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Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 66: Nursing Management: Critical Care


Care Plans - Customizable
eNCP 66-1: Nursing Care Plan
Patient on Mechanical Ventilation
NURSING DIAGNOSIS: Risk for injury related to artificial airway, possible ventilator
malfunction, accidental disconnection/extubation, inability to breathe unassisted,
asynchrony with ventilator, and settings ineffective in maintaining adequate oxygenation
PATIENT GOALS 1. Experiences no injury from effects of mechanical ventilation
2. Maintains ABGs and ventilation/perfusion within normal parameters
3. Maintains synchronous breathing with ventilator
OUTCOMES (NOC)
INTERVENTIONS (NIC) AND RATIONALES
Mechanical Ventilation Response: Mechanical Ventilation Management: Invasive
Adult
Respiratory rate ____
Check all ventilator connections regularly to avoid accidental
disconnections.
Tidal volume ___
Monitor for adverse effects of mechanical ventilation (e.g.,
End-tidal carbon dioxide ____
tracheal deviation, infection, barotrauma, volutrauma, reduced
FIO2 meets oxygen demand ____
cardiac output, gastric distention, subcutaneous emphysema)
PaO2 ____
to determine presence of risk factors and plan for appropriate
PaCO2 ____
intervention.
Oxygen saturation ____
Monitor for mucosal damage to oral, nasal, tracheal, or
Ventilation/perfusion balance
laryngeal tissue from pressure from artificial airways, high
____
cuff pressures, or unplanned extubations
_____________________
Routinely monitor ventilator settings (e.g., FIO2, respiratory
Measurement Scale
rate, tidal volume, O2 flow rate, PEEP, airway pressure,
1 = Severe deviation from normal
thermistor temperature, and I:E ratio) to determine if
range
appropriate to clinical situation.
2 = Substantial deviation from normal
Administer muscle-paralyzing agents, sedatives, and opioid
range
analgesics as needed to promote respirations synchronous
3 = Moderate deviation from normal
with ventilator.
range

Ensure that ventilator alarms are on to rapidly assess patient


4 = Mild deviation from normal range
and intervene appropriately.
5 = No deviation from normal range
Silence ventilator alarms during suctioning to decrease
frequency of false alarms.
Difficulty breathing with

Empty condensed water from water traps to prevent aspiration


ventilator ___
of accumulated fluid.
Restlessness ___
Monitor effects of ventilator changes on oxygenation: ABG,
Hypoxia ____
SaO2, SvO2, ScvO2, end-tidal CO2, patients subjective
_____________________
response to determine appropriateness of changes.
Measurement Scale
Artificial
Airway Management
1 = Severe
Provide an oropharyngeal airway or bite block to prevent
2 = Substantial
Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

Care Plans - Customizable


3 = Moderate
4 = Mild
5 = None

66-2

biting on the endotracheal tube, if needed.


Provide additional intubation equipment and Ambu-bag in a
readily available location for use in case of an emergency.
Auscultate for presence of lung sounds bilaterally after
insertion and after changing endotracheal/tracheostomy ties to
ensure appropriate placement of endotracheal tube.
Maintain inflation of the endotracheal/tracheostoma cuff at 15
to 20 mm Hg during mechanical ventilation to prevent air leak
or excessive pressure on trachea
Institute measures to prevent spontaneous decannulation:
secure artificial airway with tape/ties; administer sedation and
muscle paralyzing agent, as needed; and use arm restraints, if
needed.

NURSING DIAGNOSIS: Decreased cardiac output related to impeded venous return by


PPV as evidenced by BP, SV and PAWP, heart rate, decreased urine output,
presence of dysrhythmias, and mental confusion
PATIENT GOAL Experiences cardiac output adequate to meet systemic oxygen needs
OUTCOMES (NOC)
INTERVENTIONS (NIC) AND RATIONALES
Cardiac Pump Effectiveness
Hemodynamic Regulation
Systolic blood pressure ____
Monitor and document heart rate, rhythm, and
pulses to track trends.
Diastolic blood pressure ____
Monitor peripheral pulses, capillary refill, and
Cardiac index ____
temperature and color of extremities to detect
Ejection fraction ___
inadequate perfusion.
Peripheral pulses ___
Monitor cardiac output and/or cardiac index and
Urine output ____
left ventricular stroke work index to identify
Central venous pressure ____
decreased venous return to the heart, decreased
_____________________
left ventricular end-diastolic volume, and
Measurement Scale
lowered blood pressure.
1 = Severe deviation from normal range
Monitor pulmonary artery wedge pressure and
2 = Substantial deviation from normal range
central venous/right-arterial pressure to
3 = Moderate deviation from normal range
anticipate need for plasma expanders,
4 = Mild deviation from normal range
vasopressors, and IV fluids as ordered because
5 = No deviation from normal range
hemodynamic complications of decreased
venous return induced by positive pressure
ventilation are exaggerated by hypovolemia.

