Nursing diagnosis: risk for dysfunctional Ventilatory Weaning Response

Risk factors may include

Sleep disturbance
Limited or insufficient energy stores
Pain or discomfort
Adverse environment, such as inadequate monitoring or support
Client-perceived inability to wean; decreased motivation
History of extended weaning

Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will

Respiratory Status: Ventilation
Actively participate in the weaning process.
Reestablish independent respiration with ABGs within acceptable range and free of
signs of respiratory failure.
Demonstrate increased tolerance for activity and participate in self-care within level
of ability.

Nursing intervention with rationale:

1. Assess physical factors involved in weaning as follows: Stable heart rate/rhythm,
blood pressure (BP), and clear breath sounds.
Rationale: The heart has to work harder to meet increased energy needs associated
with weaning. Physician may defer weaning if tachycardia, pulmonary crackles, or
hypertension are present.

2. Explain weaning techniques, for example, spontaneous breathing trial (SBT), T-

piece, pressure support ventilation (PSV), and spontaneous intermittent maximal
ventilation (SIMV). Discuss individual plan and expectations.
Rationale: Assists client to prepare for weaning process, helps limit fear of unknown,
promotes cooperation, and enhances likelihood of a successful outcome. Note:
Current guidelines
recommend SBT as the preferred method of weaning as it withdraws ventilatory
support while oxygenation is continued. The simplest form of SBT is the T-piece trial.
In PSV weaning, all breaths are spontaneous and combined with enough pressure
support to ensure that each breath is a reasonable tidal volume. Findings from
randomized trials suggest that SIMV weaning delays extubation compared with PSV
and SBT and that it should not be the primary mode of weaning in most clients (Byrd
et al, 2006).

3. Provide undisturbed rest and sleep periods. Avoid stressful procedures or situations
and nonessential activities.
Rationale: Maximizes energy for weaning process; limits fatigue and oxygen
consumption. Note: It takes approximately 12 to 14 hours of respiratory rest to
rejuvenate tired respiratory
muscles. For clients on AC, raising the rate to 20 breaths per minute can also provide
respiratory rest.

4. Evaluate and document client’s progress. Note restlessness; changes in BP, heart
rate, and respiratory rate; use of accessory muscles; discoordinated breathing with
ventilator;
increased concentration on breathing (mild dysfunction); client’s concerns about
possible machine malfunction; inability to cooperate or respond to coaching; and
color
changes.
Rationale: Indicators that client may require slower weaning and an opportunity to
stabilize, or may need to stop program. Note: Moving from pressure/volume (such as
assist/control)
ventilator to T-piece may precipitate a “flash” form of heart failure requiring prompt
intervention.

5. Recognize and provide encouragement for client’s efforts.

Rationale: Positive feedback provides reassurance and support for continuation of
weaning process.

6. Monitor cardiopulmonary response to activity.

Rationale: Excessive oxygen consumption and demand increases the possibility of
failure.

7. Consult with dietitian and nutritional support team for adjustments in composition
of diet.
Rationale: Reduction of carbohydrates and fats may be required to prevent excessive
production of CO2, which could alter respiratory drive.

8. Monitor CBC, serum albumin and prealbumin, transferrin, total iron-binding

capacity, and electrolytes, especially potassium, calcium, and phosphorus.
Rationale: Verifies that nutrition is adequate to meet energy requirements for
weaning.

9. Review chest x-ray and ABGs.

Rationale: Chest x-rays should show clear lungs or marked improvement in
pulmonary congestion or infiltrates. ABGs should document satisfactory oxygenation
on an FiO2 of 40% or less.

Risk for Infection | Nursing Care Plan

for Ventilatory Assistance
Nursing diagnosis: risk for Infection

Risk factors may include

Inadequate primary defenses—traumatized lung tissue, decreased ciliary action, stasis
of body fluids
Inadequate secondary defenses—immunosuppression
Chronic disease, malnutrition
Invasive procedure—intubation

Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will

Knowledge: Infection Control
Indicate understanding of individual risk factors.
Identify interventions to prevent or reduce risk of infection.
Demonstrate techniques to promote safe environment.

Nursing care plan intervention with rationale:

1. Note risk factors for occurrence of infection.
Rationale: Intubation interferes with the normal defense mechanisms that keep
microorganisms out of the lungs. ET tubes, especially cuffed ones, interfere with the
mucociliary transport system that helps clear airway secretions. Secretions that
accumulate below and above the ET tube cuff are ideal growth medium for pathogens.
The ET tube also prevents normal closure of the epiglottis, resulting in an incomplete
seal of the laryngeal structures that normally protect the lungs. This can contribute to
aspiration, which often leads to ventilator-associated pneumonia (VAP) (Pruitt &
Jacobs, 2006). VAP is the primary cause of hospital-acquired pneumonia (HAP)
reportedly occurring in 10% to 25% of individuals receiving mechanical ventilation
(Byrd et al, 2006). Other factors include prolonged mechanical ventilation, trauma,
general debilitation, malnutrition, age, and invasive procedures. Awareness of
individual risk factors provides opportunity to limit effects and helps prevent VAP.

