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Ventilatory Assistance Mechanical

Ventilatory Assistance Mechanical

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Published by mardsz

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Published by: mardsz on Jan 01, 2009
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09/14/2012

 
VENTILATORY ASSISTANCE (MECHANICAL)
Many patients on ventilators are now being transferred from the intensive care unit (ICU) to medical-surgical unitswith problems including (1) neuromuscular deficits, such as quadriplegia with phrenic nerve injury or high C-spineinjuries, Guillain-Barré syndrome, and amyotrophic lateral sclerosis (ALS); (2) COPD with respiratory muscle atrophyand malnutrition (inability to wean); and (3) restrictive conditions of chest or lungs, such as kyphoscoliosis andinterstitial fibrosis.The expectation is that the majority of patients will be weaned before discharge. That is the focus of this plan of care. However, some patients are either unsuccessful at weaning or are not candidates for weaning. For those patients, portions of this plan of care would need to be modified for the discharge care setting, that is, an extended care facilityor home.
Types of Ventilators
Volume-cycled ventilators are the primary choice for long-term ventilation of patients whose permanent changes inlung compliance and resistance require increased pressure to provide adequate ventilation (e.g., COPD).Pressure-cycled ventilators are desirable for patients with relatively normal lung compliance who cannot initiate or sustain respiration because of muscular/phrenic nerve involvement (e.g., quadriplegics).
CARE SETTING
Patients on ventilators may be cared for in any setting; however, weaning is usually attempted/accomplished in theacute, subacute, or rehabilitation setting.
RELATED CONCERNS
Cardiac surgery: postoperative careChronic obstructive pulmonary disease (COPD) and asthmaHemothorax/pneumothoraxSpinal cord injury (acute rehabilitative phase)Total nutritional support: parenteral/enteral feedingPsychosocial aspects of care
Patient Assessment Database
Gathered data depend on the underlying pathophysiology and/or reason for ventilatory support. Refer to theappropriate plan of care.
Discharge plan
DRG projected mean length of inpatient stay: 9.5 days (or more)
considerations:
If ventilator-dependent, may require changes in physical layout of home, acquisition of equipment/supplies, provision of a backup power source, instruction of SO/caregivers, provision for continuation of plan of care, assistance withtransportation, and coordination of resources/support systems
Refer to section at end of plan for postdischarge considerations.
 
DIAGNOSTIC STUDIES
 Pulmonary function studies:
Determine the ability of the lungs to exchange oxygen and carbon dioxide, and include but are not limited to the following:
Vital capacity (VC):
Is reduced in restrictive chest or lung conditions; normal or increased in COPD; normal todecreased in neuromuscular diseases (Guillain-Barré syndrome); and decreased in conditions limitingthoracic movement (kyphoscoliosis).
 Forced vital capacity (FVC):
Measured by spirometry, is reduced in restrictive conditions and in asthma, and isnormal to reduced in COPD.
Tidal volume (V 
 ):
May be decreased in both restrictive and obstructive processes.
 Negative inspiratory force (NIF):
Can be substituted for vital capacity to help determine whether patient caninitiate a breath.
Minute ventilation (V 
 E 
 ):
Measures volume of air inhaled and exhaled in 1 min of normal breathing. This reflectsmuscle endurance and is a major determinant of work of breathing.
 
