Initial Ventilator Settings in Various Disease States

In the ED setting, patients frequently require full respiratory support. For most ED patients who are
paralyzed as a component of rapid-sequence induction, CMV and A/C are good choices as an initial
ventilatory mode. SIMV may be better tolerated in nonparalyzed patients with obstructive airway disease
and an intact respiratory effort. PSV can be used when respiratory effort is intact and respiratory failure is
not severe.[11]
Noninvasive ventilation (CPAP, BiPAP) can be used effectively in many cases of severe COPD and CHF
to avoid tracheal intubation. Initial ventilator settings are guided by the patient's pulmonary
pathophysiology and clinical status. Adjustments can then be made to limit barotrauma, volutrauma, and
oxygen toxicity. CPAP and BiPAP require alert, cooperative patients capable of independently
maintaining their airways and are contraindicated in the presence of facial trauma.

Asthma and COPD

Hypoxia can generally be corrected through a high FiO 2, but patients with airway obstruction are at risk of
high airway pressures, breath stacking leading to intrinsic PEEP, barotrauma, and volutrauma. To
minimize intrinsic PEEP, it is recommended that expiratory flow time be increased as much as possible
and that tidal volumes and respiratory rates are set at low values. [12] Permissive hypercapnia enables a
low respiratory rate of 6-8 breaths per minute to be used, as well as an increased I:E ratio of 1:1.5 or 1:2.
PEEP may benefit some asthmatic patients by reducing the work of breathing and maintaining open
airways during expiration, but its effects are difficult to predict and must be carefully monitored. Patients
with asthma and COPD are at particular risk of barotraumatic progression to tension pneumothorax, a
complication that can initially appear similar to runaway intrinsic PEEP. These conditions may be
distinguished by temporary detachment of the patient from positive-pressure ventilation; if exhalation
results in a recovery of pulse or normal blood pressure, the diagnosis is intrinsic PEEP.
CPAP and BiPAP will benefit some asthmatics and many patients with COPD. These patients will require
careful monitoring as they can easily deteriorate from hypercarbia, intrinsic PEEP, or respiratory
exhaustion. Nevertheless, aCochraneDatabase Systematic Review analysis of trials including patients
with severe COPD exacerbations demonstrated that the use of noninvasive positive-pressure ventilation
absolutely reduced the rate of endotracheal intubation by 59% (95% confidence interval [CI] of relative
risk [RR]: 0.33-0.53), the length of hospital stay by 3.24 days (95% CI: 2.06-4.44 days), and the risk of
mortality by 48% (95% CI of RR: 0.35-0.76).[2]

Acute respiratory distress syndrome

ARDS lungs are typically irregularly inflamed and highly vulnerable to atelectasis as well as barotrauma
and volutrauma. Their compliance is typically reduced, and their dead space increased. The standard of
care for the ventilatory management of patients with ARDS changed dramatically in 2000 with the
publication of a large multicenter, randomized trial comparing patients with ARDS initially ventilated with
either the traditional tidal volume of 12 mL/kg or a lower TV of 6 mL/kg. This trial was stopped early
because the lower tidal volume was found to reduce mortality by an absolute 8.8% (P=0.007). Intriguingly,
plasma interleukin 6 concentrations decreased in the low TV group relative to the high TV group (P <
0.001), suggesting a decrease in lung inflammation.[13, 14]
The authors recommend initiating ventilation of patients with ARDS with A/C ventilation at a tidal volume
of 6 mL/kg, with a PEEP of 5 and initial ventilatory rate of 12, titrated up to maintain a pH greater than
7.25. There is not yet adequate evidence to routinely recommend PEEP greater than 5 cm H2 O, but, in
appropriately monitored circumstances, it may be attempted.[15] Intrinsic PEEP may occur in patients with
ARDS at high ventilatory rates and should be watched for and treated by reducing the rate of ventilation
under direct observation until plateau pressures decrease. The authors recommend a target plateau
pressure of less than 30 cm H2 O. Once a patient has been stabilized with adequate tidal volumes at a
plateau pressure of less than 30 cm H2 O, considering a trial of pressure-cycled ventilation is reasonable.

