risk for dysfunctional Ventilatory Weaning Response | Nursing Care Plan for Ventilatory Assistance

Nursing diagnosis: risk for dysfunctional Ventilatory Weaning Response

Risk factors may include

Sleep disturbance

Limited or insufficient energy stores

Pain or discomfort

Adverse environment, such as inadequate monitoring or support

Client-perceived inability to wean; decreased motivation

History of extended weaning

Possibly evidenced by

(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will

Respiratory Status: Ventilation

Actively participate in the weaning process.

Reestablish independent respiration with ABGs within acceptable range and free of signs of respiratory failure.

Demonstrate increased tolerance for activity and participate in self-care within level of ability.

Nursing intervention with rationale:

1. Assess physical factors involved in weaning as follows: Stable heart rate/rhythm, blood pressure (BP), and clear breath sounds.

Rationale: The heart has to work harder to meet increased energy needs associated with weaning. Physician may defer weaning if tachycardia, pulmonary crackles, or hypertension are present.

2. Explain weaning techniques, for example, spontaneous breathing trial (SBT), T-piece, pressure support ventilation (PSV), and spontaneous intermittent maximal ventilation (SIMV). Discuss individual plan and expectations.

Rationale: Assists client to prepare for weaning process, helps limit fear of unknown, promotes cooperation, and enhances likelihood of a successful outcome. Note: Current guidelines

recommend SBT as the preferred method of weaning as it withdraws ventilatory support while oxygenation is continued. The simplest form of SBT is the T-piece trial. In PSV weaning, all breaths are spontaneous and combined with enough pressure support to ensure that each breath is a reasonable tidal volume. Findings from randomized trials suggest that SIMV weaning delays extubation compared with PSV and SBT and that it should not be the primary mode of weaning in most clients (Byrd et al, 2006).

3. Provide undisturbed rest and sleep periods. Avoid stressful procedures or situations and nonessential activities.

Rationale: Maximizes energy for weaning process; limits fatigue and oxygen consumption. Note: It takes approximately 12 to 14 hours of respiratory rest to rejuvenate tired respiratory

muscles. For clients on AC, raising the rate to 20 breaths per minute can also provide respiratory rest.

4. Evaluate and document client’s progress. Note restlessness; changes in BP, heart rate, and respiratory rate; use of accessory muscles; discoordinated breathing with ventilator;

increased concentration on breathing (mild dysfunction); client’s concerns about possible machine malfunction; inability to cooperate or respond to coaching; and color

changes.

Rationale: Indicators that client may require slower weaning and an opportunity to stabilize, or may need to stop program. Note: Moving from pressure/volume (such as assist/control)

ventilator to T-piece may precipitate a “flash” form of heart failure requiring prompt intervention.

5. Recognize and provide encouragement for client’s efforts.

Rationale: Positive feedback provides reassurance and support for continuation of weaning process.

6. Monitor cardiopulmonary response to activity.

Rationale: Excessive oxygen consumption and demand increases the possibility of failure.

7. Consult with dietitian and nutritional support team for adjustments in composition of diet.

Rationale: Reduction of carbohydrates and fats may be required to prevent excessive production of CO2, which could alter respiratory drive.

8. Monitor CBC, serum albumin and prealbumin, transferrin, total iron-binding capacity, and electrolytes, especially potassium, calcium, and phosphorus.

Rationale: Verifies that nutrition is adequate to meet energy requirements for weaning.

9. Review chest x-ray and ABGs.

Rationale: Chest x-rays should show clear lungs or marked improvement in pulmonary congestion or infiltrates. ABGs should document satisfactory oxygenation on an FiO2 of 40% or less.