2. Observe color, odor, and characteristics of sputum. Note drainage around

tracheostomy tube.
Rationale: Yellow or green, purulent odorous sputum is indicative of infection; thick,
tenacious sputum suggests dehydration.

3. Engage in proper hand washing or alcohol-based hand rubs, wear gloves when
handling respiratory secretions and equipment contaminated with respiratory
secretions, maintain sterile suction techniques in open system, use closedsystem ET
tube allowing for continuous removal of secretions, reduce the number of times the
ventilator tubes are open, and provide clean nebulizer and tubing changes.
Rationale: These factors may be the simplest but are the most important keys to
prevention of hospital-acquired infection. Note: The Centers for Disease Control and
Prevention’s (CDC) (2005) guidelines recommend changing tubing no more often
than every 48 hours. Research indicates that less frequent tubing changes (every 5 to 7
days) may be acceptable.
4. Encourage deep breathing, coughing, and frequent position changes.
Rationale: Maximizes lung expansion and mobilization of secretions to prevent or
reduce atelectasis and accumulation of sticky, thick secretions.

5. Auscultate breath sounds.

Rationale: Presence of rhonchi and wheezes suggests retained secretions requiring
expectoration or suctioning.

6. Provide or instruct client and SO in proper oral care and secretion disposal, such as
disposing of tissues and soiled tracheostomy dressings.
Rationale: Reduces risk of pneumonia associated with aspiration of oral bacteria, as
well as transmission of fluidborne organisms. Note: Chlorhexidine mouth rinse has
been found to reduce
plaque and gingival inflammation as a means of preventing VAP.

7. Monitor and screen visitors. Avoid contact with persons with respiratory infections.
Rationale: Individual is already compromised and is at increased risk with exposure to
infections.

8. Provide respiratory isolation when indicated.

Rationale: Depending on specific diagnosis, client may require protection from others
or must prevent transmission of infection, for example, tuberculosis (TB) to others.

9. Maintain adequate hydration and nutrition. Encourage fluids to 2,500 mL/day

within cardiac tolerance.
Rationale: Helps improve general resistance to disease and reduces risk of infection
from static secretions.

10. Measure pH of gastric secretions, and monitor use of antacid medications, as

indicated.
Rationale: Maintaining acid level of stomach about pH of 7.2 may help reduce risk of
nosocomial infection and stress ulcers and contamination of respiratory tract by
means of reflux and
aspiration.

-----

Imbalanced Nutrition: Less than Body

Requirements
Nursing diagnosis: Imbalanced Nutrition: Less than Body Requirements related to
altered ability to ingest and properly digest food; increased metabolic demands

Possibly evidenced by
Weight loss and poor muscle tone
Aversion to eating; reported altered taste sensation
Sore, inflamed buccal cavity
Absence of or hyperactive bowel sounds

Desired Outcomes/Evaluation Criteria—Client Will

Nutritional Status
Indicate understanding of individual dietary needs.
Demonstrate progressive weight gain toward goal with normalization of laboratory
values.

Nursing intervention with rationale:

1. Evaluate ability to eat.
Rationale: Client with a tracheostomy tube may be able to eat, but client with ET tube
must be tube fed or parenterally nourished.

2. Observe and monitor for generalized muscle wasting and loss of subcutaneous fat.
Rationale: These symptoms are indicative of depletion of muscle energy and can
reduce respiratory muscle function.

3. Weigh, as indicated.
Rationale: Significant and recent weight loss (7% to 10% body weight) and poor
nutritional intake provide clues regarding catabolism, muscle glycogen stores, and
ventilatory drive
sensitivity.

4. Document oral intake if and when resumed. Offer foods that client enjoys.
Rationale: Appetite is usually poor and intake of essential nutrients may be reduced.
Offering favorite foods can enhance oral intake.

5. Provide small frequent feedings of soft and easily digested foods if able to swallow.
Rationale: Prevents excessive fatigue, enhances intake, and reduces risk of gastric
distress.

6. Encourage or administer fluid intake of at least 2,500 mL/day within cardiac

tolerance.
Rationale: Prevents dehydration that can be exacerbated by increased insensible losses
(ventilator or intubation) and reduces risk of constipation.