Several recruitment maneuvers have been devised to increase the proportion of alveoli ventilated in
ARDS. These techniques typically attempt short-term increased PEEP or volume to open occluded or
collapsed alveoli. Gattinoni et al, for example, found that among ARDS patients undergoing whole-lung
CT, applying 45 cm H2 O PEEP recruited a mean of 13% new lung tissue.[16]
A recent meta-analysis that compared high versus low levels of PEEP in patients with ALI and ARDS
found no difference in mortality before hospital discharge amongst studies that used the same tidal
volume in both control and intervention arms.[15] In a subsequent subgroup analysis that assessed lungprotective ventilation (low tidal volume, high PEEP) versus conventional mechanical ventilation, the
authors found a decrease in mortality with the use of a lung-protective ventilation strategy. The same
review also found that high levels of PEEP do improve oxygenation in patients with ALI and ARDS.
In a recent prospective, randomized, controlled trial, Guerin et al examined whether early prone
positioning during mechanical ventilation can improve outcomes in patients with severe ARDS. The
authors found that both the 28-day and unadjusted 90-day mortalities in the prone group were
significantly lower (16% and 23.6%, respectively) than in the supine group (32.8% and 41%,
respectively).[17] Although they found no difference between the groups with regard to duration of invasive
mechanical ventilation or length of stay in the ICU, they found a higher incidence of cardiac arrest in the
supine group (31% vs 16% in the prone group).
Permissive hypercapnia is a ventilatory strategy that has won particular favor in the management of
patients with ARDS and COPD/asthma who would otherwise require dangerously high tidal volumes and
airway pressures. In patients without contraindications such as head injury, cerebrovascular accident
(CVA), elevated intracranial pressure, or cardiovascular instability, permissive hypercapnia has permitted
much decreased tidal volumes, airway pressures, and respiratory rates, though evidence for a decrease
in mortality rates is incomplete.[18] The typically recommended target pH is 7.25.
Noninvasive ventilatory strategies have met with little success in the treatment of patients with ARDS. The
authors recommend great caution and close monitoring if noninvasive positive pressure ventilation
(NIPPV) is attempted among patients with ARDS.
In trials of NIPPV among patients with undifferentiated hypoxemia, the presence of pneumonia or ARDS
was associated with significantly increased risk of failure. Some subgroups of patients with ARDS may
benefit from NIPPV; however, Antonelli et al demonstrated greater success in applying noninvasive
positive pressure ventilation to patients with lower simplified acute physiology scores and higher
PaO2/FiO2 ratios.[19]

Congestive heart failure

CHF responds very well to positive-pressure ventilation, which serves the dual role of opening alveoli and
reducing preload. Many patients with CHF benefit from a trial of noninvasive CPAP or BiPAP. Some of
these patients will clinically improve so rapidly that admitting services may request discontinuation of
noninvasive ventilatory support, but great caution must be maintained if this is attempted, as fluid may
unpredictably reaccumulate, resulting in hypoxia and respiratory failure.
Intubated patients usually manage to adequately oxygenate. PEEP can be increased as tolerated to
improve oxygenation and reduce preload. However, in some patients, cardiac output can be particularly
dependent on preload and such patients may easily develop postintubation hypotension. Management of
this common complication includes a combination of fluid therapy, discontinuation of nitroglycerin or other
medical therapies, and, if necessary, medical or mechanical hemodynamic support interventions. [20]

Traumatic brain injury

Hyperventilation was traditionally recommended in the management of severe traumatic brain injury, but
recent studies have demonstrated poor outcomes thought to be secondary to excessive cerebral
vasoconstriction and reduced cerebral perfusion. However, retrospective data have demonstrated
decreased mortality among traumatic brain injury ventilated to PCO 2 between 30 and 39 mm Hg, though
this has not been prospectively validated.[21]

Nursing Care Plan

Date: ________________

Client initials __________

Nursing Care Plan

Long term goals

Nursing Diagnosis: Ineffective breathing pattern related to decreased lung compliance as evidenced by
dyspnea, tachypnea and abnormal ABGs
Client will experience adequate perfusion as evidenced by normal arterial blood gas levels* normal
for client, decreased tachycardia & dyspnea

Outcome/Short Term Planning/Interventions

Client Centered Goals Implementation

Rationale for
interventions

Evaluation

Client will have

exhibited signs of
adequate perfusion.

