A nurse is caring for a client who is receiving mechanical ventilation when the low pressure

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Nursing Care Plans
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Mechanical ventilation can partially or fully replace spontaneous breathing. Its main purpose is to improved gas exchange and decreased work of breathing by delivering preset concentrations of oxygen at an adequate tidal volume. An artificial airway (endotracheal tube) or tracheostomy is needed to a client requiring mechanical ventilation. This therapy is used most often in clients with hypoxemia and alveolar hypoventilation. Although the mechanical ventilator will facilitate movement of gases into and out of the pulmonary system, it cannot guarantee gas exchange at the pulmonary and tissue levels. Caring for a client on mechanical ventilation has become an indispensable part of nursing care in critical care or general medical-surgical units, rehabilitation facilities, and the home care settings. Ventilator-associated pneumonia (VAP) is a significant nosocomial infection that is associated with endotracheal intubation and mechanical ventilation.

Nursing Care Plans

The major goals for a client receiving mechanical ventilation include improvement of gas exchange, maintenance of a patent airway, prevention of trauma, promoting optimal communication, minimizing anxiety, and absence of cardiac and pulmonary complications.

Here are six (6) nursing care plans (NCP) and nursing diagnosis (NDx) for patients who are under mechanical ventilation:

Nursing Diagnosis

Impaired Spontaneous Ventilation

May be related to

Acute respiratory failure
Metabolic factors
Respiratory muscle fatigue

Possibly evidenced by

Adventitious breath sounds
Apnea
Apprehension
Arterial ph less than 7.35
Decreased tidal volume
Decreased oxygen saturation (Sao2 <90%)
Decreased Pao2 level (>50 to 60 mm Hg)
Diminished lung sounds
Dyspnea
Forced vital capacity less than 10 mL/kg
Increased Paco2 level (50 to 60 mm Hg or higher)
Increased or decreased respiratory rate
Inability to maintain airway (emesis, depressed gag, depressed cough).
Restlessness

Desired Outcomes

Client will maintain spontaneous gas exchange resulting in reduced dyspnea, normal oxygen saturation, normal arterial blood gases (ABGs) within client parameters.
Client will demonstrate an absence of complications from the mechanical ventilation.

