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CARE FOR CLIENT

A. Enhancing Gas Exchange


Administer analgesic agents to relieve pain
Frequent repositioning to diminish the pulmonary effects of immobility
Monitor for adequate fluid balance by assessing for the presence of peripheral edema,
calculating daily intake and output and monitoring daily weight.

B. Promoting Effective Airway Clearance


Auscultate lungs at least every 2-4 hours to assess for secretions
Suctioning
Frequent position changes
Humidification of the airway via the ventilator is maintained to help liquefy secretions
Administer bronchodilators.

C. Preventing Trauma and Infection


Tracheostomy care
Ventilator circuit and in line suction tubing are replaced periodically
Oral hygiene
If with NGT, elevate head above the stomach to prevent aspiration

D. Promoting Optimal Level of Mobility


Active/passive range of motion exercises every 6-8 hours to prevent contractures and
venous stasis.

E. Promoting Optimal Communication


Pen and paper
Sign language
Glasses and hearing aid should be accessible.

F. Monitoring and Managing Potential Complications


• Alterations in Cardiac Function
Observe for signs and symptoms of hypoxia
If a pulmonary artery catheter is in place, cardiac output, cardiac index and other
hemodynamic values can be used to assess patient’s status.

• Barotrauma and Pneimothorax


Monitor oxygen saturation and repiratory distress

• Pulmonary Infection
Monitor temperature
Monitor change in color or odor of sputum

NURSING CARE PLANS


#1 Nursing Diagnosis: Impaired Gas Exchange and Ineffective Breathing Pattern related to
underlying disease process and artificial airway and ventilator system.
Outcomes: The client will have improved gas exchange and breathing pattern, ventilation of
both lungs, no manifestation of hypoxemia (O2 saturation >90%, respiratory rate <24
breaths/min, no restlessness), arterialblood gases (ABGs) and acid-base balance will return
to preintubation level or normal values.

Interventions Rationale
1. Auscultate lung sounds and respiratory rate and pattern every 1 to 2 hours as needed.

2. Provide adequate humidity via the ventilator or nebulizer.

3. Turn and reposition the client every 2 hours.

4. Monitor ABG values and pulse oximetry. 1. Auscultation reveals the amount of fluids and
secretion in the lungs validates that the ET tube is placed correctly so that both lungs can be
ventilated, and determines ventilatory effectiveness.
2. Replaces the function of the upper airway to warm and humidify the inspired air; thins
secretions tp facilitate their removal.
3. Turning promotes the ventilation of both lungs and mobilization of secretions.
4. Degree of oxygenation can be indicated; lack of improvement in ABGs or falling oximetry
may require a change in interventions.

Evaluation: If the client’s underlying problem has been corrected by mechanical ventilation,
these outcomes will be met quickly. If the client has a pre-existing pulmonary disease or is
acutely ill, it may take several days for attainment of outcomes.

#2 Nursing Diagnoses: Ineffective Airway Clearance related to inability to cough and


stimulation of increased secretion formation in the lower tracheobronchial tree from the ET
tube.

Outcomes: The client will have improved airway clearance, as evidenced by fewer crackles,
fewer wheezes, and an absence of fever.

Interventions Rationale
1. Assess the need for suctioning: noisy, wet respirations; restlessness, increased pulse and
respirations; visible mucus bubbling into the ET tube; and an increase in peak airway
pressure.
2. Thoroughly explain the procedure before starting, and provide reassurance to the client
throughout.
3. Airway suctioning is performed on an “as-needed” basis, not at regularly scheduled
intervals.
4. Select a catheter of appropriate size. The most common sizes for adults are 12F and 14F.

5. Avoid excessive vacuum pressures that may traumatize the airway.


6. Maintain sterility throughout the procedure. Use closed system for suctioning. Clean
gloves can be used for closed suctioning; sterile gloves are needed for open suctioning.
7. Hyperoxygenate before and after each suctioning attempt and after the procedure.
Increase the FiO2 on ventilator (remember to return to previous setting upon completion) or
manually ventilate the client.
8. Instill saline infrequently and only when secretions are tenacious. 1. Detecting the need
for suctioning early can prevent desaturation.

2. Suctioning can be an uncomfortable and frightening experience.

3. Suctioning can traumatize the airway and mucosa.

4. The suction catheter should never exceed half the diameter of an artificial airway or the
natural airway it is to enter.
5. The safe range of pressure for adults is 80 to 120 mm Hg.

6. Usual cilia clearance and cough are suppressed. Closed systems avoid opening the ET
tube and exposing the airway to the environment.

7. Providing extra oxygen prevents desaturation from functioning.

8. Excess saline instillation before suctioning has been associated with pulmonary edema.

Peter Paul Ceballos Pacapac September 15 at 7:49pm


#3 Nursing Diagnoses: Impaired Spontaneous Ventilation related to imbalance between
ventilator capacity and ventilator demand.

Outcomes:.The client will have a normal respiratory rate and pattern, return of arterial blood
gases (ABGs) and pulse oximetry to normal, decreased dyspnea, absence of air trapping,
and no complications after continuous mechanical ventilation.