Monitor pulse oximetry Oximetry readings of Pulse oximetery

for oxygen saturation
90 correlate with
readings are > 90%
and notify for < 90%
PaO2 of 60. Levels
below this do
not allow for
adequate perfusion to
tissues and vital
organs. Oximtery uses
light waves to identify
the differences
between the saturation
and reduced
hemoglobin of the
tissues and may be
inaccurate in low flow
Client ABGs will be
Monitor ABGs for
states.
within normal baseline changes and trends.
ABGs remain in
limits for client.
normal limits for
Provides information client.
on acid/base status
and oxygenation.
Must consider both
Client will exhibit
oxygenation and
signs of effective
Maintain HOB
Client will exhibit
ventilation.
breathing pattern.
elevation at least 30
decreased difficulty
degrees.
breathing.

Client will have

adequate tissue
perfusion.

Monitor ECG changes

in cardiac rhythm,
dysrhythmias, or
conduction defects.

Elevating HOB
decreases risk of
aspiration and

Client will not exhibit

dysrhythmias.

facilitates lung
expansion.
Hypoxia can result in
life-threatening
dysrhythmias that
require emergent
treatments.

Nursing Care Plan

Nursing Diagnosis
Impaired Verbal Communication r/t sedation, presence of
artificial airway, or decreased level of consciousness

Long Term Goal:

Patient is able to use a
form of communication to
get needs met and relate
to his environment

Short Term Goals / Outcomes:

Patient and nurse will establish a means of communication
Patient will be able to effectively communicate and needs
Intervention

Rationale

Evaluation

Assess the patients

primary and preferred
means of
communication
(verbal, written,
gestures)

Communication can be frustrating for both

the nurse and patient. It is critical that the
nurse and patient determine the best method
for each patient.

Patient can write words

clearly on paper

Assess the patients

preferred language
and ability to
understand written
words, pictures and
gestures

The nurse can not assume that the patient is Patient speaks and reads
grasping the information that is provided. In English.
recognition of the vast array of cultures and
physical challenges that patients face, it is
the nurses responsibility to communicate
effectively

Recognize that the

presence of an
artificial airway will
hinder the patients
ability to
communicate

When air does not pass over the vocal cords, Patient has an
sounds are not produced. Other methods of endotracheal tube present
communication will have to be established

Assess energy level

Fatigue and/ or shortness of breath can make Patient gets easily

communication difficult or impossible
fatigued if frustrated
when communicating

Anticipate patient
needs and pay

Provides reassurance to the patient that

someone is there to care for them and meet

All patient needs were

met

attention to nonverbal

their needs

Listen attentively
Decreases frustration and demonstrates
when the patient
caring
attempts to
communicate. Clarify
your understanding of
the patients
communication

All patient needs were

met

Never talk in front of This will prevent increasing the patient's

the patient as though sense of frustration and feelings of
he or she can not hear helplessness
or comprehend

Staff respectful of patient

when talking

Keep distractions
This will keep the patient focused, decrease
such as television and stimuli going to the brain for interpretation
radio to minimum
and enhance the nurses ability to listen
when talking to
patients

Television muted so
patient can communicate
more effectively

Dont speak loudly

unless hearing
impaired

Loud talk does not improve the patient's

ability to understand.

Calm, appropriate manner

used to communicate
effectively

Maintain eye contact

with the patient when
speaking. Stand close,
within the patients
line of vision

Eye contact lets the patient know that they

have your attention when trying to
communicate. Patients with artificial
airways may need to lip words and standing
in front of the patient will allow the nurse a
better view to understand the patient

All patient needs were

met

Give the patient

It may be difficult for patients to respond
ample time to respond under pressure, they may need extra time to
convey thoughts

Patient and nurse able to

communicate effectively

Praise the patients

accomplishments and
acknowledge their
frustrations

Communication may be difficult and the

patient is easily frustrated. The inability to
communicate enhances a patients sense of
isolation and helplessness

Patient and nurse able to

communicate effectively

Try to use phases that

have a yes / no
answer. Use short
sentences and convey
one thought at a time.

