6 Mechanical Ventilation Nursing Care Plans

September 6, 2017

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.

Here are six (6) nursing care plans (NCP) and nursing diagnosis (NDx) for patients who are under mechanical ventilation:

Risk for Ineffective Protection

Risk for Ineffective Protection: At risk for a decrease in the ability to guard self against internal or external threats such as illness or injury.

May be related to

Decreased pulmonary compliance
Improper alarm settings
Improper ventilator settings
Increased secretions
Positive-pressure ventilation
Ventilator dependency
Ventilator disconnection

Possibly evidenced by

[not applicable]

Desired Outcomes

Client will remain free of injury as evidenced by proper ventilator settings and arterial blood gases (ABGs) within normal limits for client.
Client will have a decreased potential for injury from barotrauma and ventilator-associated pneumonia (VAP) by continuous assessments and early interventions.

Nursing Interventions	Rationale
Review the ventilator settings every hour. Notify the respiratory unit of any discrepancy in the ventilator settings immediately:	Frequent assessment guarantees that the client is receiving correct mode, rate, tidal volume, F_Io2,positive end-respiratory pressure (PEEP) and pressure support. Important attention to details can prevent problems.
Rate of mechanical breaths	The usual rate is between 10 to 14 breaths per minute.
Pressure support (PS)	Pressure support (PS) produces positive airway pressure during the inspiratory cycle of a spontaneous inspiratory effort.
Tidal volume (TV)	Typical ranges for TV are 6 to 8 mL/kg of ideal body weight. Research supports lower standard TVs to reduce barotrauma.
PEEP	PEEP serves to improve gas exchange and prevent atelectasis.
F_IO2	The amount of oxygen prescribed depends on the client’s condition and ABG results.
Mode:
Assist control (AC)	Assist control (AC) delivers full ventilatory support by providing a preset tidal volume for each client-initiated breath.
Controlled mandatory ventilation (CMV)	CMV ensures a preset rate with no sensitivity to the client’s respiratory effort. The client cannot initiate breaths or alter the pattern.
Synchronized intermittent mandatory ventilation (SIMV)	SIMV ensures a preset rate in synchronization with the client’s own spontaneous breathing.
Make sure that the ventilator alarms are on.	The alarm alert the caregiver in cases of ventilation problems. A quick response to alarm ensures the correction of problems and maintenance of adequate ventilation.
Assess respiratory rate and rhythm including the work of breathing.	It is important to maintain the client in synchrony with the ventilator and not permit “bucking” it.
Assess arterial blood gases results and monitor oxygen saturation.	Objective data guide the ventilator settings and appropriate interventions.
Assess for the signs of pulmonary infection including increased temperature, purulent secretions, elevated white blood cell count, positive bacterial cultures, and evidence of pulmonary infection on chest X-ray studies.	VAPs occur in up to 28% of clients on ventilators. Mortality rates of 40% to 50% have been reported for these clients. Most ventilator-associated infections are caused by bacterial pathogens, with gram-negative bacilli being common.
Assess for the signs of barotrauma: the client with crepitus, subcutaneous emphysema, altered chest excursion, asymmetrical chest, abnormal ABGs, a shift in trachea, restlessness, evidence of pneumothorax on chest x-ray studies.	Barotrauma is damage to the lungs from positive pressure as seen in clients with an acute respiratory disease when high pressures are needed to ventilate stiff lungs or when PEEP is used. Frequent assessments are needed because barotrauma can occur at any time and the client will not show signs of dyspnea, shortness of breath, or tachypnea if heavily sedated to maintain ventilation.
Monitor chest x-ray reports daily and obtain a stat portable chest x-ray film if barotrauma is suspected.	Vigilant monitoring helps to reduce complications.
Monitor plateau pressures with the respiratory therapist.	Monitoring for barotrauma can involve measuring plateau pressure, which is the pressure after delivery of the tidal volume but before the client is allowed to exhale. The ventilator is programmed so that after delivery of the tidal volume the client is not allowed to exhale for a half second. Therefore pressure must be maintained to prevent exhalation. Elevation of plateau pressures increases both the risk and incidence of barotrauma when the client is on mechanical ventilation. There has been less occurrence of barotrauma since guidelines have recommended lower standard tidal volumes.
Listen for alarms. Know the range in which the ventilator will set off the alarm and how to troubleshoot:	The ventilator is a life-sustaining treatment that requires prompt response to alarms:
Apnea alarm	The apnea alarm is indicative of disconnection or absence of spontaneous respirations.
Low exhale volume	The low exhale alarm indicates that the client is not returning delivered TV (through disconnection or leak).
Low-pressure alarm	The low-pressure alarm indicates a possible disconnection or mechanical ventilator malfunction.
High peak pressure alarm	The high peak pressure alarm indicates bronchospasm, retained secretions, obstruction of ET tube, atelectasis, acute respiratory distress syndrome (ARDS), or pneumothorax, among others.
Institute measures to reduce VAP.	Nosocomial infections are a leading cause of mortality.
Keep the head of bed elevated to 30 to 45 degrees or perform subglottic suctioning unless it is medically contraindicated.	Elevation promotes better lung expansion. It also reduces gastric reflux and aspiration.
Wash hands before and after suctioning, touching ventilator equipment, and/or coming into contact with respiratory secretions.	An artificial airway bypasses the normal protective mechanisms of the upper airways. Handwashing reduces germ transmission.
Brush teeth two to three times per day with a soft toothbrush. Chlorhexidine-based rinses may also be incorporated into oral care protocols.	Oral care reduces colonization of the oropharynx with respiratory pathogens that can be aspirated into the lungs.
Use a continuous subglottic suction endotracheal (ET) tube for intubation that is expected to be longer than 24 hours.	This intervention prevents the accumulation of secretions that can be aspirated.
Use sterile suctioning procedures.	This technique decreases the introduction of microorganisms into the airway.
Notify the physician of signs of barotrauma immediately; anticipate the need for chest tube placement, and prepare the client as needed.	If barotrauma is suspected, intervention must follow immediately to prevent tension pneumothorax.