Mechanical Ventilation Nursing Diagnosis and Nursing Care Plan

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Mechanical Ventilation Nursing Care Plans Diagnosis and Interventions

Mechanical Ventilation NCLEX Review and Nursing Care Plans

Mechanical ventilation is a form of life support that is indicated when the patient’s natural ventilation is inadequate to sustain life.

A mechanical ventilator is a machine used to help the patient breathe when the patient will have surgery or if the patient cannot breathe on their own due to the patient’s illness.

When a patient is connected to the mechanical ventilator, the patient is connected to the ventilator with a hollow tube that serves as an artificial airway.

The artificial airway goes in the patient’s mouth and down into the patient’s main airway or the trachea.

A mechanical ventilator helps the patient breathe on their own by decreasing the work of the lungs when breathing until the patient has improved. A mechanical ventilator pushes airflow into the lungs of the patient which will help the patient to breathe.

Health Conditions Related to Mechanical Ventilation

There are many types of health conditions that cause difficulty of breathing and probably require mechanical ventilation such as:

  • Acute respiratory syndrome(ARDS). Acute respiratory distress syndrome is a lung condition that occurs when the air sacs in the lungs are filled with fluids. Increased fluid in the lungs can decrease the amount of oxygen or increase the amount of carbon dioxide in the person’s bloodstream.
  • Chronic obstructive pulmonary disease(COPD). COPD makes the patient to harder to breathe because of the chronic inflammation of the lungs which obstructs the airways the lungs.
  • Asthma. Asthma is a condition in which the patient’s airways become narrow and swell which may produce extra mucus which makes the patient breathing difficult.
  • Cardiac arrest. A serious heart condition that makes the heart to stop beating and loss of heart function.
  • Pneumonia. Pneumonia is the infection in the lungs caused by bacteria, viruses, and fungi that leads to inflammation in the alveoli.
  • Collapsed lungs. A collapsed lung happens when the air escapes outside the lungs into the chest. The lungs may be unable to expand because of the pressure on the lungs.
  • Stroke. A stroke occurs when the blood vessels in the brain bleed and rupture due to blockage in the blood supply to the brain.
  • Coma. A coma occurs with a temporary or permanent disturbance of the brain’s function that affects the person’s consciousness.
  • Hypercapnic respiratory failure.  Hypercapnic respiratory failure is due to mechanical defects, depression of the nervous system, and an imbalance of energy demands and supplies of central controllers.
  • Sepsis. Sepsis is characterized by the extreme response of the person’s body to an infection.
  • Upper spinal cord injuries. Upper spinal cord injuries are paralysis in the person’s arm, hands, trunk, and legs.
  • Premature lung development of infants. It is common that a premature baby’s lungs are not yet fully formed because air sacs are the least developed.
  • Guillain-Barre Syndrome. Guillain-Barre Syndrome is an autoimmune disorder that attacks the immune system’s healthy nerve cells that are located in the peripheral nervous system.

Criteria for the Use of Mechanical Ventilation

Findings that should be considered when using mechanical ventilation include:

  • Respiratory rate of the patient that is greater than or equal to >30 breathes per minute
  • Patient’s inability to maintain the arterial oxygen saturation of >90%
  • Blood Ph. level of <7.25
  • Carbon dioxide partial pressure is >50 mmHg unless chronic and stable

Purposes of Mechanical Ventilation

The goal of mechanical ventilation is to provide sufficient oxygenation and ventilation that will reduce the patient’s work of breathing, and lessen the damage to the patient’s lungs. The following are the purposes of mechanical ventilation:

  • Mechanical ventilation helps the patient’s respiratory muscles to rest and the patient does not have to work as hard to breathe.
  • Mechanical ventilation gives the patient time to recover so that the patient breathing becomes normal again.
  • Mechanical ventilation helps the patient to have adequate oxygen and clears carbon dioxide.
  • Mechanical ventilation helps the patient to preserve a stable airway and helps to prevent injury from aspiration.