This allows the patient to stay focused and

reduces frustration. This is common means
to communicate as arms may be restricted
due to the use of restraints

Patient able to respond to

yes/no questions

Avoid finishing
sentences for the

This may lead to frustration and decrease the Patient and nurse able to
patients trust in you
communicate effectively

patient. Be calm and

accepting during
communication
attempts. Do not say
you understand if you
dont
Use alternate methods Alternate methods are especially helpful for
of communicating
patients with artificial airways
such as word-and
phrase cards, writing
pad and pencils, or
picture boards

Patient can write words

clearly on paper

Encourage family and This decreases the patients sense of

friends to talk to
isolation
patient even though
they may not respond

Family talks to patient

when visiting

Orient the patient to

surroundings. State
procedural and task
intentions when
providing care

Not knowing who is providing care or where Patient oriented and nods
they are can be a stressor to the
head in understanding of
patient. Patient may prefer that the nurse
care.
give them some indication of what they will
be experiencing, especially if it will cause
discomfort

Nursing Diagnosis
Pain r/t surgical site, traumatic injury, ischemic process,
monitoring devices, routine nursing care and/or immobility

Long Term Goal:

Patient will be free of pain

Short Term Goals / Outcomes:

Patient will report pain less than 3 on 0-10 scale.
Patients vital signs will be within normal limits.
Intervention

Rationale

Assess pain
A good assessment of pain will help in the
characteristics:
treatment and ongoing management of
quality (sharp,
pain.
burning); severity (0 10 scale); location;
onset (gradual,
sudden); duration
(how long);
precipitating or
relieving factors

Evaluation
Patient reports pain as 3 on
0-10 scale; intermittent and
sharp in incision area.

Monitor vital signs

Tachycardia, elevated blood pressure,

tachypnea and fever may accompany pain.

Vital signs within normal

limits.

Assess for probable

cause of pain.

Different etiologic factors respond better to Patient is experiencing pain

different therapies
from multiple traumatic
injuries

Assess for non-verbal Facial grimacing, pulling at tubes,

indicators of pain.
restlessness, resistance to passive motion
and non-synchronous ventilation can all be
indicators of pain.

Patient grimaces and

stiffens when turning.

Give analgesics as
ordered and evaluate
the effectiveness.

Narcotics are indicated for severe pain. For

acute pain, analgesics should be
administered intravenously and at the
onset. Subsequent doses, either
intravenously or orally, should be aroundthe-clock to ensure consistent analgesia.

Analgesics given as
ordered. Patient reports
pain relief after
administration.

Assess
appropriateness of a
patient-controlled
(PCA) analgesia

As the patients condition improves and

becomes responsive he may be switched to
PCA.

Patient awake and alert,

PCA ordered

Anticipate the need

for pain relief and
respond immediately
to complaints of pain.

The most effective way to deal with pain is Pain medication delivered
to prevent it. Early intervention can
prior to dressing changes
decrease the total amount of analgesic
with adequate relief.
required. Quick response decreases the
patients anxiety regarding having their
needs met and demonstrates caring.

Eliminate additional Outside sources of stress, anxiety and lack

stressors when
of sleep all may exaggerate the patients
possible. Provide rest perception of pain.
periods, sleep and
relaxation.

Patient appears relaxed, is

sleeping throughout the
night.

Institute nonpharmacological
approached to pain
(detraction, relaxation
exercises, music
therapy, etc)

Non-pharmacological approaches help

Patient is relaxing with
distract the patient from the pain. The goal radio playing.
is to reduce tension and thereby reduce
pain.

If patient is on
continuous
intravenous
analgesics, a daily
interruption should

Daily interruption of continuous infusions

of intravenous analgesics results in a
decreased number of days on the ventilator
and decrease in the length of stay

Daily interruption of
continuous analgesia held
for 60 minutes, patient
awake and alert during
interruption.

occur if the patient:

has adequate
pain control
is not receiving
neuromuscular
blocking
agents
is
hemodynamica
lly stable
is stable on the
ventilator

If patient is on patient Drug interaction may occur, if dedicated

controlled analgesia line is not possible consult pharmacist
(PCA):
before mixing drugs.

Dedicate an IV
line for PCA
only
Assess pain
relief and the
amount of pain
the patient is
requesting.
Educate
patient and
significant
others on
correct use of
PCA.

If demands for the drug are frequent the

basal or lock-out dose may need increased
to cover the patients pain.
If demands for the drug are very low, the
patient may need further education of use
of the PCA.
The patient and significant others must
understand that the patient is the only one
who should control the PCA.

For PCA:

Keep Narcan
readily
available.
Place No
additional
analgesia sign
over head of
bed.

PCA infusing without

complications. Patient and
family understand purpose
and use of PCA. Patient is
getting adequate pain relief
with current dose.

In event of respiratory depression reversal

agent must be available.

Narcan on unit if
needed. Sign placed in
room for safety.

