Ineffective airway clearance in adult patients after thoracic and upper
abdominal surgery
Lívia Maia Pascoal, PhD
a,⁎
, Jéssica Pereira Alves de Carvalho, Student Nurse
a,
Vanessa Emille Carvalho de Sousa, PhD
b, Francisco Dimitre Rodrigo Pereira Santos, RPT
a,
Pedro Martins Lima Neto, RPT
a, Simony Fabíola Lopes Nunes, RN
a, Marcos Venícios de Oliveira Lopes, PhD
caFederal University of Maranhão, Imperatriz, Maranhão 65900-000, Brazil bUniversity of Illinois at Chicago, Chicago, IL 60612, United States, cFederal University of Ceará, Fortaleza, Ceará 60430-160, Brazil
a b s t r a c t
a r t i c l e
i n f o
Article history:
Received 23 June 2015 Revised 19 November 2015 Accepted 24 November 2015
Keywords:
Nursing diagnosis Respiratory system Nursing assessment Postoperative care
Aim:The aim of this study is to analyze the accuracy of the defining characteristics of ineffective airway clearance (IAC) in patients after thoracic and upper abdominal surgery.
Background:Although numerous studies have described the most prevalent respiratory NANDA-I diagnoses, only few investigates the precision of nursing assessments.
Methods:A cross-sectional study was conducted with 192 patients in a surgical clinic. Accuracy measures were obtained by the latent class analysis method.
Results:IAC was present in 46.73% of the sample. The defining characteristics with better predictive capacity were changes in respiratory rate and changes in respiratory rhythm. However, other defining characteristics also had high specificity, such as restlessness, cyanosis, excessive sputum, wide-eyed, orthopnea, adventitious breathing sounds, ineffective cough, and difficulty vocalizing.
Conclusion:Results can contribute to the improvement of nursing assessments by providing information about the key clinical indicators of IAC.
© 2015 Elsevier Inc. All rights reserved.
1. Introduction
Respiratory complications are the most important causes of morbid-ity and mortalmorbid-ity in thoracic and upper abdominal post-surgical pa-tients, so they deserve special supervision by the health team. There are several factors arising from the surgical procedures that may alter the respiratory function and contribute to the occurrence of these com-plications. This includes use of anesthetic drugs and muscle relaxants, manipulation of the viscera, surgical incision, immobilization in bed or long periods in supine position, use of mechanical ventilation, abdomi-nal distension and pain (Helene-Junior, Saad-Junior, & Stirbulov, 2006). The most important factor for the development of respiratory com-plications in the postoperative period is the location of the surgery. The rate of complications when the surgical incision is in the chest or upper abdomen varies between 10 and 40%. Postoperative respiratory complications increase hospital stay, raises the costs and contributes significantly to mortality, especially in upper laparotomies and thora-cotomies (Apostolakis, Filos, Koletsis, & Dougenis, 2010).
Nurses can minimize the occurrence or severity of the pulmonary complications through an adequate surveillance of the patients during the postoperative period, and by the early identification of specific nurs-ing diagnoses. The NANDA International (NANDA-I) manages the devel-opment and validation of nursing diagnoses within a taxonomic structure of phenomena for which nurses are responsible. To recognize such nursing diagnoses, the nurses must identify signs and symptoms presented by the patient (Herdman & Kamitsuru, 2014).
The nursing process is the most important nursing tool to provide a better assistance to the patients. The identification of nursing diagnoses is a component of this process that aims to establish a link between the human responses and the nursing desired goals. This step represents a guide for planning and implementing the nursing care (Carpenito-Moyet, 2007).
The identification of a nursing diagnosis begins with the assessment of clinical indicators or defining characteristics (Mendes, Cavalcante, Lopes, & Lima, 2012). If a nurse is able to identify the key defining char-acteristics of a nursing diagnosis, her/his assumptions will be generated with a greater security, which is important to the healthcare quality. However, it is important to mention that the nursing diagnostic process is complex.
The complexity of the nursing diagnostic process can be attributed to various reasons, including the fact that some nursing phenomena
–
⁎ Corresponding author. Tel.: +55 99 35296062.
