Rev. Latino-Am.

Enfermagem Original Article

2017;25:e2959
DOI: 10.1590/1518-8345.2311.2959
www.eerp.usp.br/rlae

Respiratory status of adult patients in the postoperative

period of thoracic or upper abdominal surgeries1

Alana Gomes de Araujo Almeida2

Lívia Maia Pascoal3
Francisco Dimitre Rodrigo Pereira Santos4
Pedro Martins Lima Neto5
Simony Fabíola Lopes Nunes5
Vanessa Emille Carvalho de Sousa6

Objective: to evaluate the respiratory status of postoperative adult patients by assessing the
nursing outcome Respiratory Status. Method: descriptive, cross-sectional study developed
with 312 patients. Eighteen NOC indicators were assessed and rated using a Likert-scale
questionnaire and definitions. Descriptive and correlative analysis were conducted. Results: the
most compromised clinical indicators were coughing (65.5%), auscultated breath sounds (55%),
and respiratory rate (51.3%). Factors associated with worse NOC ratings in specific clinical
indicators were sex, age, pain, and general anesthesia. Conclusions: certain clinical indicators
of respiratory status were more compromised than others in postoperative patients. Patient and
context-related variables can affect the level of respiratory compromise.

Descriptors: Postanesthesia Nursing; Nursing Assessment; Adult Health; Outcome Assessment

(Health Care); Respiratory System; Postoperative Care.

Financial Support: Fundação de Amparo a Pesquisa do Maranhão - Fapema

1

2
RN
PhD, Adjunct Professor, Centro de Ciências Sociais, Saúde e Tecnologia, Universidade Federal do Maranhão, Imperatriz, MA, Brazil
3

MSc, Assistent Professor, Universidade do Sul do Maranhão, Imperatriz, MA, Brazil

4

MSc, Assistent Professor, Centro de Ciências Sociais, Saúde e Tecnologia, Universidade Federal do Maranhão, Imperatriz, MA, Brazil
5

PhD, Visiting Professor, Instituto de Ciencias da Saúde, Universidade da Integração Internacional da Lusofonia Afro-brasileira, Redenção, CE,
6

Brazil,

How to cite this article

Almeida AGA, Pascoal LM, Santos FDRP, Lima Neto PM, Nunes SFL, Sousa VEC. Respiratory status of
adult patients in the postoperative period of thoracic or upper abdominal surgeries. Rev. Latino-Am.
Enfermagem. 2017;25:e2959. [Access ___ __ ____]; Available in: ___________________ . DOI: http://dx.doi.
org/10.1590/1518-8345.2311.2959. day month year URL
2 Rev. Latino-Am. Enfermagem 2017;25:e2959.

Introduction vital capacity, oxygen saturation, pulmonary function

tests, accessory muscle use, chest retraction, pursed
There is consensus that the quality of nursing care lip breathing, cyanosis, dyspnea at rest, dyspnea with
depends greatly on the quality of the nursing assessment, mild exertion, restlessness, somnolence, diaphoresis,
therefore an accurate nursing assessment is crucial to impaired cognition, accumulation of sputum, atelectasis,
ensure that the planning and implementation of nursing adventitious breath sounds, impaired expiration, gasping,
interventions can meet the patient’s needs . One way
(1-3)
agonal respirations, grunting, clubbing of fingers, nasal
of improving the quality of nursing care is implementing flaring, restlessness, fever, and coughing(5).
standardized nursing languages, including the Nursing Studies have been developed to test the applicability
Outcomes Classification (NOC). Outcomes are defined as of NOC outcomes, the validity of NOC indicators, and to
the results of performing a process; in this sense, a positive translate and adapt NOC outcomes to specific cultural
outcome is the achievement of the goal of the process(4). contexts. We found studies assessing NOC outcomes
The NOC contain clinical indicators that are used in Intensive Care Unit (ICU) patients(9), patients with
to evaluate and rate patients’ health status in relation cancer(10), stroke(11), diabetes(12), and congenital heart
to outcome achievement using five-point Likert-type diseases(13). However, no study including operational
scales, making this tool an invaluable resource for the definitions for the nursing outcome Respiratory Status
nursing assessment. The proper use of the NOC allows and its applicability to postoperative adult patients was
the assessment of the current status of the patient published to this date.
and facilitates the identification of changes based on Some advantages of using NOC are the decrease

differences in scores documented over time(5). in documentation time allowing more time available for

