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Nursing care plan ventilatory assistance

Written by ncp nursing care plan on April 2nd, 2012


I. Pathophysiology—impairment of respiratory function
affecting O2 uptake and CO2 elimination, requiring mechanical
assist to support or replace spontaneous breathing
a. Inability to maintain adequate oxygenation (hypoxemia)
b. Inability to maintain adequate ventilation due to apnea or
alveolar hypoventilation causing a rise in PaCO2 and a fall
in serum pH (respiratory acidosis)
c. Inability to continue the work of breathing (respiratory muscle
weakness or failure)

II. Mechanical Ventilators
a. Classified by method of cycling from the inspiratory phase to
the expiratory phase with signal to terminate the inspiratory
activity of the machine:
i. Preset volume (volume-cycled ventilator)
ii. Preset pressure limit (pressure-cycled ventilator)
iii. Preset time factor (time-cycled ventilator)
b. Mode of ventilation
i. Assist control: provides a breath with either a preset volume
for ventilator-initiated breaths or peak pressure
every time client takes a breath
ii. Pressure support ventilation: delivers preset level of positive
airway pressure, rather than volume, to decrease
work of breathing between ventilator-initiated breaths
iii. Continuous positive airway pressure (CPAP): continuous
level of elevated pressure during client-initiated breaths
to maintain adequate oxygenation and decrease the work
of breathing and the work of the heart
iv. Positive end-expiratory pressure (PEEP): adjunct to
mechanical ventilation using elevated pressure during the
expiratory phase of the ventilatory cycle to increase functional
residual capacity and surface area for gas exchange
c. Complications
i. Associated with endotracheal (ET) tube: tissue damage
to lips, tongue, throat; mucous plugs impairing ventilation
and obstruction caused by client biting tube; auto
PEEP; sinusitis or otitis; cuff herniation (rare)
ii. Associated with the ventilator: infection, hemodynamic
instability from positive-pressure ventilation, barotrauma,
gastrointestinal (GI) bleeding due to stress ulcer

III. Etiology
a. Acute respiratory hypoxemia: pulmonary edema, severe
pneumonia, sepsis, shock, acute respiratory distress syndrome
(ARDS), embolism, drug reaction of overdose, lung
trauma, high altitude
b. Acute respiratory acidosis: acute exacerbation of chronic
emphysema or asthma
c. Respiratory muscle weakness or failure: paralysis of the
diaphragm due to Guillain-Barré syndrome, myasthenia
gravis, spinal cord injury, or the affects of anesthetic and
muscle relaxant drugs; central nervous system (CNS) conditions,
such as stroke, brain tumor, infections, sleep apnea;
chest trauma, including fractures, pneumothorax

IV. Statistics
a. Morbidity: Acute respiratory failure requiring mechanical
ventilation accounts for approximately 30% of admissions
to intensive care units (ICUs) (Esteban et al, 2002).
b. Mortality: Hospital rate is 36%; 6-month mortality rate is
approximately 67% for ages 65 and older (Seneff et al, 2000).
c. Cost: Mean ICU cost in United States is $31,574 to $42,570
per year (Dasta et al, 2005); average total hospital stay,
$78,474; daily costs, $2,655; estimated cost for long-term
acute-care facility admissions, $56,825 (Seneff, 2000).

Care Setting
The focus of this plan of care is the client with invasive
mechanical ventilation who remains on a ventilator, whether in
an acute or postacute care setting. The expectation is that the
majority of clients will be weaned before discharge. However,
some clients are either unsuccessful at weaning or are not candidates
for weaning. For these clients, portions of this plan of
care would need to be modified for the discharge care setting,
whether it be an extended care facility or home.

Related Concerns
Cardiac surgery: postoperative care
Chronic obstructive pulmonary disease (COPD) and
Craniocerebral trauma (acute rehabilitative phase)
Spinal cord injury (acute rehabilitative phase)
Total nutritional support: parenteral/enteral feeding
Psychosocial aspects of care

Client Assessment Database
Gathered data depend on the underlying pathophysiology
and reason for ventilatory support. Refer to the appropriate
plan of care.

Discharge Plan Considerations
If ventilator-dependent, the plan may require changes in
physical layout of home, acquisition of equipment and
supplies, provision of a back-up power source, instruction
of significant other (SO) and caregivers, provision
for continuation of plan of care, assistance with transportation,
and coordination of resources and support
Refer to section at end of plan for postdischarge considerations.

Nursing Priorities
1. Promote adequate ventilation and oxygenation.
2. Prevent complications.
3. Provide emotional support for client and SO.
4. Provide information about disease process, prognosis, and
treatment needs.

Discharge Goals
1. Respiratory function maximized and adequate to meet
individual needs
2. Complications prevented or minimized.
3. Effective means of communication established.
4. Disease process, prognosis, and therapeutic regimen understood,
including home ventilatory support if indicated.
5. Plan in place to meet needs after discharge.

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Source Credits: Nursing Care Planning Guides: For Adults in Acute, Extended and Home Care Settings by S. P. Ulrich and S. W. Canale BSN MSN / Nursing Care Plans by M. Doenges MF Moorehouse Alice Murr