E-mail addresses:livia_mp@hotmail.com(L.M. Pascoal),jessik_kline@hotmail.com
(J.P.A. de Carvalho),vanessaemille@gmail.com(V.E.C. de Sousa),
franciscodimitre@hotmail.com(F.D.R.P. Santos),pedrolima_fisio@hotmail.com
(P.M. Lima Neto),sflnunes@hotmail.com(S.F.L. Nunes).
http://dx.doi.org/10.1016/j.apnr.2015.11.015
0897-1897/© 2015 Elsevier Inc. All rights reserved.
Contents lists available atScienceDirect
Applied Nursing Research
share the same defining characteristics, i.e. the signs and symptoms are not specific to each nursing diagnosis. In addition, the patient may ex-press different diagnoses simultaneously, making difficult to distinguish the defining characteristics that best represent each problem, which in-creases the degree of uncertainty for the nurse (Andrade, Moura, Chaves, Silva, & Lopes, 2014).
In this context, there is the nursing diagnosis ineffective airway clearance (00031—IAC) that according to the NANDA-I is defined as the“inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway”(Herdman & Kamitsuru, 2014). This nursing diagnosis has been a focus of investigations in diverse popula-tions, being approached isolated or in association with other nursing di-agnoses. For instance, in the studies ofRocha, Maia, and Silva (2006)and Sousa et al. (2013), both conducted with patients in the postoperative period of cardiac surgeries, the IAC diagnosis was presented in 63.6 and 29.6% of the sample, respectively. In surveys conducted in the pedi-atric population, the literature indicates that this diagnosis was present-ed in 89.3% of children with asthma (Carvalho et al., 2015), in 31% of children with congenital heart disease (Silva, Lopes, Araujo, Ciol, & Carvalho, 2009), and in 37.7% of children with acute respiratory infec-tion (Andrade, Chaves, Silva, Beltrão, & Lopes, 2012).
Although patients submitted to thoracic and abdominal surgeries are susceptible to respiratory nursing diagnoses, studies about the occurrence of IAC in this contexts are still scarce.
The predictive capacity of the defining characteristics of a nursing diagnosis is related to the nurse's degree of certainty during the diag-nostic process. Given the above, this study aims to analyze the accuracy of the defining characteristics of IAC in patients after thoracic and upper abdominal surgery.
2. Methods
2.1. Design and sample
A cross-sectional study was developed with 192 patients on a surgi-cal clinic. The patients underwent thoracic and upper abdominal surger-ies. A research ethics committee approved the study. Prior to data collection, all the patients signed an informed consent document. The inclusion criteria were patients above 18 and below 80 years of age un-dergoing thoracic or upper abdominal surgery. The exclusion criteria were clinical instability and altered levels of consciousness. Conve-nience sampling was used during the patient's recruitment. The sample size was calculated assuming a confidence level of 95%, a minimum sen-sitivity of 80%, an extension of confidence intervals of 11%, and a preva-lence of IAC at 29.6% according to a previous study (Sousa et al., 2013).
2.2. Data collection
The data collection instrument was elaborated with the purpose of addressing the information regarding the defining characteristics of the nursing diagnosis IAC and relevant literature on pulmonary assess-ment (Jarvis, Browne, MacDonald-Jenkins, Luctkar-Flude, & Camera, 2013). This instrument also included patient related information such as sex, date of admission and data about the surgical procedure. Opera-tional definitions were created for each one of the defining characteris-tics studied. The data were collected by students from a research group after participating on a training about respiratory assessments. The training consisted of a 16-hour course about respiratory propaedeutic methods. A standardized guide with information about how to use the data collection equipment and how tofill the data collection instrument was included in the training.
2.3. Data analysis
The statistical analyses were performed in SPSS for Windows (release 19.0) and the R software (R Core Team, Vienna, Austria). For
the accuracy analysis, measures of sensitivity and specificity were ob-tained for each one of the defining characteristics of IAC presented on the NANDA-I taxonomy using the latent class method.
