Cues Nursing Diagnosis Background Knowledge Goals And Objectives Nursing Interventions & Evaluation

Rationale

Subjective: Impaired impaired spontaneous venti NOC: Respiratory Status: Ventilation NIC: Mechanical Ventilation
 Dyspnea spontaneous lation a nursing diagnosis ac Management: Invasive
ventilation related cepted by the North America Goal (Long Term)
Objective: to respiratory n Nursing Diagnosis Associa After effective nursing interventions,
 Changes in rate and muscle weakness tion, defined as a state in whi the client will be able to reestablish and
depth of respiration or paralysis ch an individual's decreased  maintain effective respiratory pattern
 increased work of evidenced by energy reserves result in inab via ventilator with absence of
breathing altered chest ility to maintain breathing ad retractions and use of accessory
 use of accessory expansion and equate to support life. muscles, cyanosis, or other signs of
muscles respiratory depth hypoxia; ABGs and oxygen saturation
 Reduced VC and changes secondary impaired spontaneous within acceptable range and participate
total lung volume to Guillain-Barre ventilation. (n.d.) Miller- in efforts to wean (as appropriate)
 Increase in Syndrome Keane Encyclopedia and within individual ability
metabolic rate Dictionary of Medicine,
Nursing, and Allied Health, Objectives:
 Decrease in partial
Seventh Edition. (2003). After nursing interventions, the client The nurse will:
pressure of oxygen
Retrieved July 23 2021 will be able to:
(P O 2 ), arterial
from https://medical- 1. Determine degree of impairment 1. Investigate etiology of 1. The client was able
oxygen saturation
dictionary.thefreedictionary.c respiratory failure. Understanding to determine degree of
(Sa O 2 ); increase
om/impaired+spontaneous+v the underlying cause of client’s impairment.
in partial pressure
entilation particular ventilatory problem is
of carbon dioxide
essential to the care of client, for
(P CO 2 )
example, decisions about future
capabilities and ventilation needs
and most appropriate type of
ventilatory support.

Assess spontaneous respiratory

pattern, noting rate, depth, rhythm,
symmetry of chest movement, use of
accessory muscles. Tachypnea,
 shallow breathing, demonstrated or
reported dyspnea (using a numeric
or similar scale); increased heart
rate, dysrhythmias; pallor or
cyanosis; and intercostal
retractions and use of accessory
muscles indicate increased work of
breathing or impaired gas exchange
impairment.

Auscultate chest periodically, noting

presence or absence and equality of
breath sounds, adventitious breath
sounds, and symmetry of chest
movement. Provides information
regarding airflow through the
tracheobronchial tree and the
presence or absence of fluid,
mucous obstruction.

Collaborate with physician, 2. The client was able

2. Receive and maintain ventilatory respiratory care practitioners to receive and maintain
assistance/support regarding effective mode of ventilator
ventilation (e.g., noninvasive assistance/support
oxygenation via continuous positive
airway pressure (CPAP)
and biphasic positive airway
pressure [BiPAP]); or intubation and
mechanical ventilation (e.g.,
continuous mandatory,
assist control, intermittent
mandatory [IMV], pressure
support). Specific mode is
determined by client’s respiratory
requirements, presence of
underlying disease process, and
the extent to which client can
participate in ventilatory efforts.

Ensure that ventilator settings and

parameters are correct as ordered by
client situation, including respiratory
rate, fraction of inspired oxygen (F
IO 2, expressed as a percentage);
tidal volume; peak inspiratory
pressure.

Verify that client’s respirations are

in phase with the ventilator.
Adjustments may be required in
flow, tidal volume, respiratory rate,
and dead space of the ventilator, or
client may need sedation to
synchronize respirations and reduce
work of breathing and energy
expenditure.

Check tubing for obstruction (e.g.,

kinking or accumulation of water)
that can impede flow of oxygen.
Drain tubing as indicated; avoid
draining toward client or back into
the reservoir, resulting in
contamination and providing
medium for growth of bacteria.
 Inflate tracheal or ET tube cuff
properly, using minimal leak and
occlusive technique. Check cuff
inflation every 4 to 8 hours and
whenever cuff is deflated and
reinflated. The cuff must be properly
inflated to ensure adequate
ventilation and delivery of desired
tidal volume and to decrease risk of
aspiration.

3. Prepare for weaning process if Determine mode for weaning. 3. The client was able
appropriate Pressure support mode or multiple to prepare for weaning
daily T-piece trials may be superior process
to IMV; lowlevel pressure support
may be beneficial for spontaneous
breathing trials; and early
extubation and institution of
noninvasive positive pressure
ventilation may have substantial
benefits in alert, cooperative client.

Assist client in “taking control” of

breathing if weaning is attempted or
ventilatory support is interrupted
during procedure or activity.
Coaching client to take slower,
deeper breaths; practice abdominal
or pursed-lip breathing; assume
position of comfort; and use
relaxation techniques can be helpful
in maximizing respiratory function.