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.
Nursing Care Plans
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.
- Impaired Spontaneous Ventilation
- Ineffective Airway Clearance
- Deficient Knowledge
- Risk for Ineffective Protection
- Risk for Decreased Cardiac Output
May be related to
- Cognitive limitation
- Decreased motivation to learn
- New treatment
- New environment
Possibly evidenced by
- Expressing inaccurate information
- Questioning members of health care team
- Client or significant others demonstrate knowledge of mechanical ventilation and care involved.
|Assess the client’s perception and understanding of mechanical ventilation.||This information provides an important starting point in education.|
|Assess the client’s readiness and ability to learn.||Educational interventions must be designed to meet the learning limitations, motivation, and needs of the client. Clients in acute care may not be able to take in much information because of fatigue, pain, sensory overload, hypoxemia, and the like.|
|Encourage the client or significant others to express feelings and ask questions.||Questions facilitate open communication between the client and health care professionals and allow the verification of understanding and the opportunity to correct misconceptions.|
|Explain the importance of frequent assessment of vital signs, auscultation of breath sounds, ventilation checks.||This information also helps reduce anxiety by providing a basis for actions.|
|Explain to the client the reason for the inability to talk while intubated. Explain alternative efforts for communicating.||The endotracheal tube passes through the vocal cords and attempts to talk can cause more trauma to the cords. However, clients must understand how to use supplementary methods for communication such as paper, pen, pictures.|
|Explain that the client will not be able to eat or drink while intubated but assure him or her that alternative measures (IV fluids, gastric feedings, or hyperalimentation) will be taken to provide nourishment.||The risk for aspiration is high if the client eats or drinks while intubated. In long-term care settings, clients may be allowed to eat and drink after a swallow evaluation.|
|Explain that alarms may periodically sound off, which may be normal, and that the staff will be in close proximity.||Explaining expected events can help reduce anxiety.|
|Explain the need for suctioning as needed.||This information can help reduce anxiety associated with the procedure.|
|Explain the weaning process and explain that extubation demonstrates adequate respiratory function and a decrease in pulmonary secretions.||This information aids the client in maintaining some control.|
|If long-term ventilation is anticipated, discuss or plan for long-term ventilator care management and use appropriate referrals: long-term ventilator facilitates versus home care management.||Continuity of care is facilitated through the use of specialty resources.|
Recommended nursing diagnosis and nursing care plan books and resources.
- Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use.
- Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively.
- NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales.
- Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
Another great nursing care plan resource that is updated to include the recent NANDA-I updates.
- Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
Useful for creating nursing care plans related to mental health and psychiatric nursing.
- Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans.
- Maternal Newborn Nursing Care Plans (3rd Edition)
If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you.
- Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023.
- All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
- Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
Other nursing care plans related to respiratory system disorders:
- Asthma | 8 Care Plans
- Bronchiolitis | 5 Care Plans
- Bronchopulmonary Dysplasia (BPD) | 5 Care Plans
- Chronic Obstructive Pulmonary Disease (COPD) | 7 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 | 11 Care Plans
- Pulmonary Embolism | 4 Care Plans
- Pulmonary Tuberculosis | 5 Care Plans
- Tracheostomy | 5 Care Plans