Interventions Rationale
1. Check ventilator settings, FiO2, alarms, and connections and endotracheal (ET) tube
placement (use cm markings) at beginning of each shift, hourly thereafter, and after any
changes.
2. Assess lung sound every 1-2 hours as indicated.

3. Check placement of the ET tube, and secure the tube.

4. Use a bite block.


5. Assess for manifestations of skin or mucous membrane irritation every shift.

6. Assess for agitation, distress, and “fighting” the ventilator.

7. Assess for an obstructed airway. If it is obstructed, manually inflate lungs with a


resuscitation bag and 100% Oxygen and suction the airway.

8. Sedate ae.nd paralyze the client if ventilator settings and oxygenation are adequate.
9. Medicate the patient if pain is indicate.

10. Perform passive reange of motion or assisted ROM exercises, transfer the client to chair
when feasib 1. Determine baseline values, and validate that settings are accurate. Ensure
that alarms are functional

2. Lung sound should be present bilaterally (unless a previous change in lung sounds is
known.)
3. The visible portion of the ET tube should not change. Check for previous records for a
mark that is visible( in cm). securing prevents dislodgement.

4. A bite block prevents the client from chewing on the tube and ET tube compression.

5. ET tubes can place pressure on the lips and oral mucosa at the ET tube site.

6. An incorrect ventilator set-up may be providing less air than the client requires.

7. Airway obstruction with the mucus may prevent oxygenation. Providing air to the client is
imperative. A common cause of obstruction is retained secretions.

8. Sedation and paralysis may be required to prevent mismatch.

9. Pain can lead to agitation.

10. Immobility leads to decreased respiratory muscle strength.

Evaluation: The timing of goal attainment will vary greatly because of underlying co-morbid
conditions. Expect postoperative clients require CMV for 24 hours or less. Clients with end-
stage pulmonary disease may require prolonged ventilator support

#4 Nursing Diagnoses: Anxiety related to dependence on CMV for breathing

Outcomes: The client will exhibit decreased anxiety as evidenced by reduction in the level of
stress or anxiety and decreased level of stress or anxiety and decreased feelings of
powerlessness.

Interventions Rationale
1. Develop a means of communication.
2. Place a nurse-call device within the client’s reach.
3. Be available and visible.

4. Provide distractions.

5. Explain all procedures.

6. Medicate as necessary for


anxiety.

7. Provide privacy.

8. Respect the client’s rights and opinions.

9. Provide a calm environmen 1. Communication allows the client to have needs met.
2. Anxiety is increased when fear of being alone is present.
3. The client’s anxiety is alleviated when not alone.
4. Anxiety is reduced because the client does not focus on the ventilator and noises.
5. The client feels respected and fears are alleviated.
6. Anti-anxieyt medications and opioids may be needed, but use them with cautionduring
weaning because these drugs suppress respiratory drive.
7. Providing privacy demonstrate respect for the client.

8. The client feels respected and maintains dignity when include in the discussion.

9. A frenzied environment engenders anxiety; if the client becomes anxious, ventilation is


more difficult and oxygen needs increase.

Evaluation: Expect the client to remain moderately anxious while receiving CMV.

#5 Nursing Diagnoses: Risk for Infection related to impaired primary defenses in the
respiratory tract.

Outcomes: The client will remain free of infection, as evidenced by clear sputum, no fever,
clear lung sounds, no increased difficulty with ventilation, white blood cell count within
normal limits, and respiratory rate within 24 breaths/min.
Interventions Rationale
1. Wash your hands thoroughly
2. Use sterile technique for open suctioning.
3. Monitor the client for increased breathing effort, localized changes in auscultation, and
changes in PaO2.
4. Provide oral care every 2 hours.
5. Drain water from ventilator tubing; do not drain water back into the humidifier.
6. Monitor WBC count and differential.
7. Monitor sputum for changes in color, consistency, amount, and odor. 1. Hand washing
reduces spread of infection.
2. The respiratory tract is considered sterile.
3. Infected lung segments transmit sound differently (more solid) and do not permit gas
exchange.
4. The client’s mouth becomes dry, and stomatitis may develop from lack of oral secretions.
5. Water may become a source of contamination, especially with Pseudomonas.
6. WBC count increases may indicate infection.
7. Infection may cause sputum to increase, darken, thicken, and become malodorous.

Evaluation: Infection usually develops after 72 hours of intubation unless the client is
immunosuppressed; then infection develops more rapidly.
#6 Nursing Diagnoses: Impaired Verbal Communication related to mute state when the ET
tube is in place.

Outcomes: The client will be able to communicate with the health care providers in order to
have basic needs met.

Interventions Rationale
1. Help the client develop a means of communication. Keep a pencil and paper pad or a
picture board readily available.
2. Be patient and willing to spend time communicating. 1. With the ET tube passing through
the vocal cords, the client cannot cough effectively or speak.
2. Prevents feelings of frustration, and reduces anxiety.

Evaluation: Depending on pre-existing problems (language), disease-related problems


(confusion), or treatment-related problems (restraints) affecting communication, the timing
to develop effective communication may be long or short.

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