This prevents inadvertent analgesia

overdosing.

Nursing Diagnosis
Anxiety r/t fear of the environment and threat to physical well
being

Long Term Goal:

Patient will be anxiety
free

Short Term Goals / Outcomes:

Patient will report a reduction in the level of anxiety experienced
Patient will demonstrate a reduction in the manifestations of anxiety
Intervention

Rationale

Assess patients anxiety

using a reliable scale

Almost all patients in a critical care

Patient is a 0 on RAAS
setting will experience some level of
scale
anxiety. Using a sedation scale allows
an objective assessment of the patient
and prevents patients from being sedated
too deeply for a long period of time.

Acknowledge awareness of Acknowledgment of the patients

patients anxiety
feelings validates the feelings and
communicates acceptance of these
feelings.

Evaluation

Patient is restless at
times. Reoriented and
reassured.

Maintain a calm manner

while interacting with
patient.

The health care provider can transmit his Patient displays less
or her own anxiety to the hypersensitive anxiety when nurse talks
patient. The patients feeling of stability to him.
increases in a calm and non-threatening
atmosphere.

Orient patient to the

environment and new
experiences or people as
needed.

Orientation and awareness of the

surroundings promote comfort and may
decrease anxiety.

Patient explained all

procedures and care
before done, less
anxious.

Use simple language and

brief statements when
instructing patient about
nursing care and
procedures.

While experiencing moderate to severe

anxiety, patient may be unable to
comprehend anything more than simple,
clear and brief instructions.

Patient less anxious

when oriented before
care.

Assess patient for pain and Sedatives should only be used after
treat prior to beginning
providing adequate analgesia and
sedation assessment.
treating reversible physiological causes
of anxiety. Pain, hypoxia,
hypoglycemia, withdrawal, sleep
deprivation and immobility are all
potential reversible causes of anxiety.

Patient rates pain as a 0

on 0-10 scale.

Administer sedatives as
ordered.

Sedatives are administered to provide an

amnesic effect. Ultra short acting agents
should be used first because they achieve
a steady state quickly and require fewer
loading doses.

Patient receiving Propfol

via continuous IV
infusion for a RAAS
goal of -1

Attempt daily weaning of

Allows patient to receive the minimal

Sedation is weaned daily

sedatives when the patient

is:

less than or equal to

sedation goal on
assessment scale
not being treated for
delirium
not receiving
neuromuscular
blocking agents
hemodynamically
stable
stable on the
ventilator

amount of sedation necessary to achieve

sedation goal, without being over
sedated
Verify wording

while still maintaining

sedation goal.

Assess the patient for an

acute delirium at least once
a shift, using an approved
scale.

Many processes in the critical care

No signs of acute
environment and disease states can
delirium exist
induce delirium. Delirium can manifest
as either an agitated (hyperactive) or
quiet (hypoactive) state. A mixed
delirium can exist in the critical
patient. For delirium to be present the
patient must display acute fluctuation in
mental status accompanied by
inattention; and either disorganized
thought or a level of consciousness other
than alert.

Administer haloperidol
(Haldol), or a combination
of haloperidol and
lorazepam (Ativan) as
ordered.

Haloperidol blocks dopamine receptors

while lorazepam enhances the action of
the inhibitory neurotransmitter
GABA. Lorazepam potentates the
tranquilizing effects of haloperidol, so
less needs administered.

Patient sleeping and

calm after medications
administered

Monitor for side effects of The patient may experience potential

haloperidol and lorazepam. life-threatening side effects such as QT
prolongation and torsades de
pointes. These may result in sudden
death especially if the drug is given IV
push.

No side effects noted

Use non-pharmacological
strategies:

Patient resting calm,

eyeglasses present,
watching television.

promote restful sleep

patterns
limit unnecessary

Anxiety may escalate with excessive

conversation, noise and equipment
around the patient. Decreasing the
stimulation in the environment and
correcting any sensory deficiencies may
help the patient to not misinterpret

noise
provide eyeglasses
and hearing aids
reorient to
surroundings

events and noises in the environment.

Nursing Diagnosis
Disturbed Sleep Pattern r/t environment, patient care
activities, discomfort, medication, withdrawal

Long Term Goal:

Patient will achieve optimal
amounts of sleep

Short Term Goals / Outcomes:

Patient will appear rested or verbalize feelings of rest
Patient will show an improvement in the sleep pattern
Intervention

Rationale

Evaluation

Document
observation of
sleeping and wakeful
behaviors. Record
number of sleep
hours. Note physical
and/or physiological
circumstances that
interrupt sleep.

