Possibly evidenced by
Changes in rate and depth of respirations
Dyspnea and increased work of breathing, use of accessory muscles
Reduced VC and total lung volume
Tachypnea and bradypnea or cessation of respirations when off the ventilator
Cyanosis
Decreased PO2 and SaO2, increased PCO2
Increased restlessness, apprehension, and metabolic rate
Desired Outcomes/Evaluation Criteria—Client Will
Respiratory Status: Ventilation
Reestablish and maintain effective respiratory pattern via ventilator with absence of retractions and use of accessory muscles, cyanosis, or other signs of hypoxia; ABGs and oxygen saturation within acceptable range.
Participate in efforts to wean (as appropriate) within individual ability.
Caregiver Will
Demonstrate behaviors necessary to maintain client’s respiratory function.
Nursing care plan intervention with rationale:
1. Investigate etiology of respiratory failure.
Rationale: Understanding the underlying cause of client’s particular ventilatory problem is essential to the care of client, for example, decisions about future capabilities and ventilation needs and most appropriate type of ventilatory support.
2. Observe overall breathing pattern. Note respiratory rate, distinguishing between spontaneous respirations and ventilator breaths.
Rationale: Client on a ventilator can experience hyperventilation, hypoventilation, or dyspnea and “air hunger” and attempt to correct deficiency by overbreathing.
3. Auscultate chest periodically, noting presence or absence and equality of breath sounds, adventitious breath sounds, and symmetry of chest movement.
Rationale: Provides information regarding airflow through the tracheobronchial tree and the presence or absence of fluid, mucous obstruction. Note: Frequent crackles or rhonchi
that do not clear with coughing or suctioning may indicate developing complications, such as atelectasis, pneumonia, acute bronchospasm, and pulmonary edema. Changes in chest symmetry may indicate improper placement of the ET tube or development of barotrauma.
4. Count client’s respirations for 1 full minute and compare with desired respirations and ventilator set rate.
Rationale: Respirations vary depending on problem requiring ventilatory assistance; for example, client may be totally ventilator dependent or be able to take breath(s) on own between ventilatordelivered breaths. Rapid client respirations can produce respiratory alkalosis and prevent desired volume from being delivered by ventilator. Slow client respirations and hypoventilation increases PaCO2 levels and may cause acidosis.
5. Verify that client’s respirations are in phase with the ventilator.
Rationale: Adjustments may be required in flow, tidal volume, respiratory rate, and dead space of the ventilator, or client may need sedation to synchronize respirations and reduce work of
breathing and energy expenditure.
6. Position client by elevating head of bed or chair if possible; place in prone position, as indicated.
Rationale: Elevating the client’s head and helping client get out of bed while still on the ventilator is both physically—helps decrease risk of aspiration—and psychologically beneficial. Note: Use of prone position is thought to improve oxygenation in client with severe hypoxic respiratory failure. However, it is not widely used due to the difficulties associated with placing and providing care to the intubated client in prone position as well as lack of studies showing its benefit in reducing mortality or duration of ventilation (Sud et al, 2008).
7. Inflate tracheal or ET tube cuff properly, using minimal leak and occlusive technique. Check cuff inflation every 4 to 8 hours and whenever cuff is deflated and reinflated.
Rationale: The cuff must be properly inflated to ensure adequate ventilation and delivery of desired tidal volume and to decrease risk of aspiration. Note: In long-term clients, the cuff may
be deflated most of the time or a noncuffed tracheostomy tube used if the client’s airway is protected.
8. Check tubing for obstruction, such as kinking or accumulation of water. Drain tubing as indicated, avoiding draining toward client or back into the reservoir.
Rationale: Kinks in tubing prevent adequate volume delivery and increase airway pressure. Condensation in tubing prevents proper gas distribution and predisposes to bacterial growth.
9. Check ventilator alarms for proper functioning. Do not turn off alarms, even for suctioning. Remove from ventilator and ventilate manually if source of ventilator alarm cannot be quickly identified and rectified. Ascertain that alarms can be heard in the nurses’ station.
Rationale: Ventilators have a series of visual and audible alarms, such as oxygen, low volume or apnea, high pressure, and inspiratory/ expiratory (I:E) ratio. Turning off or failure to reset
alarms places client at risk for unobserved ventilator failure or respiratory distress or arrest.
10. Keep resuscitation bag at bedside and ventilate manually whenever indicated.
Rationale: Provides or restores adequate ventilation when client or equipment problems require client to be temporarily removed from the ventilator.
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