Possibly Evidenced By
Decreased minute volume, vital capacity, tidal volume Dyspnea; increased use of accessory muscles
Tachypnea or bradypnea or cessation of respirations when off the ventilator Decreased PO2and SaO2, increased PCO2
Increased restlessness, apprehension, metabolic rate
Desired Outcomes/Evaluation Criteria—Client Will
Respiratory Status: VentilationReestablish and maintain effective respiratory pattern via ventilator with absence of retractions and use of accessory muscles, cyanosis, or other signs of hypoxia; ABGs and oxygen saturation within acceptable range.
Participate in efforts to wean (as appropriate) within individual ability.
Caregiver Will
Demonstrate behaviors necessary to maintain client’s respiratory function.
NOC
ACTIONS/INTERVENTIONS RATIONALE
Mechanical Ventilation Management: Invasive Independent
Investigate etiology of respiratory failure.
Observe overall breathing pattern. Note respiratory rate, distinguishing between spontaneous respirations and ventilator breaths.
Auscultate chest periodically, noting presence or absence and equality of breath sounds, adventitious breath sounds, and symmetry of chest movement.
Count client’s respirations for 1 full minute and compare with desired respirations and ventilator set rate.
Verify that client’s respirations are in phase with the ventilator.
Position client by elevating head of bed or chair if possible;
place in prone position, as indicated.
Inflate tracheal or ET tube cuff properly, using minimal leak and occlusive technique. Check cuff inflation every 4 to 8 hours and whenever cuff is deflated and reinflated.
NIC
Understanding the underlying cause of client’s particular venti- latory problem is essential to the care of client, for example, decisions about future capabilities and ventilation needs and most appropriate type of ventilatory support.
Client on a ventilator can experience hyperventilation, hypoven- tilation, or dyspnea and “air hunger” and attempt to correct deficiency by overbreathing.
Provides information regarding airflow through the tracheo- bronchial tree and the presence or absence of fluid, mucous obstruction. Note: Frequent crackles or rhonchi that do not clear with coughing or suctioning may indicate developing complications, such as atelectasis, pneumonia, acute bron- chospasm, and pulmonary edema. Changes in chest sym- metry may indicate improper placement of the ET tube or development of barotrauma.
Respirations vary depending on problem requiring ventilatory assistance; for example, client may be totally ventilator de- pendent or be able to take breath(s) on own between venti- lator-delivered breaths. Rapid client respirations can produce respiratory alkalosis and prevent desired volume from being delivered by ventilator. Slow client respirations and hypoventilation increase PaCO2levels and may cause acidosis.
Adjustments may be required in flow, tidal volume, respiratory rate, and dead space of the ventilator, or client may need se- dation to synchronize respirations and reduce work of breathing and energy expenditure.
Elevating the client’s head and helping client get out of bed while still on the ventilator is both physically—helps de- crease risk of aspiration—and psychologically beneficial.
Note: Use of prone position is thought to improve oxy- genation in client with severe hypoxic respiratory failure.
However, it is not widely used due to the difficulties associ- ated with placing and providing care to the intubated client in prone position as well as lack of studies showing its benefit in reducing mortality or duration of ventilation (Sud et al, 2008).
The cuff must be properly inflated to ensure adequate ventila- tion and delivery of desired tidal volume and to decrease risk of aspiration. Note: In long-term clients, the cuff may be deflated most of the time or a noncuffed tracheostomy tube used if the client’s airway is protected.
CHAPTER 5RESPIRATORY—VENTILATORY ASSISTANCE
ACTIONS/INTERVENTIONS
(continued)RATIONALE
(continued)Check tubing for obstruction, such as kinking or accumulation of water. Drain tubing as indicated, avoiding draining toward client or back into the reservoir.
Check ventilator alarms for proper functioning. Do not turn off alarms, even for suctioning. Remove from ventilator and ventilate manually if source of ventilator alarm cannot be quickly identified and rectified. Ascertain that alarms can be heard in the nurses’ station.
Keep resuscitation bag at bedside and ventilate manually whenever indicated.
Assist client in “taking control” of breathing if weaning is attempted or ventilatory support is interrupted during procedure or activity.
Collaborative
Assess ventilator settings routinely and readjust, as indicated:
Note operating mode of ventilation, that is, AC, pressure support (PS), and so on.
Observe oxygen concentration percentage (FiO2); verify that oxygen line is in proper outlet or tank; and monitor in-line oxygen analyzer or perform periodic oxygen analysis.