Please note that mechanical ventilation does not heal the patient, rather, it allows the patient to be stale while the patient is on medication and treatment that helps the patient to recover.

Types of Mechanical Ventilation

Positive-pressure ventilation. Positive pressure ventilation is a type of ventilation that pushes air into the person’s lungs. Examples of positive-pressure ventilators are the following:

  1. Invasive ventilation. Invasive ventilation has a tube inserted into the airway of the patient that is performed in the hospitals. Examples of invasive ventilation are:

  • Endotracheal intubation– a tube is inserted into the airway of the patient through the patient’s mouth or nose.
  • Tracheostomy-the tube is inserted into the hole made as an airway.

Non-invasive ventilation. Noninvasive ventilation is a kind of ventilation that will help the patient with respiratory problems while at home, the noninvasive ventilation comes with masks. Examples of noninvasive ventilation are:

  • Continuous positive airway pressure(CPAP) which delivers continuous and steady air pressure.
  • Auto titrating positive airway pressure(APAP) changes the pressure of air according to the patient’s breathing pattern.
  • Bilevel positive airway pressure which delivers air for inhalation and exhalation through different pressure.

2. Negative-pressure ventilation. Negative-pressure ventilation is a type of ventilation that sucks the air into the person’s lungs by making the chest expand and contract. Negative-pressure ventilators are early ventilators that are rarely used now such as:

  • Iron lung was the first mechanical ventilator that is made up of a cylinder that enveloped the patient completely up to the patient’s neck.
  •  Chest cuirass is a small shell that can be strapped to the patient’s chest to create negative pressure.

Risks of Mechanical Ventilation

The patient on mechanical ventilation is at risk of the following:

1. Infection. Infection is the main risk for patients with mechanical ventilation because of the artificial airways that permit the germs to enter the patient’s lungs. The patient’s risk for infection increases the longer the mechanical ventilation is needed approximately around 2 weeks.

2. Lung damage. Lung damage is another risk for patients having mechanical ventilation because of the inflation or repetitive opening and collapse of the alveoli of the lungs.

Sometimes the patients are unable to be weaned off with a ventilator and require prolonged support. When this happens the tube is removed from the patient’s mouth and may be changed to a smaller airway in the neck which is called, tracheostomy. Using a ventilator on the patient may prolong the dying process if the patient is unlikely to recover.

Basic Mechanical Ventilation Settings

Mechanical ventilator settings are usually calibrated depending on the health condition being treated, but the basic principles are the following:

  • Tidal volume and respiratory rate. This sets the minute ventilation. An increase in volume may cause a risk of over-inflation while too low volume may cause atelectasis. Rates that are too high may cause a risk for hyperventilation and respiratory alkalosis. The rate that is too low may cause a risk of inadequate minute ventilation and respiratory acidosis. Patients with acute respiratory distress syndrome require to have a low tidal volume of 6 to 8 ml/kg ideal body weight. Patients who are on mechanical ventilation during surgery or patients who have normal lungs require a low tidal volume. Ideal body weight is used to determine the correct tidal volume for patients who have the disease of the lungs and patients who are receiving mechanical ventilation.
  • Sensitivity. Sensitivity adjusts the level of negative pressure required that helps to trigger the ventilator. The normal setting of the ventilator is -2cm H2O. If the setting is too high the weak patient will unable to initiate breathing. Setting that is too low may lead to overventilation that may cause the machine to auto-cycle. The patients with increased levels of auto-PEEP especially the patients with COPD and asthma may experience difficulty in inhaling deeply which may be enough to reach sufficient negative intra-airway pressure.
  • I: E Ratio. I: R Ratio means inspiratory: expiratory ratio of the time spent on inhalation versus that spent on the patient’s exhalation. The I: E ratio can be adjusted in modes of ventilation. The normal mechanics of ratio for patients is 1:3. Patients with asthma or COPD must have a ratio of 1:4 or even more to the auto-PEEP limit.
  • Inspiratory flow rate. The inspiratory flow rate can be adjusted in some ventilation modes. The flow of inspiratory flow rate should be about 60L to 120 L/per minute for patients with limitations to airflow to help facilitate more exhalation time that limits auto-PEEP.
  • FIO2. The FIO2 or the fraction of inspired oxygen is set initially to 1.0 or 100% oxygen and is decreased to the lowest level subsequently to maintain adequate oxygenation.
  • PEEP. PEEP can be used in any mode of a ventilator. The PEEP increases end-expired lung volume and makes the airspace closure reduced at the end of the expiration. Patients undergoing mechanical ventilation may help from the application of PEEP at 5cm H2O which will limit the atelectasis that usually accompanies the endotracheal intubation, sedation, paralysis, and supine positioning. An increased level of PEEP may improve oxygenation in disorders like cardiogenic pulmonary edema and acute respiratory distress syndrome. Lower level FIO2 is permitted by the PEEP while maintaining arterial oxygenation adequately. This effect is important to limit the lung injury that results from prolonged exposure to high FIO2. If the PEEP is increased the intrathoracic pressure may impede venous return., which will provoke hypotension in hypovolemic patients and may decrease the left ventricular afterload and may over distend the lungs that may causing ventilator-associated lung injury.