In 2015, the American Nurses Association patient care(14), improved patient satisfaction(15), reduced

(ANA) released a position statement supporting the variability in the nursing assessment(11), and improved

use of recognized nursing terminologies to facilitate quality of care by the establishment of parameters for

interoperability of the data collected by nurses. the clinical assessment(16). However, whenever NOC

However, many factors have hampered the use of outcomes are assessed without clear conceptual and

standardized nursing languages in practice such as lack operational definitions for clinical indicators, there is

of knowledge about the available nursing languages, lack uncertainty and subjectivity, which is an important gap in

of integration of standardized nursing languages to the nursing practice. Therefore, this study aimed to evaluate
the respiratory status of postoperative adult patients by
nursing curriculum, lack of professional training on the
assessing the nursing outcome Respiratory Status.
use of nursing languages, great demand for bureaucratic
and administrative services, work overload, and the
Method
existence of different terminologies that still lack clear
selection criteria or directions for use(6). In spite of these This was a descriptive cross-sectional study. The
difficulties, nurses need to understand the importance of study was performed between 2014 and 2015 in the
standardized nursing documentation and, if necessary, post-surgical unit of a large tertiary hospital located in
gain the knowledge and skills necessary to effectively the northeastern Brazil.
include nursing data in standardization efforts(7). The study involved 312 participants who were
Thoracic and upper abdominal surgical procedures hospitalized for surgical treatment of different conditions
often affect the pulmonary volume and capacity, or diseases. Participants were recruited and assessed
which leads to impaired respiratory function. Patients during the first 48 hours after surgery, based on the
submitted to those types of surgery are at risk of following inclusion criteria: age between 18 and 80
postoperative respiratory complications such as years, and thoracic or upper abdominal surgery. Patients
bronchospasm, atelectasis, infection, and respiratory who were using gastric-tube feeding, tracheostomy, or
failure(8). Approaches to improving quality of care should had serious cognitive impairment were excluded because
be aimed at preventing such complications and thus, their condition might limit their ability to be examined
improving outcomes in the surgical population. during the study.
The NOC includes the outcome Respiratory Status, The sample size was determined by using a formula
which is defined as “movement of air in and out of the for infinite populations (n=Zα2.P.(1-P)/E2) assuming
lungs and exchange of carbon dioxide and oxygen at the a confidence level (Zα) of 95%, standard error (E) of
alveolar level”. The clinical indicators for this outcome are: 5.6%, and a prevalence (P) of respiratory nursing
respiratory rate, respiratory rhythm, depth of inspiration, diagnoses at 46.7% according to a previous study(17).
auscultated breath sounds, airway patency, tidal Therefore, the minimum sample size was 305 patients,
volume, achievement of expected incentive spirometer, but 312 patients participated in the study.

www.eerp.usp.br/rlae
 Almeida AGA, Pascoal LM, Santos FDRP, Lima Neto PM, Nunes SFL, Sousa VEC. 3