Observe end-tidal CO2(ETCO2) values.
Assess set respiratory frequency (f).
Assess VT. Verify proper function of spirometer, bellows, or computer readout of delivered volume; note alterations from desired volume delivery.
Flow rate
Pressure limit
Kinks in tubing prevent adequate volume delivery and increase airway pressure. Condensation in tubing prevents proper gas distribution and predisposes to bacterial growth.
Ventilators have a series of visual and audible alarms, such as oxygen, low volume or apnea, high pressure, and inspiratory/
expiratory (I:E) ratio. Turning off or failure to reset alarms places client at risk for unobserved ventilator failure or respiratory distress or arrest.
Provides or restores adequate ventilation when client or equip- ment problems require client to be temporarily removed from the ventilator.
Coaching client to take slower, deeper breaths; practice abdom- inal or pursed-lip breathing; assume position of comfort;
and use relaxation techniques can be helpful in maximizing respiratory function.
Controls or settings are adjusted according to client’s primary disease and results of diagnostic testing to maintain param- eters within appropriate limits.
Client’s respiratory requirements, presence or absence of an underlying disease process, and the extent to which client can participate in ventilatory effort determine parameters of each setting. PS has advantages for client on long-term ventilation because it allows client to strengthen pulmonary musculature without compromising oxygenation and venti- lation during the weaning process.
FiO2is adjusted (21% to 100%) to maintain an acceptable oxygen percentage and saturation, for example, 90%, for client’s condition.
Measures the amount of exhaled CO2with each breath and is displayed graphically to spot CO2exchange problems early before they show up on ABGs. In some cases, a slightly higher level of CO2can be beneficial, such as for the client with long-standing emphysema. In this instance, elevated PCO2is accepted without correction, leading to the term
“permissive hypercapnia” (Byrd, 2012).
Respiratory rate of 10 to 15 per minute may be appropriate except for client with COPD and CO2retention. In these in- dividuals, rate and volume should be adjusted to achieve personal baseline PaCO2, not necessarily a “normal”
PaCO2.
Monitors amount of air inspired and expired. Changes may indicate alteration in lung compliance or leakage through machine or around tube cuff. Note: For the client without preexisting lung disease, the VTand rate are traditionally selected by using VTof 8 to 10 mL/kg delivered 12 times per minute in the AC mode. For clients with COPD, the VTand rate are slightly reduced to 10 mL/kg at 10 breaths per minute to prevent overinflation and hyperventilation (Girard
& Bernard, 2007). Many clinicians now use a smaller VT(6 to 8 mL/kg), especially in clients with ARDS and sometimes in obstructive and restrictive lung disease, in order to reduce air-trapping and mechanical stress on the lung.
Speed with which the VTis delivered is usually about 50 L/min, but is variable in order to maintain I:E ratio appropriate for specific situation.
Regulates the amount of pressure the volume-cycled ventilator can generate to deliver the preset VTwith usual setting at 10 to 20 cm H2O above the client’s peak inspiratory pressure.
Airway pressure should remain relatively constant. Increased pressure alarm reading reflects (1) increased airway resis - tance as may occur with bronchospasm; (2) retained secre- tions; and (3) decreased lung compliance as may occur with obstruction of the ET tube, development of atelectasis, ARDS, pulmonary edema, worsening COPD, or pneumothorax. Low
(continues on page 162)
ACTIONS/INTERVENTIONS
(continued)RATIONALE
(continued)Monitor I:E ratio
Set sigh rate, when used
Note inspired humidity and temperature; use heat moisture exchanger (HME), as indicated.
Monitor serial ABGs and pulse oximetry.
airway-pressure alarms may be triggered by pathophysiolog- ical conditions causing hypoventilation, such as disconnection from ventilator, low ET cuff pressure, ET tube displaced above the vocal cords, client “overbreathing,” or out of phase with the ventilator.
Expiratory phase is usually twice the length of the inspiratory rate, but may be longer to compensate for air-trapping to improve gas exchange in the client with COPD.
Clinicians once recommended that periodic machine breaths that were 1.5 to 2 times the preset VTbe given 6 to 8 times per hour. At present, accounting for sighs is not recom- mended if the client is receiving VTof 8 to 10 mL/kg or if PEEP is required. When a low VTis used, sighs are preset at 1.5 to 2 times the VTand delivered 6 to 8 times per hour if the peak and plateau pressures are within acceptable limits (Byrd, 2012).