 Inspiratory pressure (Pi
max
 ):
Measures respiratory muscle strength (less than -20 cm H
2
O is consideredinsufficient for weaning).
 Forced expiratory volume (FEV):
Usually decreased in COPD.
 Flow-volume (F-V) loops:
Abnormal loops are indicative of large and small airway obstructive disease andrestrictive diseases, when far advanced.
 ABGs:
Assesses status of oxygenation, ventilation, and acid-base balance.
Chest x-ray:
Monitors resolution/progression of underlying condition (e.g., adult respiratory distress syndrome[ARDS]) or complications (e.g., atelectasis, pneumonia).
 Nutritional assessment:
Done to identify nutritional and electrolyte imbalances that might interfere with successfulweaning.
NURSING PRIORITIES
1. Promote adequate ventilation and oxygenation.2. Prevent complications.3. Provide emotional support for patient/SO.4. Provide information about disease process/prognosis and treatment needs.
DISCHARGE GOALS
1. Respiratory function maximized/adequate to meet individual needs.2. Complications prevented/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.
NURSING DIAGNOSIS: Breathing Pattern, ineffective/Spontaneous Ventilation, impairedMay be related to
Respiratory center depressionRespiratory muscle weakness/paralysis Noncompliant lung tissue (decreased lung expansion)Alteration of patient’s usual O
2
/CO
2
ratio
Possibly evidenced by
Changes in rate and depth of respirationsDyspnea/increased work of breathing, use of accessory musclesReduced VC/total lung volumeTachypnea/bradypnea or cessation of respirations when off the ventilator CyanosisDecreased P
O
2
and Sa
O
2
; increased P
CO
2
 Increased restlessness, apprehension, and metabolic rate
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:Respiratory Status: Ventilation (NOC)
Reestablish/maintain effective respiratory pattern via ventilator with absence of retractions/use of accessorymuscles, cyanosis, or other signs of hypoxia; ABGs/oxygen saturation within acceptable range.Participate in efforts to wean (as appropriate) within individual ability.
CAREGIVER WILL:
Demonstrate behaviors necessary to maintain patient’s respiratory function.
 
ACTIONS/INTERVENTIONS
Mechanical Ventilation (NIC)
Independent
Investigate etiology of respiratory failure.Observe overall breathing pattern. Note respiratory rate,distinguishing between spontaneous respirations andventilator breaths.Auscultate chest periodically, noting presence/absenceand equality of breath sounds, adventitious breath sounds,and symmetry of chest movement.Count patient’s respirations for one full minute andcompare with desired/ventilator set rate.Verify that patient’s respirations are in phase with theventilator.Elevate head of bed or place in orthopedic chair if  possible.Place in prone position when tolerated.Inflate tracheal/ET cuff properly using minimalleak/occlusive technique. Check cuff inflation every 4–8hr and whenever cuff is deflated/reinflated.Check tubing for obstruction, e.g., kinking or accumulation of water. Drain tubing as indicated,avoiding draining toward patient or back into thereservoir.
RATIONALE
Understanding the underlying cause of patient’s particular ventilatory problem is essential to the care of patient, e.g.,decisions about future patient capabilities/ventilationneeds and most appropriate type of ventilatory support.Patients on ventilators can experiencehyperventilation/hypoventilation, or dyspnea/”air hunger,” and attempt to correct deficiency byoverbreathing.Provides information regarding airflow through thetracheobronchial tree and the presence/absence of fluid,mucus obstruction.
 Note:
Frequent crackles or rhonchithat do not clear with coughing/suctioning may indicatedeveloping complications (atelectasis, pneumonia, acute bronchospasm, pulmonary edema). Changes in chestsymmetry may indicate improper placement of the ET,development of barotrauma.Respirations vary, depending on problem requiringventilatory assistance, e.g., patient may be totallyventilator-dependent, or be able to take breath(s) on own between ventilator-delivered breaths. Rapid patientrespirations can produce respiratory alkalosis and/or  prevent desired volume from being delivered byventilator. Slow patient respirations/ hypoventilationincreases Pa
CO
2
levels and may cause acidosis.Adjustments may be required in tidal volume, respiratoryrate, and/or dead space of the ventilator, or patient mayneed sedation to synchronize respirations and reducework of breathing/energy expenditure.Elevation of patient’s head or getting out of bed whilestill on the ventilator is both physically and psychologically beneficial.Prone position relaxes abdominal muscles, improvingdiaphragmatic excursion, increasing Pa
O
2
.The cuff must be properly inflated to ensure adequateventilation/delivery of desired tidal volume.
 Note:
Inlong-term patients, the cuff may be deflated most of thetime or a noncuffed tracheostomy tube used.Kinks in tubing prevent adequate volume delivery andincrease airway pressure. Water prevents proper gasdistribution and predisposes to bacterial growth.
 

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