Data collection was performed by a research team Results

composed by undergraduate nursing students led by
the main researcher. Before data collection, the team Of the 312 participants (mean age 38, SD 16,

participated in a training about the specific steps of the range 18–78), 67.9% are male, 46.8% never were

physical examination of the chest and lungs and took married or lived in a paired relationship, and 54% have

a written test that determined their ability to perform had primary or secondary education. Table 1 show the

the physical examination. Data collection was conducted clinical characteristics of the patients. Most patients

individually with each patient, after consent, at a single (56.5%) had never smoked. The most frequent surgery

time point during hospitalization. Each patient was performed was exploratory laparotomy (78.2%) and

interviewed in the hospital ward and received a guided 70.6% patients underwent local or regional anesthesia.
On examination, all patients had normal vital parameters.
physical examination based in an instrument specially
Findings from the assessment of the NOC outcome
developed for the study.
Respiratory Status are summarized on Table 2, from the
Interviews and physical examinations aimed to
most to the less compromised clinical indicator. Coughing,
collect data for the assessment of 18 NOC indicators
auscultated breath sounds, and respiratory rate were the
belonging to the Respiratory Status outcome. The
most compromised clinical indicators, as each of them
instrument also included demographic variables such as
were rated by the evaluators at some level of compromise
gender, age, marital status, and education, and clinical
(1 to 4) on more than 50% of the assessments.
information such as surgical procedure and indication
To test the correlations between impairment of
for surgery.
clinical indicators and patients’ personal and clinical
Following data collection, the researchers met to
characteristics, we studied the bivariate effect of
discuss and rate the level of compromising of each of
different variables on the NOC ratings (Tables 3 and 4).
the 18 clinical indicators by consensus, using the NOC
The table 3 data shows that older patients had worse
ratings. Conceptual and operational definitions that
NOC ratings to oxygen saturation than younger patients
were obtained and adapted from the literature(18-19)
(Mann-Whitney: mean rank 172 vs. 139; P = 0.001),
were used as a basis to rate each indicator into five
but younger patients had worse ratings to auscultated
levels: 1 representing the highest degree of severity
breath sounds than the older ones (mean rank 172 vs.
and 5 representing the lowest level of severity or
141; P = 0.002). Male patients had less chance of having
lack of compromise. Indicators were considered
compromised auscultated breath sounds (odd ratio: 0.55,
compromised when they were rated below or equal
95% CI: 0.34-0.89), depth of inspiration (odd ratio: 0.45,
to 4.
95% CI: 0.26-0.81), and adventitious breath sounds (odd
The raw data were stored in Microsoft Excel
ratio: 0.43, 95% CI: 0.20-0.94) compared to females.
format and statistical analyses were performed using As pointed out in table 4 patients with pain had
the Statistical Package for the Social Sciences (SPSS) more chances of having dyspnea with mild exertion (odd
version 21.0. For the descriptive analysis, absolute ratio: 3.40, 95% CI: 1.44-8.07) and altered auscultated
mean values and ranges of the variables of interested breath sounds (odd ratio: 1.65, 95% CI: 1.05-2.61)
are reported. To check the normality assumption, the compared to those without pain. Patients without
Kolmogorov–Smirnov test was applied. pain also had less chances of having compromised
Odds Ratio with confidence intervals, Qui-square, respiratory rhythm (odd ratio: 0.47, 95% CI: 0.24-
and Fisher tests were applied in the analysis of 0.92). Surprisingly, patients with pain had less chances
associations between the clinical indicators and gender, of having cyanosis (odd ratio: 0.56, 95% CI: 0.51-0.62).
presence of pain, and type of anesthesia. The Mann General anesthesia was related with an increased
Whitney test was used to compare groups on age and chance of having compromised somnolence (odd ratio:
presence of compromised clinical indicators. The tests 5.91, 95% CI: 1.77-19.77), chest retraction (odd ratio:
were applied at significance level equal to 0.05. 4.43, 95% CI: 2.13-9.22), dyspnea with mild exertion
The study protocol was approved by the Ethics (odd ratio: 3.64, 95% CI: 1.71-7.73), diaphoresis (odd
Committee of the Federal University of Maranhão, ratio: 3.51, 95% CI: 1.08-11.41), and accessory muscle
according to Protocol no. 629.315. Informed written use (odd ratio: 1.81, 95% CI: 1.08-3.02). On the other
consent was obtained from all patients before hand, patients submitted to general anesthesia had
enrollment in compliance with the Resolution n . o less chance of having cyanosis (odd ratio: 0.28, 95%
466/12 about the Guidelines and Regulatory Standards CI: 0.24-0.34). Patients who received local/regional
for research involving human beings of the National anesthesia also had less chances of having compromised
Health Council. respiratory rate (odd ratio: 0.55, 95% CI: 0.33-0.93).