Nursing Care of the Patients on Mechanical Ventilation

  • Maintain effective breathing pattern of the patient.
  • Maintain adequate and proper gas exchange.
  • Improve or maintain the nutritional status of the patient while on mechanical ventilation.
  • Avoid the risk of developing a pulmonary infection.
  • Avoid problems that may be related to immobility.

Mechanical Ventilation Nursing Diagnosis

Mechanical Ventilation Nursing Care Plan 1

Ineffective Airway Clearance

Nursing Diagnosis: Ineffective Airway Clearance related to endotracheal intubation secondary to mechanical ventilation as evidenced by abnormal breath sounds, dyspnea, and excessive secretion.

Desired Outcomes: The patient will keep clear and open airways as evidenced by auscultation of normal breath sounds after suctioning.

Nursing Interventions for Mechanical VentilationRationale
1. Check for the patient’s sputum color, odor, quantity, and consistency.The presence of thick and tenacious secretions may increase the airway resistance and the patient’s work of breathing. Discolored odoriferous sputum indicated infection.
2. Check the lungs of the patient by auscultation and check for the presence of abnormal breath sounds.Decreased breath sounds or the presence of abnormal breath sounds may indicate obstruction on the patient’s airways and indicates the need for suctioning.
3. Assess the saturation of oxygen before and after suctioning the secretions by using a pulse oximeter.Checking the patient’s oxygen saturation helps the nurse to evaluate the effectiveness of the therapy. Oxygen saturation measures the quantity of oxygen that circulated to the patient’s blood.
4. Inform the patient and caregiver about suctioning procedure and how it may help him or her. Explain the procedure in simple terms.Suctioning will help maintain a patent airway and may help to improve oxygenation by removing the secretions from the mechanical ventilator. It is important to explain the procedure first because suctioning can be frightening for the patient. Explain the need to keep the airways patent. The nurse may give pain relief and sedation before the procedure as indicated prescribed by the physician.
5. Maintain mobilization by turning the patient every 2 hours.Turning helps the nurse in mobilizing secretions and may help in preventing ventilator-associated pneumonia.
6. Evaluate and check the patient’s arterial blood gases level.Arterial blood gases may show signs of compromised respiration in the patient. Evaluating the arterial blood gases helps to measure or check the level of oxygen and carbon dioxide in the patient’s blood.

Mechanical Ventilation Nursing Care Plan 2

Anxiety

Nursing Diagnosis: Anxiety related to the inability to breathe adequately with support and change in health status secondary to mechanical ventilation as evidenced by facial tension, restlessness, tachypnea, and uncooperative behavior.

