RESEARCH ARTICLES
Nursing intervention for inefficient breathing pattern diagnosis in the elderly
Daniella Pires NunesI; Agueda Maria Ruiz Zimmer CavalcanteII; Patrícia Silva NunesIII; Dálete Delalibera Corrêa de Faria MotaIV; Adélia Yaeko Kyosen NakataniV
INurse. Doctoral Student in Nursing. University of São Paulo. School of Nursing, Postgraduate Program in Nursing in Adult Health. São Paulo, Brazil. E-mail: dpiresnunes@yahoo.com.br
IINurse. Doctoral Student in Nursing. Federal University in São Paulo. Nursing Department. São Paulo, Brazil. E-mail: enf_agueda@yahoo.com.br
IIINurse. Master Student in Public Health. Federal University of Goiás. E-mail: patriciasn_gyn@hotmail.com
IVNurse. Doctoral in Nursing. Federal University of Goiás. College of Nursing. Goiânia, Goiás, Brazil. E-mail: dalete.mota@globo.com
VNurse. Doctorate Nursing. Federal University of Goiás. College of Nursing. Goiânia, Goiás, Brazil E-mail: adeliafen@gmail.com
VIThanks to the Conselho Nacional de Desenvolvimento Científico e Tecnológico for financing.
ABSTRACT
This study aimed to identify the care reported by nursing staff when diagnosis ineffective breathing pattern related to fatigue in elderly and map the interventions. This is a descriptive study conducted at the clinic of the University Hospital, in 2008, in Goiania, Goias. The sample consisted of 43 professional nursing staff. It was applied a questionnaire based on the classification of the North American Nursing Diagnosis Association - International (NANDA-I) and the Nursing Intervention Classification (NIC). The data revealed 125 nursing activities that converged in 16 interventions proposed by the NIC. The interventions reported in greater proportion were: positioning (24,0%), oxygen (15,2%), energy control (9,6%), the first two being optional additional interventions and the other a suggested intervention. It was observed that the nurses know activities for the management of diagnostic focus; however tend to prioritize care less resolute.
Keywords: Nursing care; elderly; fatigue; respiratory disorders.
INTRODUCTION
The nursing process (NP) proves to be necessary for the provision of a comprehensive and quality care. In the care to elderly patient with chronic damage has been implemented the NP in order to minimize functional losses, reduce the chances of hospitalization through changes of habits and choices for acquisition of healthy behaviors and thus produce efficaciousness in assistance offered. The NP is implemented in five distinct steps, data collection, nursing diagnosis, planning, implementation and evaluation - and makes it possible to develop individualized care and humanized to the individual1,2.
The Brazilian nurses are gradually incorporating the NP and adopting taxonomies of North American Nursing Diagnosis Association International (NANDA-I) and the Nursing Intervention Classification (NIC) in order to facilitate the diagnostic reasoning and decision-making about the desirable results and about interventions to reach them3. Nursing interventions are defined from the establishment of nursing diagnoses in order to classify the caution provided with a standardized language to provide a systematization of information and nursing care. It can also be performed in different environments of care, with various tools and methodologies, applied to patients with various problems of health4,5.
Considering that some studies have shown that the elderly hospitalized are mainly respiratory and cardiovascular, and that this state can cause fatigue and worsen the breathing pattern1-3, it is wondered the interventions that the nursing staff uses for an elderly patient with ineffective breathing pattern related to fatigue. The identification of interventions carried out by nursing professionals will fund the implementation of a care based on diagnosis and reasoning knowledge of elderly individuals will identify gaps in care and will make changes, based on reflection of scientific knowledge obtained.
Thus, the present study was developed to identify the care, reported by the nursing staff, for elderly patients with ineffective breathing pattern related to fatigue and map these care according to the interventions proposed by the nursing Interventions classification.
THEORETICAL REFERENTIAL
In the Taxonomy II of NANDA-I, the diagnosis ineffective breathing pattern is defined as "inspiration and/or expiration that does not provide adequate ventilation"6:294. This diagnosis has been revealed as one of the most frequent in the elderly hospitalized with major impact on the restoration of health7-9.
In a Brazilian study, the nursing diagnosis ineffective breathing pattern, bathing/hygiene self-care deficit, imbalanced nutrition: less than body requirements and risk of infection accounted for the most prevalent among the 62 diagnoses identified in 1665 records of elderly hospitalized. The main care was watching breathing pattern, help in the bed bath, communicate acceptance of diet and implement care routines in venipuncture2.