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

Care Plans - Customizable

66-3

NURSING DIAGNOSIS: Ineffective airway clearance related to presence of artificial


airway, problems with positioning, accumulation of secretions, and immobility as
evidenced by presence of abnormal breath sounds, absent cough, and presence of thick or
copious secretions
PATIENT GOAL Experiences normal breath sounds with repositioning, chest physical therapy,
and appropriate suctioning
OUTCOMES (NOC)
INTERVENTIONS (NIC) AND RATIONALES
Respiratory Status: Airway Patency
Ventilation Assistance
Accumulation of sputum ____
Auscultate breath sounds, noting areas of
decreased or absent ventilation and presence of
Adventitious breath sounds ____
adventitious breath sounds to detect risk for
_____________________
inadequate ventilation.
Measurement Scale
Assist with frequent position changes to
1 = Severe
2 = Substantial
mobilize respiratory sections.
3 = Moderate
Monitor the effects of position changes on
4 = Mild
oxygenation: ABG, SaO2, SvO2, ScvO2, and end5 = None
tidal CO2 levels to monitor trends and
effectiveness of interventions.
Mechanical Ventilation Management: Invasive
Perform chest physical therapy to prevent
pooling of secretions in the lungs.
Stop NG tube feedings during suctioning and
30-60 minutes before chest physical therapy to
prevent aspiration.
Perform suctioning based on presence of
adventitious breath sounds and/or increased
inspiratory pressure to remove secretions.
Use aseptic technique in all suctioning
procedures to prevent introducing
microorganisms into a compromised respiratory
system.
NURSING DIAGNOSIS: Impaired physical mobility related to imposed movement
restrictions as evidenced by limited range of motion, difficulty turning, and muscle
weakness
PATIENT GOALS 1. Maintains normal range of motion
2. Experiences no physiologic consequences of immobility
OUTCOMES (NOC)
INTERVENTIONS (NIC) AND RATIONALES
Immobility Consequences: Physiologic Exercise Therapy: Joint Mobility
Pressure sores _____
Perform passive or assisted range-of-motion
(ROM) exercises to maintain patients joint and
Contracted joints ____
muscle functioning and improve circulation.
Lung congestion ____
Encourage active ROM exercises according to
Hypoactive bowel ____
Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

Care Plans - Customizable


Venous thrombosis ____
_____________________
Measurement Scale
1 = Severe
2 = Substantial
3 = Moderate
4 = Mild
5 = None
Muscle strength ____
Muscle tone ____
Joint movement ____
_____________________
Measurement Scale
1 = Severely compromised
2 = Substantially compromised
3 = Moderately compromised
4 = Mildly compromised
5 = Not compromised

66-4
regular, planned schedule to increase muscle
strength and tone.
Assist patient to optimal body position for
passive/active joint movement to prevent
contractures and other musculoskeletal
complications (e.g., external rotation of hips).
Encourage patient to sit in bed, on side of bed
(dangle), or in chair to improve circulation
and oxygenation and facilitate exercises.
Positioning
Position in proper body alignment to prevent
strain on muscles and joints.
Use appropriate devices to support limbs (e.g.,
hand roll, trochanter roll) to prevent contracted
joints.
Turn the immobilized patient at least every 2
hours, according to a specific schedule, to
maintain skin integrity, mobilize respiratory
secretions, and prevent venous stasis.