Desired Outcomes:

  • The patient will show decreased anxiety as evidenced by being calm and cooperative during the interventions.
  • The patient will show the use of the proper coping mechanism.
Nursing Interventions for Mechanical VentilationRationale
1. Ask the patient about his/her understanding of the need and purpose of mechanical ventilation.Accurate knowledge about mechanical ventilation will help facilitate the development of correct treatment and strategies.
2. Evaluate the client for any signs of anxiety about mechanical ventilation.Mechanical ventilation may give a drastic change that may lead to a patient’s anxiety. Respiratory rate and pattern may be affected by anxiety that may result in rapid and shallow breathing and may lead to abnormalities of the patient’s arterial blood gas.
3. Minimize the stimuli that may distract the patient such as the alarms on the ventilator system.Providing a quiet environment by decreasing stimuli will allow the patient to rest. Anxiety may be triggered by excessive noise, conversation, and even the equipment around the patient.
4. Encourage the patient’s family and significant others to visit the patient.The presence and support of the family and significant others provide security for the patient and will reduce the patient’s anxiety.
5. Provide the patient with a word or phrase card, a writing pad, and a pencil if the patient’s communication is impaired.These tools will let the patient communicate which will reduce anxiety.
6. Show a confident and understanding attitude to the patient by being available to the patient for support, as well as by explaining the patient’s care and progress.A patient’s trust is important in establishing relationships during periods of anxiety. A trusting relationship between the nurse and the patient will help give comfort to the patient by communicating the patient’s anxious feelings.

Mechanical Ventilation Nursing Care Plan 3

Deficient Knowledge

Nursing Diagnosis: Deficient Knowledge related to cognitive limitation and new treatment secondary to mechanical ventilation as evidenced by questioning members of the health care team.

Nursing Stat Facts
Nursing Stat Facts

Desired Outcome: The patient and the patient’s family and significant others will show an understanding of the uses and advantages of mechanical ventilation.

Nursing Interventions for Mechanical VentilationRationale
1. Ask the patient and the patient’s family about his or her knowledge of the importance of mechanical ventilation.The perception and knowledge of the patient and the significant others regarding mechanical ventilation are very important to help the nurse in setting goals and knowing the starting point for educating the patient and the patient’s family.
2. Evaluate the patient’s willingness, readiness, and ability to learn about mechanical ventilation.Educating the patient about mechanical ventilation is important to meet the motivation, limitations, and the need of the patient to learn. Patients that are experiencing acute care may have difficulty learning because of fatigue and pain.
3. Ask the patient and the significant others to vent out their feelings and encourage them to ask questions.Encouragement to the patient and significant others to ask questions will help in facilitating open communication between the nurse, the patient, and the patient’s family. Verify the patient’s understanding to be able to correct the misconceptions.
4. Educate the patient and the significant others about the reason for the inability to talk while the patient is intubated. Encourage alternate efforts for communicating.When the patient is intubated, the endotracheal tube passes through the vocal cords and talking may cause more trauma to the patient’s cords. The nurse should instruct the use of other methods of communication such as paper, pen, and pictures.
5. Advise the patient and the patient’s family that the patient may not be able to eat or drink and alternative measures such as IV fluids, gastric feeding, and hyperalimentation will be given to provide nourishment to the patient.The patient is not allowed to eat or drink because the patient is at risk of aspiration when intubated. IV fluids, gastric feedings, and hyperalimentation may be provided to maintain the patient’s nutritional needs.
6. If long-term ventilation is anticipated, educate the family and significant others about the long-term ventilator care intervention and refer to the physician accordingly.The use of specialized resources can facilitate the continuous care of the patient.

Mechanical Ventilation Nursing Care Plan 4

Risk for Ineffective Protection

Nursing Diagnosis: Risk for Ineffective Protection related to acute respiratory failure and respiratory muscle fatigue secondary to mechanical ventilation.