Nursing Interventions	Rationale
Prior intubation assessment:
Observe for changes in the level of consciousness.	Early signs of hypoxia include disorientation, irritability, and restlessness. While lethargy, stupor, and somnolence are considered as late signs.
Assess the client’s respiratory rate, depth, and pattern, including the use of accessory muscles.	Changes in the respiratory rate and rhythm are early signs of possible respiratory distress. As moving air in and out of the lungs becomes more difficult, the breathing pattern changes to include the use of accessory muscles to increase chest excursions.
Assess the client’s heart rate and blood pressure.	Tachycardia may result from hypoxia; Increased in blood pressure happen in the initial phases then followed by lowered blood pressure as the condition progresses.
Auscultate the lung for normal or adventitious breath sounds.	Adventitious breath sounds such as wheezes and crackles are an indication of respiratory difficulties. Quick assessment allows for early detection of deterioration or improvement.
Assess the skin color, examine the lips and nailbeds for cyanosis.	Bluish discoloration of the skin (cyanosis) indicates an excessive concentration of deoxygenated blood and that breathing pattern is ineffective to maintain adequate tissue oxygenation.
Monitor oxygen saturation using pulse oximetry.	Pulse oximetry is useful in detecting early changes in oxygen. Oxygen saturation levels should be between 92% and 98% for an adult without any respiratory difficulties.
Monitor arterial blood gases (ABGs) as indicated.	Increasing Paco2 and decreasing PaO2 indicates respiratory failure. If the client’s condition begins to fail, the respiratory rate and depth decreases and Paco2 begin to rise.
After intubation assessment:
Assess for correct endotracheal (ET) tube placement through: Observation of a symmetrical rise of both chest sides. Auscultation of bilateral breath sounds. X-ray confirmation.	Correct ET tube placement is important for effective mechanical ventilation.
Assess for client’s comfort and the ability to cooperate while on mechanical ventilation.	Client discomfort may be secondary to incorrect ventilator settings that result in insufficient oxygenation. Once intubated and breathing on the mechanical ventilator, the client should be breathing easily and not “fighting or bucking” the ventilator.
Assess the ventilator settings and alarm system every hour.	Assessment ensures that settings are accurate and alarms are functional.
Therapeutic interventions prior to intubation:
Maintain the client’s airway. Use the oral or nasal airway as needed.	An artificial airway is used to prevent the tongue from occluding the oropharynx.
Maintain client in a High-Fowler’s position as tolerated. Frequently check the position.	This position promotes oxygenation via maximum chest expansion and is implemented during events of respiratory distress. Do not let the client slide down; this causes the abdomen to compress the diaphragm, which could cause respiratory change.
Encourage deep breathing and coughing exercises.	Deep breathing facilitates oxygenation. A deep cough is effective in clearing mucus out of the lungs.
Use nasotracheal suction as needed if coughing and deep breathing are not useful.	Suctioning is needed to clients who are unable to remove secretions from the airway by coughing.
Preparation for endotracheal intubation:
Notify the respiratory therapist to bring a mechanical ventilator.	Mechanical ventilators are classified according to the method by which they support ventilation. The two types are negative-pressure and positive-pressure ventilators (used most frequently).
If possible, before intubation, explain to the client the steps and purpose of the procedure and the temporary inability to speak (due to the ET tube passing through the vocal cords).	Preparatory information can decrease anxiety and promote cooperation with intubation.
Prepare the following equipment:
ET tubes of different sizes.	Endotracheal tubes come in various sizes and shapes. Adult sizes range from 7 to 9 mm. Selection is based on the client’s size.
Blades, laryngoscope, and stylet	Blades and scopes facilitate the opening of the upper airway and visualization of the vocal cords for placement of oral ET tubes. A stylet makes the ET tube firmer and gives additional support to direction during intubation.
Syringe, benzoin, and waterproof tape or other securing materials.	A syringe is used to inflate the balloon (cuff) after the ET tube is in position. Tape and benzoin are used to secure the ET tube.
Local anesthetic agent (e.g., Xylocaine spray or jelly, benzocaine spray, cocaine, lidocaine, and cotton-tipped applicators.	These anesthetic agents suppress the gag reflex and promote general comfort.
Administer sedation as ordered.	Sedation facilitates comfort and ease of intubation.
Assist with intubation:
Place the client in a supine position, hyperextending the neck unless contraindicated and aligning the client’s oropharynx, posterior oropharynx, and trachea.	This position is necessary to promote visualization of landmarks for accurate tube insertion.
Apply cricoid pressure as directed by the physician.	Use of cricoid pressure to prevent passive regurgitation during rapid sequence intubation. It may also prevent passive regurgitation of gastric and oesophageal contents.
Provide oxygenation and ventilation using an Ambu bag and mask as needed before and after each intubation attempt. If intubation is difficult, the physician will stop periodically so that oxygenation is maintained with artificial ventilation by the Ambu bag and mask.	This provides assisted ventilation with 100% oxygen before intubation. Increasing oxygen tension in the alveoli may result in more oxygen diffusion into the capillaries.
Therapeutic interventions after intubation:
Assist with the verification of correct ET tube placemen. Use a carbon dioxide detector as indicated.	Correct placement is needed for effective mechanical ventilation and to prevent complications associated with malpositioning such as vomiting, hypoxia, gastric distention, lung trauma. The carbon dioxide detector is attached to the ET tube immediately after intubation to verify tracheal intubation. Other capnography devices that provide numerical measurements of end-tidal carbon dioxide (normal value is 35 to 45 mm Hg) and capnograms may also be used.
Continue with manual Ambu bag ventilation until the ET tube is stabilized. Assist in securing the ET tube once tube placement is confirmed.	Stabilization is necessary before initiating mechanical ventilation.
Document the ET tube position, noting the centimeter reference marking on the ET tube.	Documentation provides a reference for determining possible tube displacement, usually 21 cm for the women and 23 cm at the lips for men.
Insert an oral airway and/or bite block for the orally intubated client.	An oral airway and/or block prevents the client from biting down on the ET tube.
Use bilateral soft wrist restraints as needed, explaining the purpose of their use.	These restraints may prevent self-extubation of the ET tube. Although all clients do not require restraints to prevent extubation, many do.
Institute mechanical ventilation with prescribed settings.	Modes for ventilating (assist/control, synchronized intermittent mandatory ventilation), tidal volume, rate per minute, fraction of oxygen in inspired gas (FIO2), pressure support, positive end-expiratory pressure, and the like must be preset and carefully evaluated for response.
Institute aseptic suctioning of the airway.	Suction helps remove secretions. A Yankaeur suction device should be available. Suctioning procedures should not be done frequently but as needed only in order to lessen the risk for infection and airway trauma.
Anticipate the need for nasogastric and/or oral gastric suction.	Abdominal distention may indicate gastric intubation and can also occur after cardiopulmonary resuscitation when the air is inadvertently blown or bagged into the esophagus, as well as the trachea. Suction prevents abdominal distention. Oral gastric suctioning may also reduce the risk for sinusitis.
Administer muscle-paralyzing agents, sedatives, and opioid analgesics as ordered.	These medications decrease the client’s work of breathing, decrease myocardial work, and may facilitate effective gas exchange.
Examine the cuff volume by checking whether the client can talk or make sounds around the tube or whether exhaled volumes are significantly less than volumes delivered. To correct, slowly reinflate the cuff with air until no leak is detected. Notify the respiratory therapist to check cuff pressure.	Cuff pressure should be maintained at 20 to 30 mm Hg. Maintenance of low-pressure cuffs prevents many tracheal complications formerly associated with ET tubes. Notify the physician if the leak persists. The ET tube cuff may be defective, requiring the physician to change the tube.
Respond to alarms, noting that high-pressure alarms may be of client resistance or the client’s need for suctioning. A low-pressure alarm may be a ventilator disconnection. If the source of the alarm cannot be located, ventilate the client with an Ambu bag until assistance arrives.	The key is that the client receives oxygenation support at all times until mechanical ventilation is no longer required.

Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources.

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Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively.
NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales.
Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
Another great nursing care plan resource that is updated to include the recent NANDA-I updates.
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
Useful for creating nursing care plans related to mental health and psychiatric nursing.
Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans.
Maternal Newborn Nursing Care Plans (3rd Edition)
If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023.
All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.

A nurse is caring for a client who is receiving mechanical ventilation when the low pressure

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