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
Risk for Decreased Cardiac Output
- Risk for Decreased Cardiac Output
May be related to
- Mechanical ventilation
- Positive-pressure ventilation
Possibly evidenced by
- [not applicable]
- Client will maintain adequate cardiac output, as evidenced by systolic BP within 20 mm Hg of baseline; HR to 60 to 100 beats per minute with regular rhythm; strong peripheral pulses; urine output greater than 30 ml/hour, warm, and dry skin; and normal level of consciousness.
|Assess the client’s level of consciousness, blood pressure, heart rate, and hemodynamic parameters if in place (central venous pressure, pulmonary artery diastolic pressure (PADP), and pulmonary capillary wedge pressure, cardiac output).||Mechanical ventilation can produce a decreased venous return to the heart, resulting in decreased BP, compensatory increased heart rate, and decreased cardiac output. This may happen abruptly with ventilator changes: rate, tidal volume, or positive-pressure ventilation. The level of consciousness will decrease if cardiac output is severely compromised. Therefore close monitoring during ventilator changes is imperative.|
|Assess the capillary refill, skin temperature, and peripheral pulses.||Pulses are weak with reduced stroke volume and cardiac output. Capillary refill is slow with reduced cardiac output. Cold, pale, clammy skin is secondary to compensatory sympathetic nervous system stimulation and associated with low cardiac output and oxygen desaturation.|
|Monitor for dysrhythmias.||Cardiac dysrhythmias may result from the low perfusion state, acidosis, or hypoxia.|
|Monitor fluid balance and urine output.||Optimal hydration status is needed to maintain effective circulating blood volume and counteract the ventilatory effects on cardiac output. With positive pressure ventilation, pressure from the diaphragm decreases blood flow to the kidneys and could result in a drop in urine output. The brain is very sensitive to a decrease in blood flow and may respond by releasing antidiuretic hormone (ADH) (to increase water and sodium retention), further reducing urine output. After the initial decrease in venous return to the heart, volume receptors in the right atrium signal a decrease in volume, which triggers an increase in the release of ADH from the posterior pituitary and retention of water by the kidneys.|
|Notify the physician immediately of signs of a decrease in cardiac output, and anticipate possible ventilator setting changes.||Vigilant monitoring reduces the risk for complications. Hypotension and decreased cardiac output may be related to positive-pressure ventilator itself or use of positive end-expiratory pressure (PEEP) mode.|
|Maintain an optimal fluid balance.||Volume therapy may be required to maintain adequate filling pressures and optimize cardiac output. However, if PADP and/or pulmonary capillary wedge pressure rises and cardiac output remains low, fluid restriction may be necessary.|
|Administer medications as ordered (diuretics, inotropic agents).||Diuretics may be useful to maintain fluid balance if fluid retention is a problem. Inotropic agents may be useful to increase cardiac output.|
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