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
Anxiety: Vague uneasy feeling of discomfort or dread accompanied by an autonomic response.
May be related to
- Change in health status
- Change in environment
- Inability to communicate verbally
- Inability to breathe adequately without support
- Inability to maintain adequate gas exchange
- Unknown outcome
Possibly evidenced by
- Facial tension
- Focus on self
- Uncooperative behavior
- Vigilant watch on equipment
- Client will use effective coping mechanism.
- Client will describe a reduction in level of anxiety experienced.
- Client will demonstrate reduced anxiety as evidenced by calm manner and cooperative behavior.
|Assess the client’s understanding of the need for mechanical ventilation.||Accurate appraisal can facilitate the development of appropriate treatment strategies.|
|Assess the client for signs of anxiety.||Being on a mechanical ventilator can be a drastic change that will produce a high level of anxiety. Anxiety can affect the respiratory rate and pattern, resulting in rapid, shallow breathing and leading to arterial blood gas abnormalities and the client “fighting or bucking” the ventilator.|
|Reduce distracting stimuli. Inform the client of alarms on the ventilatory system, and reassure the client about the close proximity of health care personnel to respond to alarms.||Decreasing stimuli provides a quiet environment that enhances rest. Anxiety may escalate with excessive noise, conversation, and equipment around the client. An informed client who understands the treatment plan will be more cooperative.|
|Display a confident, calm manner and understanding attitude. Be available to the client for support, as well as for explanations of the client’s care and progress.||The presence of a trusted person may be helpful during periods of anxiety. An ongoing relationship establishes a basis for comfort in communicating anxious feelings.|
|Provide relaxation techniques.||Using anxiety-reduction techniques enhances the client’s sense of personal mastery and confidence.|
|Encourage sedentary diversional activities.||These activities enhance the client’s quality of life and help pass time.|
|Encourage visiting family and friends.||The presence of significant others reinforces feelings of security for the client.|
|If impaired communication is the problem, provide the client with word-and-phrase cards, a writing pad, and pencil, or a picture board.||These tools broaden the opportunity for communicating which may reduce frustrations.|
|Refer to the psychiatric liaison clinical nurse specialist, psychiatrist, or hospital chaplain, as appropriate.||Specialty expertize may provide a wider range of treatment options and may be needed to achieve successful outcomes.|
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Respiratory Care Plans
Care plans about respiratory system disorders:
- Asthma | 4 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