorders is linked with impaired spontaneous ventilation and these should be taken into consideration when forming a nursing care plan for the individual. These may include chronic obstructive pulmonary disease, severe anemia, cardiovascular collapse, cystic fibrosis, Guillain-Barre syndrome, parenchymal lung disorders, sleep apnea and paralysis.
Chronic Obstructive Pulmonary Disease (COPD) is a progressive disease of the respiratory system that leads to chronically inflamed and narrowing airways, thus hampering breathing via decreases or obstacles in airflow. Severe anemia often causes oxygen deprivation due to reduced hemoglobin levels, leading to decrease in oxygen absorption, hypoxemia and impaired spontaneous ventilation. Cardiovascular collapse is often caused by severe trauma, leading to a lack of oxygen delivery to tissue and organs, including the lungs. Cystic Fibrosis is a genetically inherited disorder causing the accumulation of thick and sticky mucus, that results in obstruction of the airways and lungs. Guillain-Baré Syndrome is generally caused by a viral or bacterial infection and causes the immune system to attack the myelin sheaths that cover the peripheral nerves, resulting in decreased or blocked nerve signals, among other effects. Parenchymal Lung Disorders affect the lobar and alveoli units of the lungs directly, such as in the case of emphysema, leading to impaired gas exchange and impaired spontaneous ventilation due to lack of oxygen. Sleep apnea is a sleep-related disorder with pauses in breathing occurring periodically during sleep. Paralysis of the nervous system can hinder and possibly completely block the nerve signals necessary for spontaneous respiration from occurring.
Suggestions for Use
When attempting to diagnose impaired spontaneous ventilation, a patient’s medical history should be evaluated thoroughly and thoroughly. If a root cause cannot be determined, diagnostic tests such as pulmonary function tests (PFTs), electrocardiograms (ECGs) and chest x-rays may need to be performed. Once established, treatment will depend upon the cause and could range from lifestyle changes such as smoking cessation to further analysis via biopsy or blood tests. Surgery may be indicated in some cases.
Suggested Alternative Nursing Diagnoses
In cases where respiratory fatigue is present, Dyspnea and Impaired Gas Exchange should be considered instead of impaired spontaneous ventilation. Dyspnea is an individual’s subjective experience with difficulty in breathing, while Impaired Gas Exchange relates to impaired uptake of oxygen into the bloodstream and release of carbon dioxide.
Dyspnea is mainly characterized by feelings of breathlessness and can range from mild to extreme. It has many possible causes including airway obstruction, viral upper respiratory tract infections and asthma. Impaired Gas Exchange, on the other hand, relates to inability of oxygen to enter the bloodstream and carbon dioxide to exit, possibly due to obstructions, infection or a decrease in surfactant.
A nursing diagnosis of impaired spontaneous ventilation should only be used if the underlying cause has been identified. If no root cause can be discovered, then an alternative nursing diagnoses should be utilized instead. Additionally, respiratory assessments should be performed on all individuals suffering from ways of dyspnea and/or impaired gas exchange.
When nursing the individual with impaired spontaneous ventilation, the nurse should aim to achieve the following NOC outcomes:
Explanation: This measures the individual’s dependence on mechanical breathing support, and is assessed on a scale of 0-1, with 1 representing complete independence.
Respiratory Status: Ventilation
Explanation: This focuses on the individual’s ability to take in oxygen from their environment and get rid of carbon dioxide. It is again measured on a scale of 0-1, with 1 representing conditions that are free from distress.
Explanation: This outcome looks at the effectiveness of the individual’s ability to take oxygen from their environment, and transport it to their cells. It ranges from 0-4, with 4 indicating normal exchange of oxygen.
Evaluation Objectives and Criteria
In order to evaluate the effectiveness of care that was implemented for impaired spontaneous ventilation, the nurse must assess three specific areas. These are:
Changes in Ventilator Dependence:
The nurse should observe and track the individual’s reliance on mechanical breathing assistance over the course of treatment. Any increases in ventilator dependence should be noted.
Improvements in Respiratory Status:
The nurse should monitor the individual’s ability to take in oxygen from their environment and expel carbon dioxide. Again, any unfavorable changes in status should be recorded.
Updates in Gas Exchange:
Finally, the nurse must keep a close eye on the individual’s ability to transport oxygen from their environment to their cells. Again, any decreases in gas exchange should be noted and reported.
When nursing an individual with impaired spontaneous ventilation, the following interventions should be included in the plan of care:
Explanation: This intervention helps mobilize the secretions in the lungs, assisting individuals in the expulsion of these secretions and aiding in the proper functioning of the individual’s respiratory system.
Explanation: Oxygen therapy is used to supplement oxygen levels, as a lack of adequate oxygen in the body can lead to serious health consequences.
Explanation: This intervention utilizes a combination of manual techniques, medications and devices to help clear the airways and ensure proper exchange of oxygen and carbon dioxide.
Explanation: As this condition can cause anxiety and confusion, this intervention focuses on providing emotional and psychological support to the individual in order to alleviate feelings of distress.
Nursing activities to be employed when caring for an individual with impaired spontaneous ventilation can vary based on the severity of the individual’s condition and their response to treatment. However, some general activities targeted specifically towards this disorder include performing pulmonary hygiene, monitoring ventilation and vital signs, providing oxygen therapy and educating the individual on self-care strategies.
Nursing diagnosis of impaired spontaneous ventilation covers any situation in which an individual is unable to engage in spontaneous breathing. Depending on the underlying cause, this diagnosis can indicate a range of conditions and should always be approached with caution. Patients should be fully evaluated and assessed both through medical examination and through tests such as electrocardiograms, after which a suitable plan of care can be put into place. With the right course of treatment, it is possible for the individual to learn to breathe properly on their own and manage their symptoms.
- What is impaired spontaneous ventilation?
Impaired spontaneous ventilation is the medical condition that occurs when the body is unable to engage in normal, unassisted breathing. It can be caused by a number of factors and complications, such as structural defect, infections, paralysis and others.
- What are the signs and symptoms of this condition?
The most common signs and symptoms of impaired spontaneous ventilation are feelings of shortness of breath, dizziness, confusion and fatigue. In some cases, chest pain, labored breathing, tachypnea and cyanosis may also occur.
- How is this condition treated?
The treatment for impaired spontaneous ventilation depends on the underlying cause. It may involve certain lifestyle and dietary changes, medications and/or surgery.
- What tests are done to diagnose this condition?
To diagnose impaired spontaneous ventilation, a range of tests may be done, including pulmonary function tests, electrocardiograms and chest x-rays.
- Who is at risk of developing this condition?
Anyone can be at risk of developing impaired spontaneous ventilation, although certain conditions, such as COPD, asthma, cystic fibrosis and heart disease, increase the risk factor.