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4 Rev. Latino-Am. Enfermagem 2017;25:e2959.

Table 1 – Distribution of patients according to smoking, type of surgery, type of anesthesia, complaints, and vital
parameters. Imperatriz, MA, Brazil, 2014-2015
Variables N* %

Smoking

Never smoker 175 56.5

Passive smoker 18 5.8

Quitter smoker 42 13.5

Current smoker 75 24.2

Type of Surgery

Exploratory laparotomy 244 78.2

Thoracotomy 66 21.1

Cholecystectomy 46 14.7

Appendectomy 32 10.3

Other 50 16.9

Type of anesthesia

Local or regional anesthesia 204 70.6

General anesthesia 85 29.4

Complaints

Pain 177 57

Cough 105 33.6

Vital parameters N† Min Max Mean SD

Respiratory rate 312 11 50 21.29 4.45

Heart rate 312 42 132 80.40 16.32

SpO2 309 61 99 93.91 3.97

*N - Some patients were submitted to more than 1 type of surgery, †N - Variations in N ocurred because not all questions were answered by all subjects.

Table 2 – Distribution of Nursing Outcomes Classification (NOC) indicators of Respiratory Status by level of severity.
Imperatriz, MA, Brazil, 2014-2015
Severe Substantial Moderate Mild None
NOC Indicators*
n % n % n % n % n %

Coughing 7 6.4 8 7.3 8 7.3 49 44.5 38 34.5

Auscultated breath sounds 34 10.9 50 16.1 33 10.6 54 17.4 140 45.0

Respiratory rate 8 2.6 6 1.9 30 9.6 116 37.2 152 48.7

Oxygen saturation 3 1.0 5 1.6 26 8.4 110 35.6 165 53.4

Accessory muscle use 8 2.6 9 2.9 36 11.6 84 27.0 174 55.9

Depth of inspiration 5 1.6 -- -- 8 2.6 78 25.2 218 70.6

Adventitious breath sounds 4 1.3 4 1.3 12 3.9 28 9.0 262 84.5

Respiratory rhythm 2 0.6 6 1.9 5 1.6 28 9.1 268 86.7

Chest retraction -- -- 5 1.6 10 3.2 23 7.4 273 87.8

Dyspnea with mild exertion 17 5.4 -- -- 17 5.4 1 0.3 277 88.8

Accumulation of sputum 4 1.3 4 1.3 7 2.3 13 4.2 282 91.0

Dyspnea at rest 5 1.6 4 1.3 2 0.6 4 1.0 298 95.5

Diaphoresis -- -- 4 1.3 6 1.9 3 1 296 95.8

Somnolence 2 0.6 5 1.6 2 0.6 4 1.9 293 95.1

Pursed lips breathing 2 0.6 -- -- -- -- 5 1.6 303 97.7

Cyanosis -- -- 5 1.6 -- -- 1 0.3 304 98.1

Restlessness -- -- -- -- -- -- 3 1.0 307 99.0

Nasal flaring -- -- -- -- 1 0.3 2 0.6 307 99.0

*NOC - Nursing Outcomes Classification.

www.eerp.usp.br/rlae
 Almeida AGA, Pascoal LM, Santos FDRP, Lima Neto PM, Nunes SFL, Sousa VEC. 5

