Mechanical ventilation is a life-supporting intervention that provides respiratory support to patients who cannot maintain adequate ventilation and oxygenation on their own. This nursing diagnosis focuses on identifying and addressing the complex needs of mechanically ventilated patients while preventing complications and promoting optimal outcomes.
Causes (Related to)
Mechanical ventilation may be necessary for patients due to various underlying conditions and factors:
- Respiratory failure (acute or chronic)
- Neuromuscular disorders
- Post-operative support
- Traumatic injuries
- Medical conditions such as:
- ARDS (Acute Respiratory Distress Syndrome)
- Severe pneumonia
- Sepsis
- Pulmonary edema
- Head trauma
- Contributing factors including:
- Airway obstruction
- Decreased level of consciousness
- Chest wall injuries
- Drug overdose
- Severe burns
Signs and Symptoms (As evidenced by)
Patients on mechanical ventilation present with various signs and symptoms that require careful monitoring and assessment.
Subjective: (If the patient can communicate)
- Anxiety or fear
- Discomfort from endotracheal tube
- Difficulty communicating
- The feeling of air hunger
- Pain or pressure in the chest
- Sensation of choking
- Thirst
Objective: (Nurse assesses)
- Ventilator parameters and readings
- Breath sounds
- Chest movement
- Oxygen saturation levels
- End-tidal CO2 readings
- Vital signs
- Arterial blood gas values
- Level of consciousness
- Secretion characteristics
- Work of breathing
Expected Outcomes
The following outcomes indicate successful management of mechanical ventilation:
- The patient will maintain adequate oxygenation and ventilation
- The patient will remain hemodynamically stable
- The patient will show no signs of ventilator-associated complications
- The patient will demonstrate synchrony with the ventilator
- The patient will maintain a patent airway
- The patient will progress toward ventilator weaning when appropriate
- The patient will maintain optimal nutrition status
- The patient will avoid hospital-acquired infections
Nursing Assessment
Monitor Ventilator Settings and Parameters
- Check the mode of ventilation
- Verify prescribed settings
- Monitor alarms and parameters
- Assess patient-ventilator synchrony
- Document all readings
Assess Respiratory Status
- Evaluate breath sounds
- Monitor chest expansion
- Check tube placement
- Assess secretions
- Monitor oxygen saturation
- Review blood gas results
Evaluate Hemodynamic Status
- Monitor vital signs
- Assess perfusion
- Check cardiac rhythm
- Monitor fluid balance
- Observe for complications
Assess Comfort and Safety
- Evaluate sedation level
- Monitor pain status
- Check restraints if used
- Assess pressure points
- Monitor psychological status
Monitor for Complications
- Watch for signs of VAP
- Assess for barotrauma
- Check for pressure injuries
- Monitor for deep vein thrombosis
- Evaluate nutritional status
Nursing Care Plans
Nursing Care Plan 1: Ineffective Breathing Pattern
Nursing Diagnosis Statement:
Ineffective Breathing Pattern related to mechanical ventilation support as evidenced by dependence on a ventilator and altered blood gas values.
Related Factors:
- Respiratory muscle weakness
- Neuromuscular impairment
- Acute respiratory failure
- Pain
- Anxiety
Nursing Interventions and Rationales:
- Monitor ventilator settings and parameters
Rationale: Ensures adequate ventilation support - Assess breath sounds and chest movement
Rationale: Identifies changes in respiratory status - Maintain proper positioning
Rationale: Optimizes ventilation-perfusion matching
Desired Outcomes:
- The patient will maintain adequate gas exchange
- The patient will demonstrate improved respiratory function
- The patient will show synchrony with the ventilator
Nursing Care Plan 2: Risk for Infection
Nursing Diagnosis Statement:
Risk for Infection related to invasive airway and mechanical ventilation as evidenced by risk factors for ventilator-associated pneumonia.
Related Factors:
- Presence of artificial airway
- Compromised host defenses
- Prolonged ventilation
- Multiple invasive procedures
Nursing Interventions and Rationales:
- Maintain sterile technique during suctioning
Rationale: Prevents introduction of pathogens - Perform oral care every 4 hours
Rationale: Reduces bacterial colonization - Maintain head-of-bed elevation at 30-45 degrees
Rationale: Prevents aspiration
Desired Outcomes:
- The patient will remain free from infection
- The patient will maintain a normal temperature
- The patient will show no signs of VAP
Nursing Care Plan 3: Impaired Gas Exchange
Nursing Diagnosis Statement:
Impaired Gas Exchange related to ventilation-perfusion mismatch as evidenced by abnormal arterial blood gas values.
Related Factors:
- Altered oxygen delivery
- Changes in alveolar-capillary membrane
- Inflammatory process
- Secretion accumulation
Nursing Interventions and Rationales:
- Monitor arterial blood gases
Rationale: Evaluate the effectiveness of ventilation - Perform airway clearance
Rationale: Maintains patent airway - Adjust ventilator settings as ordered
Rationale: Optimizes gas exchange
Desired Outcomes:
- The patient will maintain normal blood gas values
- The patient will demonstrate improved oxygenation
- The patient will show no signs of respiratory distress
Nursing Care Plan 4: Risk for Impaired Skin Integrity
Nursing Diagnosis Statement:
Risk for Impaired Skin Integrity related to immobility and medical devices as evidenced by pressure points from ETT and other equipment.
Related Factors:
- Limited mobility
- Pressure from medical devices
- Nutritional deficits
- Moisture
Nursing Interventions and Rationales:
- Implement turning schedule
Rationale: Reduces pressure on skin - Assess skin condition regularly
Rationale: Identifies early signs of breakdown - Maintain proper ETT securing
Rationale: Prevents pressure injuries
Desired Outcomes:
- The patient will maintain intact skin
- The patient will show no signs of pressure injury
- The patient will demonstrate improved tissue perfusion
Nursing Care Plan 5: Anxiety
Nursing Diagnosis Statement:
Anxiety related to mechanical ventilation and inability to communicate, as evidenced by agitation and increased vital signs.
Related Factors:
- Communication barriers
- Fear
- Environmental stressors
- Loss of control
- Unfamiliarity with environment
Nursing Interventions and Rationales:
- Establish communication method
Rationale: Reduces frustration and anxiety - Provide frequent orientation
Rationale: Maintains patient awareness - Administer anxiolytics as ordered
Rationale: Manages anxiety symptoms
Desired Outcomes:
- The patient will demonstrate decreased anxiety
- The patient will effectively communicate needs
- The patient will maintain stable vital signs
References
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