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:
- Impaired Spontaneous Ventilation
- Ineffective Airway Clearance
- Anxiety
- Deficient Knowledge
- Risk for Ineffective Protection
- Risk for Decreased Cardiac Output
Risk for Ineffective Protection
Nursing Diagnosis
- Risk for Ineffective Protection
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, FIo2, positive end-respiratory pressure (PEEP) and pressure support. Important attention to details can prevent problems. |
| The usual rate is between 10 to 14 breaths per minute. |
| Pressure support (PS) produces positive airway pressure during the inspiratory cycle of a spontaneous inspiratory effort. |
| Typical ranges for TV are 6 to 8 mL/kg of ideal body weight. Research supports lower standard TVs to reduce barotrauma. |
| PEEP serves to improve gas exchange and prevent atelectasis. |
| The amount of oxygen prescribed depends on the client’s condition and ABG results. |
Mode: | |
| Assist control (AC) delivers full ventilatory support by providing a preset tidal volume for each client-initiated breath. |
| CMV ensures a preset rate with no sensitivity to the client’s respiratory effort. The client cannot initiate breaths or alter the pattern. |
| 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: |
| The apnea alarm is indicative of disconnection or absence of spontaneous respirations. |
| The low exhale alarm indicates that the client is not returning delivered TV (through disconnection or leak). |
| The low-pressure alarm indicates a possible disconnection or mechanical ventilator malfunction. |
| 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. |
| Elevation promotes better lung expansion. It also reduces gastric reflux and aspiration. |
| An artificial airway bypasses the normal protective mechanisms of the upper airways. Handwashing reduces germ transmission. |
| Oral care reduces colonization of the oropharynx with respiratory pathogens that can be aspirated into the lungs. |
| This intervention prevents the accumulation of secretions that can be aspirated. |
| 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. |
Recommended Resources
Recommended nursing diagnosis and nursing care plan books and resources.
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- 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.
See Also
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