Usual warming and humidifying function of nasopharynx is bypassed with intubation. Dehydration can dry up normal pulmonary fluids, cause secretions to thicken, and increase risk of infection. Temperature should be maintained at about body temperature to reduce risk of damage to cilia and hyperthermia reactions. The introduction of a heated wire circuit to the traditional system significantly reduces the problem of “rainout” or condensation in the tubing.
Adjustments to ventilator settings may be required, depending on client’s response and trends in gas exchange parameters.
N U R S I N G D I A G N O S I S : ineffective Airway Clearance
May Be Related To Presence of artificial airway Neuromuscular dysfunction Possibly Evidenced By Changes in respiratory rate Ineffective/absent cough Adventitious breath sounds Restlessness
Cyanosis
Desired Outcomes/Evaluation Criteria—Client Will
Respiratory Status: Airway PatencyMaintain patent airway with breath sounds clear.
Be free of aspiration.
Caregiver Will
Identify potential complications and initiate appropriate actions.
NOC
ACTIONS/INTERVENTIONS RATIONALE
Artificial Airway Management Independent
Assess airway patency.
Evaluate chest movement and auscultate for bilateral breath sounds.
Monitor ET tube placement. Note lip line marking and compare with desired placement. Secure tube carefully with tape or tube holder. Obtain assistance when retaping or reposition- ing tube.
NIC
Obstruction may be caused by accumulation of secretions, mu- cous plugs, hemorrhage, bronchospasm, and problems with the position of tracheostomy or ET tube.
Symmetrical chest movement with breath sounds throughout lung fields indicates proper tube placement and unob- structed airflow. Lower airway obstruction, such as pneu- monia or atelectasis, produces changes in breath sounds, such as rhonchi and wheezing.
The ET tube may slip into the right main-stem bronchus, thereby obstructing airflow to the left lung and putting client at risk for a tension pneumothorax.
CHAPTER 5RESPIRATORY—VENTILATORY ASSISTANCE
ACTIONS/INTERVENTIONS
(continued)RATIONALE
(continued)Note excessive coughing, increased dyspnea (using a 0 to 10 [or similar] scale), high-pressure alarm sounding on ventila- tor, visible secretions in endotracheal or tracheostomy tube, and increased rhonchi.
Suction as needed when client is coughing or experiencing res- piratory distress, limiting duration of suction to 15 seconds or less. Choose appropriate suction catheter. Hyperventilate before and after each catheter pass, using 100% oxygen if appropriate, using vent rather than Ambu bag, which has an increased risk of barotrauma. Suction continuously during withdrawal.
Use inline catheter suction when available.
Instruct client in coughing techniques during suctioning, such as splinting, timing of breathing, and “quad cough,” as indicated.
Reposition or turn periodically.
Encourage the client to drink fluids (if swallowing is possible) and provide fluids within individual capability.
Collaborative
Provide chest physiotherapy as indicated, such as postural drainage and percussion.
Administer intravenous (IV) and aerosol bronchodilators as indicated.
Assist with fiber-optic bronchoscopy, if indicated.
The intubated client often has an ineffective cough reflex, or client may have neuromuscular or neurosensory impair- ment, altering ability to cough. Client is usually dependent on suctioning to remove secretions. Note: Research sup- ports use of a dyspnea rating scale (like those used to mea - sure pain) to more accurately quantify and measure changes in dyspnea as experienced by client.
Suctioning should not be routine, and duration should be lim- ited to reduce hazard of hypoxia. Suction catheter diameter should be less than 50% of the internal diameter of the ET or tracheostomy tube for prevention of hypoxia. Hyperoxy- genation with ventilator sigh on 100% oxygen may be de- sired to reduce atelectasis and to reduce accidental hypoxia.
Note: Instilling normal saline (NS) is no longer recom- mended (although it persists in practice) because research reveals that the fluid pools at the distal end of the ET or tra- cheal tube, impairing oxygenation and increasing bron- chospasm and the risk of infection.
Helps maintain oxygen saturation and PEEP when used.
Enhances effectiveness of cough effort and secretion clearing.
Promotes drainage of secretions and ventilation to all lung seg- ments, reducing risk of atelectasis.
Helps liquefy secretions, enhancing expectoration.
Promotes ventilation of all lung segments and aids drainage of secretions.
Promotes ventilation and removal of secretions.
May be performed to remove secretions and mucous plugs.