Mechanical ventilation can partially or fully replace spontaneous breathing. Its main purpose is to improved gas exchange and decreased work of breathing by delivering preset concentrations of oxygen at an adequate tidal volume. An artificial airway (endotracheal tube) or tracheostomy is needed to a client requiring mechanical ventilation. This therapy is used most often in clients with hypoxemia and alveolar hypoventilation. Although the mechanical ventilator will facilitate movement of gases into and out of the pulmonary system, it cannot guarantee gas exchange at the pulmonary and tissue levels. Caring for a client on mechanical ventilation has become an indispensable part of nursing care in critical care or general medical-surgical units, rehabilitation facilities, and the home care settings. Ventilator-associated pneumonia (VAP) is a significant nosocomial infection that is associated with endotracheal intubation and mechanical ventilation.
The major goals for a client receiving mechanical ventilation include improvement of gas exchange, maintenance of a patent airway, prevention of trauma, promoting optimal communication, minimizing anxiety, and absence of cardiac and pulmonary complications.
Here are six (6) nursing care plans (NCP) and nursing diagnosis (NDx) for patients who are under mechanical ventilation:
- Impaired Spontaneous Ventilation
- Ineffective Airway Clearance
- Deficient Knowledge
- Risk for Ineffective Protection
- Risk for Decreased Cardiac Output
Ineffective Airway Clearance
Ineffective Airway Clearance: Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway.
May be related to
- Decreased energy and fatigue
- Endotracheal intubation
- Stasis of secretions
Possibly evidenced by
- Abnormal breath sounds
- Excessive secretions
- Increased peak airway pressure
- Ineffective cough
- Client will maintain clear, open airways, as evidenced by normal breath sounds after suctioning.
Assessment for Ineffective Airway Clearance for Mechanical Ventilation.
|Observe the color, odor, quantity, and consistency of sputum.||Thick, tenacious secretions increase airway resistance and the work of breathing. A sign of infection is discolored odoriferous sputum.|
|Auscultate the lungs for the presence of normal or adventitious breath sounds.||Diminished lung sounds or the presence of adventitious sounds may indicate an obstructed airway and the need for suctioning.|
|Monitor oxygen saturation prior to and after suctioning using pulse oximetry.||This assessment provides an evaluation of the effectiveness of therapy.|
|Assess arterial blood gases (ABGs).||Signs of respiratory compromise including decreasing Pao2 and increasing Paco2.|
|Monitor for peak airway pressures and airway resistance.||Increases in these parameters signal the accumulation of secretions or fluid and the potential for ineffective ventilation.|
|Explain the suctioning procedure to the client; give reassurance throughout the procedure.||Suctioning can be frightening to the client. Reinforce the need to maintain a patent airway. Provide sedation and pain relief as indicated.|
Interventions for Ineffective Airway Clearance for Mechanical Ventilation.
|Turn the client every 2 hours.||Turning mobilizes secretions and helps prevent ventilator-associated pneumonia.|
|Institute airway suctioning as indicated based on the presence of adventitious breath sounds and/or increased ventilatory pressure.||The frequency of suctioning should be based on the client’s clinical status, not on a preset routine such as every 2 hours. Oversuctioning can cause hypoxia and injury to bronchial and lung tissue.|
|Use closed in-line suction.||This technique decreases the infection rate, may reduce hypoxia, and is often less expensive. Sterile technique is a priority.|
|Avoid saline instillation before suctioning.||Saline instillation before suctioning has an adverse effect on oxygen saturation.|
|Hyperoxygenated as ordered.||Hyperoxygenation before, during, and after endotracheal suctioning decreases hypoxia and cardiac dysrhythmias related to the suctioning procedure.|
|Silence any ventilator alarms during suctioning. Reset the alarms after suctioning.||Silencing alarms decrease the frequency of false alarms during suctioning and reduces stressful noise to the client. Alarms need to be turned on again after suctioning to ensure safety.|
|Administer an adequate fluid intake (IV and nasogastric, as appropriate).||Maintaining hydration increases ciliary action to remove secretions and reduces viscosity of secretions. It is easier to mobilize thinner secretions with coughing|
|Administer pain medications, as appropriate, before suctioning.||These medications decrease peak periods of pain and assist with an effective cough needed to clear secretions.|
|Consult a respiratory therapist for chest physiotherapy as indicated.||Chest physiotherapy includes the techniques of postural drainage and chest percussion to loosen and mobilize secretions.|
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Respiratory Care Plans
Care plans about respiratory system disorders:
- Asthma | 8 Care Plans
- Bronchiolitis | 5 Care Plans
- Chronic Obstructive Pulmonary Disease (COPD) | 5+ Care Plans
- Cystic Fibrosis | 5 Care Plans
- Hemothorax and Pneumothorax | 3 Care Plans
- Influenza (Flu) | 5 Care Plans
- Lung Cancer | 5 Care Plans
- Mechanical Ventilation | 6 Care Plans
- Near-Drowning | 5 Care Plans
- Pleural Effusion | 6 Care Plans
- Pneumonia | 8+ Care Plans
- Pulmonary Embolism | 4 Care Plans
- Pulmonary Tuberculosis | 5 Care Plans
- Tracheostomy | 5 Care Plans