According to the NANDA-I, the related factors related to the presence of diagnosis ineffective breathing pattern are: anxiety, neurological damage, musculoskeletal injury, bone deformities and the wall of the thorax, neuromuscular dysfunction, pain, fatigue and respiratory muscle fatigue, hyperventilation, neurological immaturity, spinal cord injury, obesity, body position and hypoventilation syndrome6:294.
This diagnosis was observed in 60% of the elderly people with cardiovascular disease admitted in a medical clinic, being the fatigue, the predominant related factor10. Several authors corroborated that, among the elderly, one of the most common symptoms is fatigue resulting from events such as anemia, heart failure, hemodialysis and cancer11-14.
The related factor fatigue is a subjective and diffuse experience that involves physical, psychological and cognitive aspects. It can be acute, when there are extreme tiredness description resulting from physical or mental stress and improves with rest; or chronic, when there are reports of fatigue that does not improve with rest and loss of functionality15,16.
Although the focus on use of NANDA-I is the identification of the title diagnosis, the presence of other components is crucial in the elaboration of the care plan and especially in the selection of nursing interventions17. The nurses can assist in the improvement of the breathing pattern of elderly patients through activities such as evaluation, standard depth and breath sounds, skin coloration, the cough reflex and pulmonary secretion; monitoring the amount of air inspired and expired; and the effectiveness of nebulizers and bronchodilators used18. When the diagnosis ineffective breathing pattern and is not properly treated can lead to other problems such as impaired gas exchange and ineffective airway clearance, which indicate elements that characterize patients with greater clinical losses9.
METHODOLOGY
It is descriptive, transversal study with quantitative approach. The data were collected in the medical clinic of a university hospital in the city of Goiânia (GO), in the period from August to October 2008.
The sample consisted of 55 members of nursing working in the medical Clinic area and involved with the care of elderly patients. The inclusion criteria were to be employee of the sector for more than six months and agree to participate in the survey, by signing the informed consent. Of these members, 12 workers were excluded from the survey (a nurse had less than 6 months in the sector, a technician removed the consent during data collection and 10 technicians were not found in three consecutive visits).
The subjects were contacted in the workplace and informed about the objectives of the research and methodology to know about the proposal of the study as well as to request their participation. Upon acceptance, workers were scheduled timetables after hours, in the hospital sector, for realization of data collection.
The data collection were held in the months of August to October 2008, in which two instruments were used. The first aimed to identify the demographic profile and work of the subject of the search. This instrument was conducted by the researcher through interview. Before applying the second, the researcher explained the concept of ineffective breathing pattern diagnosis, as well as the related factor fatigue and possible characteristics that define this diagnosis according to the NANDA-I. After this description, the professional should score the possible activities and nursing care to be offered to patients with this diagnosis. It should be noted that, during the search, the nursing professionals of that institution had performed mandatory course for training on systematization of nursing care, which was being implemented.
The data were entered and analyzed in the program Statistical Package for the Social Sciences (SPSS) version 16.0. Descriptive statistics was used for the analysis of the characteristics of the professionals and cross mapping for activities reported by the team. The cross mapping followed the following order: mapping of activities described with assistance and priority activities for the diagnosis, as NANDA-I and NIC Association; mapping of interventions and activities suggested and the optional additional; and some mapping activities described by the participants who have addressed the interventions envisaged for other nursing diagnoses.
The present research was submitted to the Ethics Committee and Human and Animal Medical Research of the Clinic Hospital of the Federal University of Goiás (UFG) and approved (Protocol No. 007/08).
RESULTS AND DISCUSSION
Of the 43 (100%) professional participants, seven were nurses, 34 technicians and two nursing assistants. The majority were female (78.6%), with an average age of 39 years old, 74.4% reported between 1 to 5 years working in the medical clinic, 55.8% had no other employment.
The nursing staff referred to 125 activities to diagnosis ineffective breathing pattern related to fatigue. These activities were mapped in 16 NIC interventions, the most reported: positioning, oxygen therapy, energy control, monitoring of vital signs, asthma control and administration of medications. The prevalent activities reported by the nursing staff were: to raise the bed headboard (18.4%), to administer oxygen therapy (15.2%), to observe vital signs (8.8%), to communicate the doctor or nurse (8.8%) and to administer medicine (8.8%).