Lack of sleep can cause changes in

metabolism, immune response and
respiratory dysfunction. These may lead to
delayed healing and prolonged need for
mechanical ventilatory support. It may also
be a factor in the development of ICU
psychosis. There are many factors in the
critical care environment that can interrupt
sleep.

Patient sleeping 30 -45

minutes at a time. Wakes
up every time caregiver
enters room or monitor
alarms.

Modify the
environment by
decreasing noise,
comfortable
temperature,
darkness, closed
door.

The environment must be conducive to

sleep.

Light dimmed and curtain

drawn. Patient requested
extra blanket and is
sleeping.

Provide a relaxing
activity before
bedtime.

A back rub, providing pillows for comfort,

calming music, or reading can all help the
patient relax before sleeping.

Back rub given and patient

listening to CD player prior
to falling asleep.

Administer hypnotics Any medications prescribed for sleep

or sedatives as
should be short course of therapy and only
ordered.
used if less aggressive means are
ineffective.

Patient requested
medication for sleep.

Organize nursing care

to provide minimal
interruptions and
allow for at least two
hours of
uninterrupted sleep.

Patient sleeping a least 1

a time.

It takes at least 60 -90 minutes to complete

one sleep cycle. The completion of an
entire sleep cycle is necessary to benefit
from sleep.

Nursing Diagnosis
Imbalanced Nutrition: Less than body requirements r/t special
diet modifications, NPO status, increased caloric needs

Long Term Goal:

Patient will ingest enough
calories to meet metabolic
demands

Short Term Goals / Outcomes:

Patient will maintain weight
Patient will demonstrate normal lab values (albumin, prealbumin, etc)
Patient will demonstrate timely wound healing
Intervention

Rationale

Evaluation

Obtain admission
weight and weigh
daily.

During aggressive nutritional support

patients weight should remain stable or
gain to pound daily

Admission weight
100kg Current weight
101kg

Obtain a nutritional
history and prior
etiological factors for
reduced nutrition.

To ensure proper nutrition it is essential

that the nurse obtain a history. The history
should include weight loss, food allergies,
use of nutritional supplements, swallowing
difficulties, nausea or vomiting,
constipation or diarrhea, alcohol
consumption and any special diet the
patient was following.

Patients history negative

for nutritional deficiency.
Follows regular diet.

Monitor lab values

that indicate
nutritional status:

albumin /
prealbumin

Transferrin

Albumin indicates the degree of protein

Albumin 3.0 g/dl. All other
depletion. 2.5 g/dl indicates severe
labs within normal range.
depletion. Prealbumin is a more immediate
indicator of protein adequacy.
Transferrin is important for iron transfer
and typically depletes as serum protein
decreases.

RBC and WBC

counts

RBC and WBC are usually decreased in

malnutrition, indicating anemia and
decreased resistance to infection.

Electrolytes

Potassium is typically increased and

sodium is typically decreased in
malnutrition.

Consult with

As the stress of a critical illness mounts, the Patient requires 25

nutritionist to
calculate patients
caloric, protein and
fluid requirements.

patient requires increased calories and as

much as 1.5 to 2 g/kg/day of
protein. Normally a patient will require
about 1ml of fluid per calorie.

kcal/Kg/day and 1 gram

protein.

Consult with
nutritionist to
calculate energy
demand by using
indirect calorimetry.

Indirect calorimetry uses a metabolic care

Calculated by nutritionist.
to calculate basal energy expenditure. This
will guide how best to feed the patient.

If enteral feedings are

being used:

start at slow
rate and
increase as
tolerated
check residual
every two to
four hours

Continuous feeds and starting slow cause

less gastro-intestinal upset
To prevent aspiration, residuals should be
checked and feedings stopped if the
residual is twice the amount of the hourly
rate.

administer
metoclopramid
e as ordered
check
placement of
the feeding
tube

keep head of
bed elevated
between 30
and 45 degrees

change feeding
system set-up
every 24 hours

monitor for
and prevent
diarrhea

10ml residual obtained. No

signs of aspiration noted.
No diarrhea present.

A motility agent to aid with high residuals

Enteral feedings being

used. Placement checked
with aspirate of 4.5.