Table 3 – Correlations between Nursing Outcomes Classification (NOC). indicators and personal characteristics of the
patients. Imperatriz, MA, Brazil, 2014-2015
Variables Present Absent Statistics
Age Mean ranks
Auscultated breath sounds 140.95 171.96 p=0.002*
Oxygen saturation 171.50 138.74 p=0.001*
Gender Male Female
Auscultated breath sounds p=0.015†
Compromised 126 45 OR=0.55
Non-compromised 85 55 IC95%=0.341-0.892
Depth of inspiration p=0.007†
Compromised 72 19 OR=0.45
Non-compromised 138 80 IC95%=0.256-0.810
Adventitious breath sounds p=0.029†
Compromised 39 9 OR=0.43
Non-compromised 171 91 IC95%=0.201-0.935
*P-value based on the exact Mann-Whitney test. †P-value based on the Pearson’s chi-square test.

Table 4 – Correlations between Nursing Outcomes Classification (NOC). indicators and clinical characteristics of the
patients. Imperatriz, MA, Brazil, 2014-2015
Variables Present Absent Statistics
Pain
Dyspnea with mild exertion p=0.003*
Compromised 28 7 OR=3.40
Non-compromised 149 127 CI95%=1.441-8.068
Auscultated breath sounds p=0.029*
Compromised 106 64 OR=1.65
Non-compromised 70 70 CI95%=1.052-2.608
Cyanosis p=0.039†
Compromised 6 0 OR=0.56
Non-compromised 170 133 CI95%=0.508-0.620
Respiratory rhythm p=0.026*
Compromised 17 24 OR=0.47
Non-compromised 160 107 CI95%=0.243-0.924
Type of Anesthesia General Local/Regional
Somnolence p=0.003*
Compromised 9 4 OR=5.91
Non-compromised 75 197 CI95%=1.767-19.768
Retracción torácica p=0.000*
Compromised 21 14 OR=4.43
Non-compromised 64 189 CI95%=2.128-9.222
Dyspnea with mild exertion p=0.000*
Compromised 18 14 OR=3.64
Non-compromised 190 67 CI95%=1.719-7.733
Diaphoresis p=0.047†
Compromised 7 5 OR=3.51
Non-compromised 78 196 CI95%=1.084-11.417
Accessory muscle use p=0.022*
Compromised 46 80 OR=1.81
Non-compromised 39 123 CI95%=1.088-3.023
Cyanosis p=0.002†
Compromised 5 0 OR=0.28
Non-compromised 202 80 CI95%=0.236-0.341
Respiratory rate p=0.024*
Compromised 33 110 OR=0.55
Non-compromised 51 94 CI95%=0.330-0.927
*P-value based on the Pearson’s chi-square test. †P-value based on the Fisher’s exact test.

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6 Rev. Latino-Am. Enfermagem 2017;25:e2959.