7. Assess GI function: presence and quality of bowel sounds and changes in

abdominal girth, nausea, and vomiting. Observe and document changes in bowel
movements, such as diarrhea
and constipation. Test all stools for occult blood.
Rationale: A functioning GI system is essential for the proper utilization of enteral
feedings. Mechanically ventilated clients are at risk of developing abdominal
distention (trapped air or
ileus) and gastric bleeding (stress ulcers).

8. Adjust diet to meet respiratory needs, as indicated.

Rationale: High intake of carbohydrates, protein, and calories may be desired or
needed during ventilation to improve respiratory muscle function. Carbohydrates may
be reduced and fat somewhat increased just before weaning attempts to prevent
excessive CO2 production and reduced respiratory drive.

9. Administer tube feeding or hyperalimentation, as needed.

Rationale: Provides adequate nutrients to meet individual needs when oral intake is
insufficient or not appropriate.

10. Monitor laboratory studies as indicated, such as prealbumin, serum transferrin,

BUN/Cr, and glucose.
Rationale: Provides information about adequacy of nutritional support or need for
change.

Impaired Oral Mucous Membrane |

Nursing Care Plan for Ventilatory
Assistance

Nursing diagnosis: Impaired Oral Mucous Membrane

Risk factors may include

Inability to swallow oral fluids
Presence of tube in mouth
Lack of or decreased salivation
Ineffective oral hygiene

Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will

Tissue Integrity: Skin and Mucous Membrane
Report or demonstrate a decrease in symptoms.

Caregiver Will
Identify specific interventions to promote healthy oral mucosa as appropriate.

Nursing intervention with rationale:

1. Routinely inspect oral cavity, teeth, gums for sores, lesions, and bleeding.
Rationale: Early identification of problems provides opportunity for appropriate
intervention and preventive measures.

2. Administer mouth care routinely per protocol and as needed, especially in client
with an oral intubation tube; for example, cleanse mouth with water, saline, or
preferred alcoholfree mouthwash. Brush teeth with soft toothbrush, WaterPik, or
moistened swab.
Rationale: Prevents drying and ulceration of mucous membrane and reduces medium
for bacterial growth. Promotes comfort.

3. Change position of ET tube and airway on a regular and prn (as necessary)
schedule as appropriate.
Rationale: Reduces risk of lip and oral mucous membrane ulceration.

4. Apply lip balm; administer oral lubricant solution.

Rationale: Maintains moisture and prevents drying.

Impaired Gas Exchange | Nursing Care

Plan for Respiratory Alkalosis

Nursing diagnosis: impaired Gas Exchange related to ventilation-perfusion imbalance,

such as altered oxygen supply, altered blood flow, altered oxygen-carrying capacity of
blood,

alveolar-capillary membrane changes

Possibly evidenced by
Dyspnea, tachypnea
Changes in mentation
Hypocapnia, tachycardia
Hypoxia

Desired Outcomes/Evaluation Criteria—Client Will

Electrolyte and Acid-Base Balance
Demonstrate improved ventilation and adequate oxygenation of tissue as evidenced
by ABGs within client’s acceptable limits and absence of symptoms of respiratory
distress.
Verbalize understanding of causative factors and appropriate interventions.
Participate in treatment regimen within level of ability or situation.
Nursing intervention with rationale:
1. Monitor respiratory rate, depth, and effort; ascertain cause of hyperventilation if
possible, for example, anxiety, pain, and improper ventilator settings.
Rationale: Identifies alterations from usual breathing pattern and influences choice of
intervention.

2. Assess level of awareness and cognition. Note neuromuscular status—strength,

tone, reflexes, sensation, and presence of tremors.
Rationale: Decreased mentation (mild to severe) and tetany or seizures may occur
when alkalosis is severe due to shifts in calcium.

3. Instruct and encourage client to breathe slowly and deeply. Speak in a low, calm
tone of voice. Provide safe environment.
Rationale: May help reassure and calm the agitated client, thereby aiding the
reduction of respiratory rate. Assists client to regain control. Note: Clients with
hyperventilation syndrome as a cause of their respiratory alkalosis may particularly
benefit from reassurance and client education in breathing techniques.

4. Demonstrate appropriate breathing patterns, if appropriate, and assist with

respiratory aids, such as rebreathing mask or bag.
Rationale: Decreasing the rate of respirations can halt the “blowing off” of CO2,
elevating PaCO2 level and normalizing pH.

5. Provide comfort measures; encourage use of meditation and visualization. Use

tepid sponge bath or cool cloths.
Rationale: Promotes relaxation and reduces stress. Control and reduction of fever
reduces potential for seizures and helps reduce respiration rate.

6. Provide safety and seizure precautions, such as bed in low position, padded side
rails, frequent observation.
Rationale: Changes in mentation and CNS and neuromuscular hyperirritability may
result in client harm, especially if tetany or convulsions occur.