Ineffective breathing pattern diagnosis related to fatigue is widespread and involves a variety of diseases2,10,19. With reference to the elderly patient with ineffective breathing pattern diagnosis and, mainly, the related factor fatigue, this study allowed a moment of reflection by the nursing staff about the care of individual form for this human response.
The cross mapping between the NIC and the activities reported by the nursing staff for the elderly patients with ineffective breathing pattern related to fatigue identified similarity to all the activities described. This demonstrates that there is correspondence between the reported practices of clinical medicine with that proposed by NIC. This mapping used 16 different interventions, being predominantly mapped interventions activities positioning, energy control and oxygen therapy.
The intervention is described as "deliberate positioning of the patient or by his body to promote physiological and/or psychological well-being"20:575. The most reported activity in this study was to elevate the headboard of the bed. The upright position favors maximum lung expansion, promotes maximum inspiration and alveolar oxygenation improves. Perform changes of position often can promote expectoration by mobilizing pulmonary secretions that are retained in the alveoli21,22.
Study to assess the effect of body position on the cardiorespiratory changes in the elderly showed that the cardiac output and arterial saturation exhibit higher values in a sitting position, followed by the dorsal decubitus22. This data is relevant to the implementation of interventions that promote the improvement of respiratory function.
The energy control is set to "regulating energy use to treat or prevent fatigue and optimize the functions"20:372. It is note that the nursing staff aimed to control the energy of patients for the following actions: minimize physical exertion, promote relaxation, keep the bed rest and change of decubitus. Such activities are intended to treat or prevent fatigue and optimize the functions; assist the patient to prioritize activities in order to accommodate energy levels; organize physical activities that reduce the competition for the oxygen supply to the vital functions; assist the patient to schedule rest periods20. The largest number of actions reported by nursing professionals for energy control intervention is positive and demonstrates the value of fatigue, which is often little highlighted, and erroneously considered acceptable.
Among the characteristics of the person with fatigue there are the subjective feeling of fatigue varying in degree of sensation of discomfort, of duration and intensity; asthenia, lethargy, exhaustion, feeling of weakness, extreme tiredness, lack of energy and motivation that lead the individual to feel incapacitated to perform his activities of daily life and, therefore, resulting in reduced his ability to work15.
Both the intervention positioning as energy control belong to the level of optional additional interventions. This means that interventions apply only to some patients with the diagnosis, which allows the nurse to customize the plan of care for each patient20. Considering the situation of illness for chronic diseases in which fatigue is because of the emergence of the diagnosis, and may also emerge as a symptom common to elderly clients, positioning and control interventions of energy suggested could be considered instead of optional, consisting in most necessary interventions and targeted to individuals with such problems.
In the suggested interventions level it was highlighted the oxygen therapy that referred to "oxygen administration and monitoring of its effectiveness"20:490. This intervention was mapped as the NIC activity "adjusting the equipment and administer oxygen through a heated and humidified system"20:490. Heating the air inspired until close to body temperature and saturate the inspired gas with water vapor upon reaching the nasopharynx are important functions of the nose. However, in some situations, the capacity of the respiratory system to warm and humidify inspired gas can be compromised, such as respiratory failure, in cases of endotracheal intubation, tracheostomy and even, by the physiological process of aging23. Thus, the supplemental oxygen humidification inhaled can minimize the risk of oral and nasal mucosal dryness and retained secretions in the airways, making difficult the expectoration. However, only high oxygen gas flows require use of humidifiers, while less than 4 l/min flows do not require this device21,23,24.
The oxygen therapy should be carefully monitored in order to the professional to decide, on the basis of the individual's clinical condition, the oxygen supply system more suitable. For that, it should be noted the purpose of the therapy, the patient's age and the performance and effectiveness of the equipment in the execution of the therapy. Oxygen therapy intervention modifies significantly the patient's clinical symptoms when administered judiciously and concomitant to care and evaluations listed in nursing24.
Another suggested intervention by the nursing staff was administering medicines - preparation, supply and assessment of the effectiveness of medications prescribed and non-prescribed, characterized by activity administer medicines. In a systematic review on the pharmacological and non-pharmacological treatment for Dyspnea in patients with chronic obstructive pulmonary disease (COPD) and lung cancer, it was found that the Dyspnea in both diseases is treated with corticosteroids, bronchodilators, anxiolytics, local anesthetics and oxygen and can be associated with the use of specific techniques for breathing, positioning, energy conservation, exercise, and some dietary changes and nutritional supplements25.