The latent class method is based on the assumption that an unob-served or latent variable (nursing diagnosis) determines the associa-tions between other measured variables (defining characteristics). This method is recommended when there is no perfect gold standard, as occurs with nursing inferences about human responses. A model of two latent classes of random effects was applied to calculate the speci-ficity and sensitivity values of the defining characteristics with the refer-ence confidence interval of 95% (Qu, Tan, & Kutner, 1996).
Thefirst latent class model included the set of all defining character-istics and it was called null model. From this model, we excluded the de-fining characteristics that did not present statistical significance (specificity/sensitivity confidence intervals below 50% and/or including this value). Then, a new model was created including all the defining characteristics at the significance level of 0.05.
Definitions of the accuracy measures calculated in this study are presented as follows. Sensitivity is the probability of a defining charac-teristic being present in patients with the investigated nursing diagno-sis. Specificity represents the probability of absence of a defining characteristic in patients without the investigated nursing diagnosis (Lopes, Silva, & Araujo, 2012).
3. Results
There were a total of 192 assessments made during the study period. Of these, 111 (57.8%) patients were male, 88 (45.8%) married, and the mean age was 40.5 years (±17.8 years). The majority of the patients had low educational level, as 97 (50.5%) had only completed the prima-ry education. Nearly 50% of patients reported a monthly income of less than 1,017 Brazilian Reais (R$), or roughly $442 US as shown inTable 1.
The patients were assessed on an average of 1.9 days after surgery (±2.38 days) and the main clinical conditions were cholelithiasis (29.8%), gunshot wounds (15.8%), stab wounds (14.6%), appendicitis (8.8%), and acute abdomen (7.0%). The most prevalent surgeries were exploratory laparotomy (44.1%), cholecystectomy (30.3%), and thora-cotomy (13.8%). The most frequent anesthesia techniques were spinal anesthesia (54.0%) and general anesthesia (42.2%).
Table 2shows the distribution of defining characteristics in the sam-ple. The most frequent defining characteristics were absent cough (65.4%), diminished breath sounds (63.2%), changes in respiratory rate (50.8%), and changes in respiratory rhythm (42.4%).
Table 3shows the results obtained by the statistical analysis of the la-tent class models. According to the sensitivity and specificity values, the most accurate defining characteristics were changes in respiratory rate and changes in respiratory rhythm. However, other defining characteris-tics also had high specificity, such as restlessness (98.03%), cyanosis (97.83%), excessive sputum (100%), wide-eyed (96.37%), orthopnea (85.40%), adventitious breathing sounds (86.28 %), ineffective cough (95.17%), and difficulty vocalizing (86.50%). Ineffective airway clearance was present at 46.73% of the sample.
4. Discussion
Respiratory complications are frequent on the postoperative period regardless of the type of surgery. However, the incidence of this kind of complication is greater on thoracic and upper abdominal surgery patients (Apostolakis et al., 2010). Such complications may contribute to the occurrence of signs and symptoms that are defining characteristic of respiratory nursing diagnoses, such as IAC. This fact alone demon-strates the importance in the correct usage of nursing process.
capacity may contribute to an accurate identification of nursing diagno-ses, leading to more effective plans of care. However, there is a lack of research that addresses the nursing diagnosis IAC in thoracic and upper abdominal surgical patients.
The most prevalent surgeries in the sample were exploratory laparot-omy, cholecystectlaparot-omy, and thoracotomy. Thisfinding corroborates with a study developed bySilva, Lopes, Duarte, and Medeiros (2010)whose sur-gical procedures more prevalent were cholecystectomy (47.36%) and ex-ploratory laparotomy (36.84%). The literature points out that exex-ploratory laparotomy can result in significant changes in the pulmonary volumes and capacities, in the respiratory mechanics on oxygenation, and in the pulmonary defense mechanisms, compromising the normal respiratory function and leading to postoperative complications (Siddiqui, Yasmeen, Taranikanti, & Panda, 2014). Another point to be highlighted is that breathing movements are decreased after the thoracotomy, due to the perforation of the intercostal muscles and the parietal pleura. As a result, patients submitted to these procedures usually have discomfort and al-tered respiratory function (Canet & Gallart, 2014).