7. Discuss cause of condition, if known, and appropriate interventions and self-care

activities.
Rationale: Promotes participation in therapeutic regimen and may reduce recurrence
of disorder.

8. Assist with identification and treatment of underlying cause.

Rationale: Respiratory alkalosis is a complication, not an isolated occurrence and
rarely requires emergent treatment (unless pH is greater than 7.5); thus, correction of
alkalosis is undertaken by addressing the primary condition, such as hyperventilation
of panic attack, organ failure, severe anemia, and drug effect. Because respiratory
alkalosis usually occurs in
response to some stimulus, treatment is unsuccessful unless the stimulus is controlled.

9. Monitor and graph serial ABGs and pulse oximetry.

Rationale: Identifies therapy needs and effectiveness. Note: Rapid correction of
PaCO2 in individual with chronic respiratory alkalosis (has a lower serum
bicarbonate) may cause metabolic acidosis to develop.

10. Monitor serum potassium and replace, as indicated.

Rationale: Hypokalemia may occur as potassium is lost via urine or shifted into the
cell in exchange for hydrogen in an attempt to correct alkalosis.

Nursing diagnosis: Ineffective airway

clearance related to foreign body (artificial
airway) in the trachea; inability to cough or
ineffective cough
Possibly evidenced by
Changes in rate or depth of respiration
Cyanosis
Abnormal breath sounds
Anxiety and restlessness

Desired Outcomes/Evaluation Criteria—Client Will

Respiratory Status: Airway Patency
Maintain patent airway with breath sounds clear.
Be free of aspiration.

Caregiver Will
Identify potential complications and initiate appropriate actions.

Nursing intervention with rationale:

1. Assess airway patency.
Rationale: Obstruction may be caused by accumulation of secretions, mucous plugs,
hemorrhage, bronchospasm, and problems with the position of tracheostomy or ET
tube.

2. Evaluate chest movement and auscultate for bilateral breath sounds.

Rationale: Symmetrical chest movement with breath sounds throughout lung fields
indicates proper tube placement and unobstructed airflow. Lower airway obstruction,
such as pneumonia
or atelectasis, produces changes in breath sounds, such as rhonchi and wheezing.
3. Monitor ET tube placement. Note lip line marking and compare with desired
placement. Secure tube carefully with tape or tube holder. Obtain assistance when
retaping or
repositioning tube.
Rationale: The ET tube may slip into the right main-stem bronchus, thereby
obstructing airflow to the left lung and putting client at risk for a tension
pneumothorax.

4. Note excessive coughing, increased dyspnea (using a 0 to 10 scale), high-pressure

alarm sounding on ventilator, visible secretions in endotracheal or tracheostomy tube,
and increased rhonchi.
Rationale: The intubated client often has an ineffective cough reflex, or client may
have neuromuscular or neurosensory impairment, altering ability to cough. Client is
usually dependent on suctioning to remove secretions. Note: Research supports use of
a dyspnea rating scale (like those used to measure pain) to more accurately quantify
and measure
changes in dyspnea as experienced by client.

5. Suction as needed when client is coughing or experiencing respiratory distress,

limiting duration of suction to 15 seconds or less. Choose appropriate suction catheter.
Hyperventilate before and after each catheter pass, using 100% oxygen if appropriate,
using vent rather than Ambu bag, which has an increased risk of barotrauma. Suction
continuously or intermittently during withdrawal.
Rationale: Suctioning should not be routine, and duration should be limited to reduce
hazard of hypoxia. Suction catheter diameter should be less than 50% of the internal
diameter of the ET or tracheostomy tube for prevention of hypoxia.
Hyperoxygenation with ventilator sigh on 100% oxygen may be desired to reduce
atelectasis and to reduce accidental hypoxia. Note: Instilling normal saline (NS) is no
longer recommended (although it persists in practice) because research reveals that
the fluid pools at the distal end of the ET or tracheal tube, impairing oxygenation and
increasing bronchospasm and the risk of infection.

6. Use inline catheter suction when available.

Rationale: Reduces risk of infection for healthcare workers and helps maintain
oxygen saturation and PEEP when used.

7. Instruct client in coughing techniques during suctioning, such as splinting, timing

of breathing, and “quad cough,” as indicated.
Rationale: Enhances effectiveness of cough effort and secretion clearing.

8. Reposition or turn periodically.

Rationale: Promotes drainage of secretions and ventilation to all lung segments,
reducing risk of atelectasis.

9. Encourage the client to drink fluids and provide fluids within individual capability.
Rationale: Helps liquefy secretions, enhancing expectoration.

10. Provide chest physiotherapy as indicated, such as postural drainage and

percussion.
Rationale: Promotes ventilation of all lung segments and aids drainage of secretions.