Visualization by x-ray should occur with

insertion. The best method to check
placement is by obtaining aspirate from the
tube with a pH less than five
To prevent aspiration of tube feeding
contents and ventilator assisted pneumonia
To prevent bacterial colonization of the
stomach

Diarrhea is common with enteral

feedings. If patient is receiving bolus feeds
switching to continuous may decrease the
occurrences. If patient is lactose intolerant,
switch to a feed that does not contain
lactose. Adequately diluting liquid
medication with water may also help.

If parenteral nutrition
is being used:
To prevent catheter related sepsis

full barrier
precautions are
used during
insertion of the
catheter
use a
dedicated line
for the infusion

The line should be a virgin port and

nothing else administered through it to
decrease the risk of precipitation forming in
the catheter.

Parenteral nutrition
infusion via left subclavian
catheter. No signs of
infection noted. Blood
glucose within normal
limits.

To prevent catheter related sepsis

change the
solution bag
and tubing
every 24 hours

monitor for
overfeeding

monitor blood
glucose
frequently

Due to the high concentration of glucose

and lipids overfeeding can occur. Lipids
should not be administered if the patient is
receiving another lipid based medication
Due to the high glucose contents rapid
shifts in glucose can occur with rate
adjustments.

Nursing Diagnosis
Compromised Family Coping r/t overwhelming situation

Long Term Goal:

Family will develop
methods to cope with
present situation

Short Term Goals / Outcomes:

Family members will identify the effect patients illness has on the family unit.
Family members will identify resources available for help.
Family members will actively participate in care and decision making for the ill family member.
Family members will use supportive services and effective coping strategies.
Intervention

Rationale

Evaluation

Identify each family

members
understanding and
beliefs about the
situation.

Misconceptions about the prognosis,

expectations for daily care and the role of
the family in managing health problems
needs to be clarified.

Assess normal coping

patterns in the family,
including strengths,
limitations and
resources

Successful adjustment is influenced by

previous experiences. Families with a
history of unsuccessful coping may need
additional resources.

Identify and respect

familys coping
mechanisms as
appropriate.

Not all cultures or people display the same

response to stress. The nurse must respect
and accept the way each individual
responds to stress.

Evaluate resources or
support systems
available to the
family.

In some situations there may be no readily

available resources; other families may
hesitate to notify other family members
because of unresolved past conflicts.

Encourage the family The information the family needs will vary
to ask questions or
depending on the former experiences with
express concerns.
the illness.
Provide honest,
appropriate answers
to family members
questions.

Families must feel like they are getting

truthful and consistent answers amongst
healthcare providers to develop a sense of
trust.

Schedule care
conferences with the
family and healthcare
providers (physicians,
nurses, etc) to discuss
patient and family
needs.

This aids the family in staying realistically

involved, make decisions, and address any
concerns they may have surrounding the
extent of care and prognosis of the patient.

Provide the family

with a written
orientation guide to
the critical care
environment.

This is a stressful and uncertain time for

families. Basic needs such as waiting area,
telephone locations and how to contact the
unit should be provided. Some basic
information about the equipment and
common conditions should also be
provided to relieve their anxiety.

Assign the same

nurse to care for the

Consistent information from the same care

provider will build trust with the family

Family has dealt with

patient admission to the
hospital
frequently. Although
tearful, they seem to
understand all information
given to them. They ask
appropriate questions.
Family meets with the
healthcare team weekly for
patient updates and
understands the possible
outcomes for the patient.
When visiting they talk to
the patient and have
calming effect. They often
pray with pastoral care
during visiting.

patient whenever
possible.

members.

Develop an
individualized
visitation policy
based on the needs of
the patient.

Allowing the family more access to the

patient will enhance communication,
provide the family with more opportunity
to provide emotional support to the patient
and allow more opportunities for teaching.

Educate the family on Clarification and education to the family

the patients
may alleviate some anxiety and fears and
condition and needed help the family focus on realistic outcomes.
care. Provide written
material to reinforce
teaching.
References:
Gulianick, M. and Myers, J. (2003). Nursing Care Plans: Nursing Diagnosis and Interventions. Mosby:
St. Louis Taylor, K. Chapter 2. Care of the Critically Ill Patient

Nursing Care Plan

Nursing Diagnosis: Deficient Fluid Volume related to hypovolemia
Long Term Goals: The patient will experience adequate renal perfusion as evidenced by urine output
of at least 30 cc/hr

Outcome/ Short
Term PatientCentered Goals
The patient will
exhibit signs of
adequate perfusion:
*normal MAP 70
or greater
*urine output of 30
cc/hr
*HR 60-100
bpm.