Another aspect to be mentioned in this study is the type of anesthe-sia. Anesthetic drugs impair the lung function by reducing the functional capacity, misbalancing the ventilation/perfusion ratio, raising the rear portions of the diaphragm and affecting the mucociliary clearance mechanism (Sasaki, Meyer, & Eikermann, 2013). Besides that, respirato-ry complications on the postoperative period of thoracic and upper ab-dominal surgeries are linked to anesthesia, the surgery itself and the patient's clinical condition (Inoue et al., 2013).
The prevalence of IAC at 46.73% corroborates the studies developed byRocha et al. (2006)andSousa et al. (2013), both performed with pa-tients in the postoperative period of cardiac surgery, whose prevalence were 63.6 and 33.7%, respectively. The high prevalence of IAC in the study ofRocha et al. (2006), can be explained by the advanced age of the patients (between 67 and 77 years), and by the surgical procedures, which usually increase the hemodynamic impairment. Aging causes clinical and physiological changes including reduction of airway protec-tive reflexes. Thus, aged patients are most likely to have impairments on the ability of cleaning secretions from the airway (Urman & Kaye, 2012). Several respiratory postoperative changes can be attributed to thoracic and upper abdominal surgeries, including airway obstruction, hypersecre-tion, superficial ventilation due to pain, chest and lung restriction, muscle dysfunction, and abnormal breathing pattern (Inoue et al., 2013). These changes may trigger the occurrence of the defining characteristics of IAC and justify the high incidence of this diagnosis in this population.
Other studies present different incidences for IAC. Studies developed byPascoal et al. (2012)andAndrade et al. (2014)with children with acute respiratory infection showed 91.9 and 37.7% of incidence for IAC, re-spectively. In turn, the study conducted bySilveira, Lima, and Lopes (2008)shows a prevalence of 66.7% in children with asthma, andFontes and Cruz (2007)found a prevalence of 43.3% in medical–surgical patients. According toPascoal et al. (2012), the variability found in the literature can be linked to several factors such as patient's age/peculiarities, sample size, pathophysiology of the patient's clinical conditions, and the method-ology applied in the studies.
Table 1
Demographics and characteristics of the study patients.
Variables n %
Gender
Female 81 42.2
Male 111 57.8
Educational level
Illiterate 32 16.7
Primary 97 50.5
Secondary 58 30.2
Tertiary 5 2.6
Marital status
Single 71 37.0
Married 88 45.8
Divorced 8 4.2
Widowed 13 6.8
Cohabiting 12 6.3
Total 192 100
n Mean Standard deviation P25 P50 P75
Age 192 40.55 17.76 25 37 54
Incomea 168 1446.76 1285.31 724 1017 1448
aNot all patients provided information about their income.
Table 2
Defining characteristics identified on the study patients.
Variables Present % Absent % Totala
Defining characteristics
Restlessness 2 1.1 188 98.9 190 Cyanosis 10 5.3 180 94.7 190 Dyspnea 55 28.6 137 71.4 192 Excessive sputum 05 2.6 186 97.4 191 Changes in respiratory rate 97 50.8 94 49.2 191 Changes in respiratory rhythm 81 42.4 110 57.6 191 Wide-eyed 12 6.3 180 93.8 192 Orthopnea 30 15.6 162 84.4 192 Adventitious breath sounds 36 18.3 150 80.6 186 Diminished breath sounds 120 63.2 70 36.8 190 Absent cough 125 65.4 66 34.6 191 Ineffective cough 12 6.3 176 93.7 188 Difficulty vocalizing 40 20.9 151 79.1 191
aNot all defining characteristics were assessed on the total sample.
Table 3
Sensibility (Se), specificity (Sp), and 95% confidence intervals (95%CI) for the defining characteristics of ineffective airway clearance.