Other suggested interventions and mapped to the activities reported by the nursing staff were: monitoring of vital signs, reduced anxiety and ventilatory assistance. The first is often carried out by nursing staff. However, the emphasis for some professionals to assist the individual in minimizing anxiety and stress factors, through the participation and presence of chaperones during the period of hospitalization. This fact reinforces the presence of the relatives as emotional support, co-workers in the care and participants of the processes of decisions as regards planning of care and treatment of the elderly26.
Priority interventions include the activities most likely to the diagnostic solution. In this study the control of asthma, respiratory monitoring and control of airway interventions were reported by some professionals. These results serve as a warning, since such activities should be the most often reported against other less resolute, indicating inadequacy in the selection of interventions by nursing professionals. On the other hand, it is necessary to evaluate the responses of individuals after the implementation of these interventions, in order to meet and clarify the best nursing intervention to the problem in focus.
This study advances in the recognition of actions used by nursing staff and their congruence with interventions proposed by the NIC. It demonstrates that there is clarity of reasoning about the clinical diagnosis here studied and it highlights the experience and flexibility in its management. However, it is highlighted the need for reflection about a different interventions indicated prioritization and definition of those interventions best suited to each situation, considering the diagnosis as well as the related factor and the defining characteristics. It is recognized that it was raised the verbal report and not the actual practice on the part of professionals, which may be developed in future research.
From the results found in this study, it enables the investigation of a set of interventions directed at ineffective breathing pattern related to fatigue, based on reports from nursing staff, which leads to the construction of new knowledge generated by the patients' care.
It emphasizes that this set of interventions referred to the nursing staff should be directed to the individual who possesses the diagnosis, making the requirements geared to the needs and actual conditions of the individual. Thus, the selection of interventions is a piece of information which, according to NIC, it may be useful for the construction of care protocols, facilitation of education, determination of service costs and resource allocation planning, besides enabling the development of public policies and guidelines, based on the results of researches20,27.
Later, from the protocols of care, becomes necessary the qualification of professionals in both technical and instrumental aspects as on humanization of care in its ethical dimension, walking in the feeling of awakening the importance of systematization of assistance in order to improve the indicators (length of stay, mortality) and consequently the financial cost and, seeking humanization of assistance by professional accountability.
CONCLUSIONS
This study has identified a wide range of actions for the nursing diagnosis ineffective breathing pattern related to fatigue which were compatible with 16 different interventions proposed by the NIC. The language of NIC was considered a factor in maintaining to some professionals who reported the not understanding of some activities. On the other hand, most professionals demonstrated familiarity with this terminology.
The present study showed that the most frequent interventions were positioning, oxygen and energy control. This result demonstrates that the nursing staff has knowledge about the strategies applicable in individual assistance with ineffective breathing pattern related to fatigue.
It is necessary, from the data described here, to test the set of actions more effective in treating face to this diagnosis. It is nursing staff´s responsibility to organize, plan and execute nursing care according to need individualized, exerting a full quality assistance and humanized.
REFERENCES
1. Guedes HM, Nunes DP, Nakatani AYK, Bachion MM. Identificação de diagnósticos de enfermagem do domínio atividade/repouso em idosos admitidos em hospital. Rev enferm UERJ. 2010; 18:513-8.
2. Almeida MA, Aliti GB, Franzen E, Thomé EGR, Unicovsky MR, Rabelo ER et al. Diagnósticos de enfermagem e intervenções prevalentes no cuidado ao idoso hospitalizado. Rev Latino-Am Enfermagem. 2008; 16:707-11.
3. Fontes CMB, Cruz DALM. Diagnósticos de enfermagem documentados para pacientes de clínica médica. Rev esc Enferm USP. 2007; 41:395-402.
4. Salgado PO, Chianca TCM. Identification and mapping of the nursing diagnoses and actions in an Intensive Care Unit. Rev Latino-Am Enfermagem. 2011; 19: 928-35.
5. Scain SF, Franzen E, Santos LB, Heldt E. Acurácia das intervenções de enfermagem para pacientes com diabetes mellitus tipo 2 em consulta ambulatorial. Rev Gaúcha Enf. 2013; 34:14-20.
6. NANDA.Diagnósticos de enfermagem da NANDA: definições e classificações 2012-2014. Porto Alegre (RS): Artmed; 2012.
7. Aquino RD, Fonseca SM, Lourenço EPL, Leite AL, Bettencourt ARC. Mapeamento dos diagnósticos de enfermagem em uma unidade de pneumologia. Acta Paul Enferm. 2011; 24:13-22.