Planning/Interventions

Monitor HR, BP and

hemodynamic
parameters every hour.

Rationale

Monitor daily weights.

Hemodynamic
parameters reveal
information about
adequacy of fluid
volume status.

Assess for signs and

symptoms of
intravascular volume
depletion if urine output
decreases. Consider
common causes of
decreased cardiac
output.

Acute renal failure

may be caused by
decreased cardiac
output related to
hypovolemia, trauma,
inadequate volume
replacement, burns,
heart failure, sepsis.

Evaluation

*HR, BP and
hemodynamics
are within normal
limits.

Promptly plan for

administration of fluids
to increase intravascular
fluid volume.

Both crystalloids and

colloids may be used
to boost intravascular
volume depending
upon the cause of the
fluid loss. Normal
saline fluid challenges
may be used until the
patients CVP reaches
12.

*Urine output
increases following
fluid replacement.
*HR, BP, CVP and
urine output are WNL
*Moist mucous
membranes.

Assess patient for signs

and symptoms of fluid
volume overload.

Fluid volume overload

is a possibility
anytime fluid
replacement occurs.

*The patient will

maintain normal
hemodynamic
parameters, clear
breath sounds, normal
respirations.

Administer
norepinephrine to
improve renal perfusion
if fluid challenges do
not improve MAP to 70
or greater.

Norepinephrine is now MAP = 70 or greater.

indicated to increase
BP and MAP for
patients with acute
renal failure.

Consult a nephrologist
if patient does not
respond to volume
resuscitation.

Studies have shown

that patients who are
referred to nephrology
early have better
outcomes.

Nursing Diagnosis: Excess Fluid Volume related to renal failure

Long Term Goals: The patient will experience normal fluid volume status as evidenced by balanced
intake and output, weight loss, stable vital signs, normal breath sounds and no JVD.

Outcome/
Short Term
PatientCentered
Goals

Planning/Interventions

The patient will Monitor HR, BP,

exhibit signs of hemodynamic pressures
optimal fluid
and urine output hourly.
volume status:
*normal

Rationale

Evaluation

Onset of tachycardia, increased

work of breathing, onset of
crackles, or elevated CVP or
PA pressures can all provide

HR 60-100
beats/min.
BP (MAP) = 70100.
Lungs are clear to

MAP (70-100)
*lungs clear
to auscultation Monitor daily weights
*HR 60-100 and maintain accurate I
bpm
& O.
*Intake
approximately
=
output

signs of fluid volume excess.

Daily weights provide an
accurate indicator of fluid
volume status. (1 lb = 500
mL).

Assess for possible

causes of fluid volume
excess.

Intrinsic renal failure is

commonly caused by
prolonged prerenal failure or
nephrotoxins. Nephrotoxicity
is a significant factor for
patients who have pre-existing
decreased renal function:
diabetics, older adults and
patients with decreased renal
perfusion.

Avoid administration of
drugs known to cause
nephrotoxicity:
NSAIDS,
aminoglycosides,
cephalosporins, contrast
media, ACE inhibitors.

For patients with diminished

renal function, exposure to
nephrotoxic agents can produce
serious insult to the kidneys.

Restrict total fluid intake

from all sources.

This will help to prevent

worsening fluid volume excess.
Possibly would add previous
days output plus insensible
fluid loss for total 24
allowance.

Concentrate IV
medication infusions.

To reduce total volume

administered over 24 hrs.

Prepare for continuous

renal replacement therapy
if output does not
improve.

Continuous renal replacement

therapy provides a means by
which fluid is removed in a
very controlled manner to
avoid hemodynamic
compromise. Renal
replacement therapy is
indicated when the patient
develops any of the following

auscultation.
Neck veins are
flat.
Respirations are
regular and easy.
Intake = 500;
Output = 450.

Fluid is removed
at the desired
hourly rate;
Patient remains
hemodynamically
stable.

during ongoing medical

therapy: oliguria with fluid
overload, hyperkalemia,
hyponatremia, severe acidemia,
azotemia, mental changes,
neuropathy, or pericarditis.