Defining characteristics Se (95%CI) Sp (95%CI)
Restlessness 0.00 (00.00–0.00) 98.03 (95.17–100.00) Cyanosis 8.8 (3.23–15.26) 97.83 (94.01–100.00) Dyspnea 37.09 (26.68–47.02) 78.76 (69.42–86.91) Excessive sputum 5.64 (1.11–10.95) 100.00 (99.20–100.00) Changes in respiratory rate 97.53 (93.78–100.00) 90.02 (79.82–100.00) Changes in respiratory rhythm 91.00 (78.74–100.00) 100.00 (95.92–100.00) Wide-eyed 9.24 (3.41–16.10) 96.37 (92.34–100.00) Orthopnea 16.79 (9.27–24.97) 85.40 (77.90–92.20) Adventitious breath sounds 25.57 (16.33- 35.26) 86.28 (78.58–93.07) Diminished breath sounds 65.73 (54.65–76.28) 39.09 (29.34–49.31) Absent cough 62.25 (52.34–72.90) 31.78 (22.28–41.11) Ineffective cough 7.96 (2.75–14.38) 95.17 (90.32–99.04) Difficulty vocalizing 29.34 (19.05–34.44) 86.50 (76.67–93.40) Nursing diagnosis
Diagnostic accuracy studies contribute to evidence-based practice, because they allow the estimation of the probability of a nursing diag-nosis occurrence in specific populations. In this study, the defining char-acteristics that showed better predictive capacity for IAC were changes in respiratory rate and changes in respiratory rhythm.
Similarly,Sousa et al. (2013)found a high specificity value for chang-es in rchang-espiratory rate on a study with adult postoperative cardiac patients (in the absence of this defining characteristic, the likelihood of IAC to be absent was 98.59%). Other studies have also reported a high prevalence of this defining characteristic on postoperative surgical patients (Fontes & Cruz, 2007; Rocha et al., 2006).
Surgical procedures generally cause some degree of respiratory dys-function, especially in patients that undergo thoracic and upper abdom-inal surgeries. Changes of the pulmonary function in the postoperative period are linked to the manipulation of the thoracic and abdominal cavity, the intense pain and the inadequate pulmonary insufflation resulting from the alterations on the breathing pattern, which are com-mon on postoperative patients (Siddiqui et al., 2014; Silva et al., 2010). Other changes caused by this type of surgery are the reduction of lung volumes and lung capacity, the changes on the ventilation/perfu-sion ratio, the decreasing of the pulmonary expansibility, the decreasing of the diaphragmatic function, and the ineffectiveness of the defense mechanisms such as cough (Trevisan, Soares, & Rondinel, 2010). These changes are maximum at thefirst 48 hours after surgery (Silva et al., 2010). These factors compromise the normal respiratory function, trig-gering changes in the respiratory rate and rhythm, which are defining characteristics of IAC.
The defining characteristic restlessness had a high specificity value (98.03%), which corroborates with thefindings ofSousa et al. (2013), which found 98.6% specificity value for this defining characteristic. Rest-lessness can occur due to respiratory imbalances, usually respiratory failure and hypoxia. These disturbances increase the respiratory work and raise the demand for energy, which may be reflected by excessive sleepiness, anxiety, restlessness and irritability (Jarvis et al., 2013). On the other hand, it is important to highlight that the unrest may also be related to postoperative sensation of pain. However, it should be noted that in the clinical practice, this indicator is not usually associated with changes in the respiratory function.
Excessive sputum also had high specificity value (100%). Postopera-tive patients may present this response due to the action of anesthetic drugs and narcotic medications, which decreases the mucociliary clear-ing mechanism, impairs the lung function, facilitates the retainclear-ing of se-cretions and causes hypoventilation, which consequently increases the respiratory effort (Inoue et al., 2013).
Ineffective cough had a high specificity value on this study (95.7%). Similarly,Sousa et al. (2013)found a specificity value of 97.1% for the same defining characteristic. If the coughing mechanism is not effective, the airway remains blocked which can explain the direct relationship be-tween ineffective cough and IAC (Fontes & Cruz, 2007; Rocha et al., 2006). Another importantfinding was the high prevalence of absent cough (65.1%). This can be explained by the fact that the cough reflex is com-promised on the postoperative period due to anesthesia, effect of seda-tives, pain and immobility (Sasaki et al., 2013). However, it is believed that the absence of cough is also related with the defining characteristic excessive sputum.