8. Scherb CA, Head BJ, Maas ML, Swanson EA, Moorhead S, Reed D, et al. Most frequent nursing diagnoses, nursing intervention, and nursing-sensitive patient outcomes of hospitalized older adults with heart failure: part I. International Journal of Nursing Terminologies and Classifications. 2011; 22:13-22.
9. Carlson-Catalano J, Lunney M, Paradiso C, Bruno J, Luise BK, Martin T, et al. Clinical validation of ineffective breathing pattern, ineffective airway clearance and impaired gas exchange. Image J Nurse Sch. 1998; 30:243-8.
10. Nunes DP, Nakatani AYK. Diagnóstico de enfermagem na admissão e alta hospitalar de idosos com doenças cardiovasculares. Goiânia (GO): Funape; 2008. p.60-84.
11. Thein M, Ershler WB, Artz AS, Tecson J, Robinson BE, Rothstein G, et al. Diminished quality of life and physical function in community-dwelling elderly with anemia. Medicine. 2009; 88:107-14.
12. Hagglund L, Boman K, Lundman B. The experience of fatigue among elderly women with chronic heart failure. Eur J Cardiovasc Nurs. 2008; 7:290-5.
13. Kozachik SL, Bandeen-Roche K. Predictors of patterns of pain, fatigue, and insomnia during the first year after a cancer diagnosis in the elderly. Cancer Nurs. 2008; 31:334-44.
14. Lobbedez T, Desbordes E, Joly F, Ficheux M, Henri P, Ryckelynck JP. Fatigue in elderly patients on dialysis. Nephrol Ther. 2008; 4:584-9.
15. Mota DDCF, Pimenta CAM. Fadiga em pacientes com câncer avançado: conceito, avaliação e intervenção. Rev Bras Cancerol. 2002; 48:577-83.
16. Fini A, Cruz DALM. Características da fadiga de pacientes com insuficiência cardíaca: revisão de literatura. Rev Latino-Am Enfermagem [Scielo-Scientific Electronic Library Online] 2009; 17 [citado em 08 nov 2013]. Available at: www.eerp.usp.br/rlae
17. Oliveira ARS, Costa AGS, Freitas JG, Lima FETm Lima FET, Damasceno MMC, Araújo TL. Validação clínica dos diagnósticos, intervenções e resultados de enfermagem: revisão narrativa da literatura. Rev enferm UERJ. 2013; 2:113-20.
18. Cavalcante AMRZ, Nakatani AYK, Bachion MM, Garcia TR, Nunes DP, Nunes PS. Análise de atividades não realizadas pela equipe de enfermagem para o diagnóstico padrão respiratório ineficaz em idosos. Rev esc de enfermagem da USP. 2012; 46:604-11.
19. Cavalcante AMRZ. Intervenções de enfermagem para padrão respiratório ineficaz em idosos [dissertação de mestrado]. Goiânia (GO): Universidade Federal de Goiás; 2009.
20. Dochterman JM, Bulechek GM. Classificação das Intervenções de Enfermagem – NIC. 4ª ed. Porto Alegre (RS): Artmed; 2008.
21. Doenges ME, Moorhouse MF, Geissler AC. Plano de cuidados de enfermagem: orientação para o cuidador individualizado do paciente. 5ª ed. Rio de Janeiro: Guanabara Koogan; 2003.
22. Gordon S, Sealey R, Buettner P. Body position and cardio-respiratory variables in older people. Archives of Gerontology and Geriatrics. 2011; 52:23-7.
23. Scalan DC, Wilkins RL, Stoller JK. Fundamentos da terapia respiratória de Egan. 7ª ed. São Paulo: Manol;, 2000.
24. Higgins D. Oxigen Therapy. Nurse Times. 2005; 101:30-1.
25. Jantarakupt P, Porock D. Dyspnea management in lung cancer: applying the evidence from chronic obstructive pulmonary disease. Oncol Nurs Forum. 2005; 32:785-97.
26. Pena SB, Diogo MJD´E. Expectativas da equipe de enfermagem e atividades realizadas por cuidadores de idosos hospitalizados. Rev esc enferm USP. 2009; 43:351-7.
27. Carvalho EC, Kusumota L. Processo de enfermagem: resultados e consequências da utilização para a prática de enfermagem. Acta Paul Enferm. 2009; 22: 554-7.
Recebido em: 29.11.2012
Aprovado em: 17.07.2013