FRANCIS ALFRED V.
ESCARAN
Assessment Nursing Diagnosis Planning
Objective: Impaired spontaneous Short-Term: After 1 hour of
ventilation related to nursing intervention, the
 Difficulty of
respiratory fatigue as patient will be free from
breathing
evidenced by difficulty respiratory distress as
 Restlessness
breathing. evidenced by:
 O2 SAT: 53%
 absence of nasal
flaring
 absence of
adventitious breath
sounds
 vital signs within
normal parameters
Long-Term:
After 8 hours of nursing
intervention, the patient will:
 maintain a patent
airway
 be free from ventilator
induced lung injury
 have ABG values
within normal
parameter
Nursing Interventions
Independent:
1. Elevate the head of the bed to
30-45 degrees.
2. Suction secretions as needed. 
3. Perform chest physiotherapy
every 2 hours which includes
percussion, vibration, and
postural drainage.
4. Reposition the patient every 2
hours.
5. Encourage bed rest and
promote a relaxing
Rationale Evaluation
Independent: Short-Term: After 1 hour of
nursing intervention, the
1. An upright position allows for
patient was free from
maximal lung expansion; lying flat
respiratory distress as
causes abdominal organs to shift
evidenced by:
toward the chest, which makes it
more difficult to breathe. This also  absence of nasal
helps reduce the risk of ventilator- flaring
associated pneumonia.
 absence of
2. Suctioning secretions helps in adventitious breath
clearing the airway, and promotes sounds
the patient’s comfort  vital signs within
3. Chest physiotherapy helps mobilize normal parameters
secretions preventing its stasis Long-Term:
which increases risk for infection. 
After 8 hours of nursing
intervention, the patient was
able to:
 maintain a patent
4. Frequent repositioning mobilizes
secretions, promotes blood airway
circulation, and helps in preventing  be free from
bed sores. ventilator induced
5. Adequate rest is essential to lung injury
minimize energy expenditure and  have ABG values
prevent fatigue. within normal
 Absence of signs and environment by eliminating parameter
symptoms of infection distracting stimuli. 
6. Providing oral care reduces the risk  have absence of signs
6. Provide oral care every 6 hours of ventilator-associated pneumonia and symptoms of
with chlorhexidine solution and enhances patient comfort. infection
and apply petroleum jelly on
lips.
Dependent:
1. Maintaining prescribed settings of
Dependent:
mechanical ventilation is essential
1. Maintain mechanical in promoting effective respirations.
ventilation settings as ordered
by the physician.  2. These medications are essential in
caring for the patient’s condition.
Bronchodilators enhance the
patency of the airway and
benzodiazepines result in sedation
2. Administer medications as to decrease anxiety, pain, and
ordered by the physician: agitation.
a. bronchodilators
(salbutamol and
ipratropium) via 3. Monitoring ABG values is
nebulizer important as it indicates the level of
oxygen and carbon dioxide in the
b. benzodiazepine
patient’s blood. 
(midazolam) via
intravenous infusion
3. Obtain a blood sample for Collaborative:
ABG analysis as ordered by
1. A respiratory therapist can help in
the physician. 
performing pulmonary
physiotherapy and maintenance of
Collaborative: mechanical ventilation. 
1. Work with a respiratory 2. Having adequate caloric intake is
therapist in providing important to help the patient
respiratory care for the recover the energy they need to
patient.  restore optimal respiratory function

2. Collaborate with the

nutritionist in planning for the
patient’s diet.