NURSING DIAGNOSIS: Anxiety related to pain, inability to verbally communicate, fear of


death/suffocation/choking, ICU environment as evidenced by anxious appearance,
agitation, rigid body posture, and asynchronous breathing with ventilator
PATIENT GOALS 1. Expresses relaxed facial and muscle tension
2. Reports manageable anxiety level with nonverbal communication
OUTCOMES (NOC)
INTERVENTIONS (NIC) AND RATIONALES

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

Care Plans - Customizable


Anxiety Level
Restlessness ____
Distress ____
Muscle tension ____
Facial tension ____
Verbalized apprehension ____
_____________________
Measurement Scale
1 = Severe
2 = Substantial
3 = Moderate
4 = Mild
5 = None

66-5
Mechanical Ventilation Management: Invasive
Instruct the patient and family about the rationale
and expected sensations associated with use of
mechanical ventilators to foster a realistic
understanding of therapy and reassure patient
that breathing will be maintained.
Provide patient with a means of communication
(e.g., paper and pencil, alphabet board) to reduce
anxiety associated with inability to speak and to
provide means for patient to communicate
anxieties.
Initiate relaxation techniques to help patient
manage anxiety.
Provide care to alleviate patient distress (e.g.,
positioning, tracheobronchial toileting,
bronchodilator therapy, sedation and/or
analgesia, frequent equipment checks).
Coping Enhancement
Evaluate the patients decision-making ability to
allow for patient participation in plan of care as
appropriate.
Arrange situations that encourage patients
autonomy to help patient regain and maintain a
sense of control.
Encourage family to verbalize feelings about ill
family member to lessen their anxiety and
increase their cooperation.

NURSING DIAGNOSIS: Dysfunctional ventilatory weaning response related to too-rapid


pace of weaning plan, and insufficient knowledge of the weaning plan as evidenced by
restlessness, tachypnea, dyspnea, cyanosis, pallor, fatigue, / BP, use of accessory
muscles, tachycardia, O2 desaturation
PATIENT GOALS 1. Meets progressive ventilatory weaning goals
2. Remains extubated following initial weaning process
OUTCOMES (NOC)
INTERVENTIONS (NIC) AND RATIONALES

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

Care Plans - Customizable

66-6

Mechanical Ventilation Weaning


Response: Adult
Drive to breathe ____
Spontaneous respiratory rate ____
Spontaneous respiratory rhythm ____
PaO2 ____
PaCO2 ____
Oxygen saturation ____
Vital capacity ____
Tidal volume ____
_____________________
Measurement Scale
1 = Severe deviation from normal range
2 = Substantial deviation from normal
range
3 = Moderate deviation from normal range
4 = Mild deviation from normal range
5 = No deviation from normal range

Mechanical Ventilatory Weaning


Monitor predictors of ability to tolerate weaning
based on agency protocol (e.g., degree of shunt,
vital capacity, Vd/Vt, MVV, inspiratory force,
FEV1, negative inspiratory pressure).
Position patient for best use of ventilatory
muscles and to optimize diaphragmatic descent.
Initiate weaning with trial periods (30-120
minutes of ventilator-assisted spontaneous
breathing) to evaluate ability to breathe on own.
Instruct the patient and family about what to
expect during various stages of weaning to
decrease anxiety and facilitate cooperation.
Provide some means of patient control during
weaning to provide patient a level of control in
establishing the plan.
Set discrete, attainable goals with the patient for
weaning to maintain patient confidence.
Monitor for signs of respiratory muscle fatigue
(e.g., abrupt rise in PaCO2; rapid, shallow
Difficulty breathing on own ___
ventilation; paradoxic abdominal wall motion),
Impaired drive to breathe ___
hypoxemia, and tissue hypoxia while weaning is
Asymmetric chest wall movement ___
in progress to evaluate patients weaning
_____________________
progress.
Measurement Scale
Avoid delaying return of patient with fatigued
1 = Severe
respiratory muscles to mechanical ventilation to
2 = Substantial
ensure adequate ventilation.
3 = Moderate
Consider using alternative methods of weaning as
4 = Mild
determined by patients response to the current
5 = None
method to minimize frustration and
disappointment and enhance cooperation.

ABG, Arterial blood gas; FEV1, Forced expiratory volume in 1 second; FIO2,fraction of
inspired oxygen concentration; I:E ratio, duration of inspiration to duration of expiration;
MVV, maximal voluntary ventilation volume; NG, nasogastric; PaCO2, partial pressure of
carbon dioxide in arterial blood; PaO2, partial pressure of oxygen in arterial blood;
PAWP, pulmonary artery wedge pressure; PEEP, positive end-expiratory pressure; PPV,
positive pressure ventilation; SaO2, oxygen saturation in arterial blood measured by
ABGs; ScvO2, central venous oxygen saturation; SV, stroke volume; SvO2, mixed venous
oxygen saturation..

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

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