Desired Outcomes:

  • The patient will preserve natural gas exchange that will result in decreased dyspnea, normal oxygen saturation level, and an appropriate result of arterial blood gases.
  • The patient will be free from complications from having mechanical ventilation.
Nursing Interventions for Mechanical VentilationRationale
1. Assess the patient for any changes in his or her level of consciousness due to mechanical ventilation.Signs of hypoxia such as disorientation, irritability, and restlessness should be monitored to avoid further complications.
2. Monitor the patient for any changes in the respiratory rate, depth, and breathing pattern including the use of accessory muscles. Ensure that the ventilator alarms are on at all times.Monitoring the patient for any changes in the respiratory rate, pattern, and depth is important for the patients with mechanical ventilation. Synchronize the ventilator and do not permit “bucking” and always keep an eye if the ventilator is turned on.
3. Check for the presence of the signs of pulmonary infection including the increased temperature, presence of purulent secretions, increased white blood cell count, positive bacterial cultures, and evidence of pulmonary infection that is seen in the chest x-ray studies.Patients with mechanical ventilation are prone to having ventilator-associated infections due to bacterial pathogens, the presence of gram-negative bacilli is commonly seen. Monitoring the chest x-ray findings daily is also important to reduce the risk of complications.
4. Always keep an eye on the mechanical ventilator alarms and be knowledgeable on how to troubleshoot the mechanical ventilator.The mechanical ventilator is important because it is a life-sustaining treatment that requires a prompt response to alarms. Monitor the alarms such as:
-Apnea alarm
-Low exhale volume
-Low-pressure alarm
-High peak pressure alarm
5. Inform the physician of the signs of barotrauma immediately and anticipate the need for the placement of a chest tube and prepare the patient for the procedure as needed.Barotrauma is an injury that is caused by the pressure change which helps in compressing and expanding gas contained in different body structures. Interventions are needed if barotrauma is suspected to prevent pneumothorax tension.

Mechanical Ventilation Nursing Care Plan 5

Risk for Decreased Cardiac Output

Nursing Diagnosis: Risk for Decreased Cardiac Output secondary to mechanical ventilation

Desired Outcome: The patient will maintain adequate cardiac output as evidenced by normal blood pressure, normal heart rate, normal heart rhythm, strong peripheral pulse, urine output at a normal level, and the skin is warm and dry.

Nursing Interventions for Mechanical VentilationRationale
1. Measure the patient’s level of consciousness, blood pressure, and heart rate and check if the hemodynamic parameters are in place, especially the central venous pressure, pulmonary artery diastolic pressure and pulmonary capillary wedge pressure, and cardiac output.Venous return can be decreased due to mechanical ventilation which results in a decrease in blood pressure, increased heart rate, and a decrease in cardiac output. This may happen when the ventilator changes. The patient’s level of consciousness will be affected if the cardiac output is severely compromised, therefore the monitoring of the ventilator closely is imperative.
2. Check the patient’s capillary refill, the temperature of the skin, and the pulses, especially the peripheral pulses.A decrease in the patient’s stroke volume and cardiac output will cause a weak pulse. Capillary refill may also be reduced due to a decrease in cardiac output. The skin may be cold pale, and clammy secondary to the compensatory nervous system.
3. Check for the presence of dysrhythmia, and irregular changes in the patient’s fluid balance and urine output.Low perfusion state, acidosis, and hypoxia may cause cardiac dysrhythmia. Maintaining a sufficient circulation of blood volume and optimal hydration is needed. A drop in the urine output may happen because of the positive pressure ventilation and pressure from the diaphragm that decrease blood flow to the patient’s kidneys.
4. Keep an ideal fluid balance at all times.To maintain adequate filling pressures and optimize cardiac output, volume therapy is important. If the pulmonary capillary wedge pressure rises and the cardiac output. is decreased, and fluid restriction may be necessary.
5. Administer medication to the patient as ordered such as diuretics and inotropic agents as advised by the physician.Medications such as diuretics may maintain fluid balance if there is fluid retention and medications like the inotropic agent medication may increase the patient’s cardiac output.

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines, policies, and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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