Discussion than men, even when corrected for age and standing
height(25). Consequently, women are more likely to
This study assessed 312 adult patients in the experience greater mechanical limits to expiratory
postoperative period, aiming to verify the level of flow compared with men, creating a smaller maximal
compromise of 18 clinical indicators of the NOC outcome flow(26), which can possibly explain our results.
Respiratory Status. Coughing, auscultated breath Pain was also significantly related with respiratory
sounds, and respiratory rate were the most compromised compromise. Post-surgical pain is one of the most
clinical indicators. common symptoms on the postoperative period
The postoperative period of large surgeries on (experienced by 57% of our study), and can be an
the thoracic and upper abdominal areas is usually important determinant for the patients’ recovery. Pain
accompanied by impairments on the pulmonary is an acute nociceptive response caused by thermal,
mechanics. During normal respiration, the diaphragm mechanical, or chemical injury, which activate free nerve
produces a negative pressure inside the thorax that endings. In response to postoperative pain, patients
pulls air into the lungs. Surgical incision affects the tend to alter their respiratory pattern resulting in
integrity of the respiratory muscles and interfere in reduced inspiratory depth and compromised respiratory
local nerve impulses that are involved in the mechanics function(27). We have no explanation to the finding that
of respiration (20)
. Large surgeries are also associated pain acted as a protection factor for the occurrence
with pain, respiratory muscle dysfunction, and reduced of cyanosis. Maybe the presence of pain made nurses
lung airflow. All these changes trigger an increase or more attentive to these patients’ needs, but additional
decrease in ventilation and alter the frequency and observations are needed.
depth of respiration because of the stress caused by the General anesthesia was related with compromise
surgery(21). These factors combined with the anesthesia in several clinical indicators, while local/regional
effects explain the presence of the responses that we anesthesia was a protection-factor. One of the causes
detected in the study. of respiratory complications is the residual effect of
The bivariate analysis showed that age was anesthetic drugs on the body. Opioid agents used in
significantly related with compromised oxygen general anesthesia produce a shift to the right of the
saturation (in favor of younger patients) and carbon dioxide curve, while inhalational agents alter
compromised auscultated breath sounds (in favor the pulmonary vasoconstriction, leading to respiratory
of older patients). Aging is a well-known risk factor depression and impairment of the pulmonary function(28).
for postoperative pulmonary complications (22)
. Aged In addition, general anesthesia reduces lung volume
patients are more prone to develop desaturation than and capacity, reduces chest and lung compliance,
younger patients because of their reduced physiologic and affects the diaphragm movement. On the other
reserve. Besides that, all general anesthetics produce hand, local and regional anesthesia do not affect the
cardiovascular depression that can be augmented in respiratory function, hence, patients who receive local
the aged patient(23). anesthesia generally do not have serious postoperative
Controversially, the younger patients were complications(29). We have no explanation to the finding
more compromised than the older ones in relation to that general anesthesia acted as a protection factor for
auscultated breath sounds. A possible explanation to the occurrence of cyanosis, but the literature shows
this finding is the fact that most of these patients were that postoperative cyanosis is usually more related to
under surgical treatment following violent injuries, such a patient’s disease or baseline condition than type of
as perforations caused by gunshot or knife wound. anesthesia(30).
Penetrating chest trauma opens the pleural space to the Some limitations of this study must be considered.
atmosphere leading to pulmonary complications such Since data was collected by different people, differences
as collapsed lung and pneumothorax, and the effects in the clinical assessment of respiratory changes may
of these complications can persist on the postoperative have occurred despite training. In addition, the fact
period .
(24)
that inclusion was restricted to patients on the first 48
Female patients were more prone than male hours after surgery may be interpreted as a limitation
patients to present compromise of three clinical since some patients could not answer some questions
indicators. The literature shows that there are because of their altered health status, and their relatives
differences by gender on the pulmonary function had to provide some information. Despite that, the study
of adults. Women generally have reduced airway objectives were achieved and the findings can be useful
diameter, lower resting lung diffusing capacity, smaller to promote nursing awareness of common respiratory
lung volumes, and lower maximal expiratory flow rates alterations in postoperative patients.

www.eerp.usp.br/rlae
 Almeida AGA, Pascoal LM, Santos FDRP, Lima Neto PM, Nunes SFL, Sousa VEC. 7

Conclusion ventilation in intensive care. Rev Gaúcha Enferm.

2013;34(4):137-45. doi: http://dx.doi.org/10.1590/
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postoperative patients, and that age, gender, pain, and Lucena AD. Applicability of the Nursing Outcomes
general anesthesia can affect the chance of having a more Classification (NOC) to the evaluation of cancer patients
severe level of compromise. The systematic approach with acute or chronic pain in palliative care. Appl Nurs
used for evaluating the respiratory status of the patients Res. 2016;29:12-8. doi: http://dx.doi.org/10.1016/j.
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and assistance. AG, Cavalcante TF, Lopes MV. Construction and
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Received: Jun 6th 2017
Accepted: Aug 30th 2017

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