As explained before, coughing is a reflex that occurs on the presence of impairment of airway by accumulation of secretions. However, patients in this sample did not show clinical signs of significant amount of mucus in the airways and, thus, were not expected to produce a cough. Further in-vestigations would be necessary to explain thisfinding.
Adventitious breath sounds had a high specificity value, corroborat-ing the results found bySousa et al. (2013)that found a specificity value of 80% for this defining characteristic. The positioning of the patient dur-ing the postoperative period can be linked with the occurrence of this clinical indicator, as well as the presence of devices, which favors the retaining of secretions in the airways (Hinkle & Cheever, 2013).
Besides that, the reduction of the lung volume leads to accumulation of secretions in the airways, predisposing the occurrence of atelectasis and pneumonia. The decrease in vital capacity also leads to atelectasis, once it can decrease the partial pressure of oxygen, promoting alveolar collapse (Sasaki et al., 2013). Such situations undermine the passage of air through the airway causing adventitious breath sounds. In this study, one of the clinical indicators that presented the highest prevalence was decreased breath sound, which corroborates thefindings ofSousa et al. (2013), which found a prevalence of 34.7% for this defining characteris-tic. A decreased respiratory activity can occur in post-surgical patients due to the surgical incisions in the upper abdomen, the rupture of the fibers of the respiratory muscles, pain and restraint, reducing the chest expandability (Siddiqui et al., 2014).
As cited earlier, postoperative patients may present retaining of respi-ratory secretions, which can lead to other respirespi-ratory alterations, as diffi -culty vocalizing. Although difficulty vocalizing had presented low prevalence in the sample, it had a good accuracy measure with 86.50% of specificity. We found no results from other studies to discuss thisfinding. Orthopnea had a high specificity value for identifying IAC (85.40%). Similarly,Sousa et al. (2013)found a high specificity value for this clin-ical indicator (76.81%). Patients in the postoperative period are likely to have respiratory dysfunction, which is intensified by the horizontal po-sition (Hinkle & Cheever, 2013).
We also found a high specificity value for the defining characteristic wide-eyed (96.37%). This clinical manifestation can be found in patients in respiratory distress (Kowalak & Munden, 2008). However, we found no studies pointing this defining characteristic as being important to the diagnostic conclusion regarding IAC.
The defining characteristic cyanosis had also a high specificity value (97.83%). It is known that the postoperative period triggers a series of complications related to the lung function that, if not reversed early, can leads to hypoxemia that is manifested by cyanosis (Sasaki et al., 2013; Siddiqui et al., 2014). However, further analysis would be neces-sary to ensure that this phenomenon happened in this study.
5. Conclusion
Thoracic and upper abdominal surgeries can trigger a set of clinical signs that indicate the presence of the nursing diagnosis IAC. For this reason, it is important to determine which clinical indicators better rep-resent the presence of this human response.
In this study we evaluated 192 patients and found a prevalence of IAC at 46.73%. The defining characteristics with better predictive capac-ity were changes in respiratory rate and changes in respiratory rhythm. However, other defining characteristics also had high specificity, such as restlessness, cyanosis, excessive sputum, wide-eyed, orthopnea, adven-titious breathing sounds, ineffective cough, and difficulty vocalizing.
These results show that differences in accuracy measures among the defining characteristics for IAC in postoperative patients exists. Therefore, we believe that a determination of the predictive ability of these defining characteristics increases the reliability of the diagnostic inference process and allows nurses to raise more accurate hypotheses during the patients' assessment. Thus, the results of this research can help nurses in clinical practice contributing to increase the quality of nursing care.
The lack of studies about the accuracy values of nursing diagnoses and its defining characteristics was a factor that limited the discussion of the presentedfindings. Therefore, we encourage further studies on this topic with postoperative patients and other populations with IAC to compare the predictive value of the studied defining characteristics in different populations.
Acknowledgment
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