Nursing Diagnosis & Nursing Care Plan for Ventilator Patients: A Comprehensive Guide

Mechanical ventilation is a life-sustaining intervention for patients experiencing respiratory failure or compromised airways. Effective nursing care is paramount for these patients, focusing on optimizing respiratory function, preventing complications, and ensuring patient comfort. This guide provides a detailed nursing care plan for ventilator patients, emphasizing accurate nursing diagnoses and evidence-based interventions to improve patient outcomes.

What is a Mechanical Ventilator?

A mechanical ventilator is a medical device designed to support or replace spontaneous breathing. These devices can deliver breaths under positive or negative pressure, ensuring adequate ventilation and oxygenation for patients who cannot breathe effectively on their own. Mechanical ventilators are essential in managing patients with acute respiratory failure, chronic lung conditions, and those undergoing surgery or critical illness. Typically, patients are intubated with an endotracheal tube or tracheostomy tube before being connected to a ventilator, allowing for direct airway management and controlled delivery of oxygen and ventilation. The decision to initiate mechanical ventilation is often based on clinical assessments such as declining oxygen saturation (PaO2), increasing carbon dioxide levels (PaCO2), and persistent acidosis, indicating respiratory compromise.

Mechanical ventilators are broadly categorized by how they support breathing, primarily as positive-pressure and negative-pressure ventilators. Positive-pressure ventilators are the most commonly used in modern healthcare, functioning by pushing air into the lungs.

Types of Positive-Pressure Ventilators:

• Volume-cycled ventilators: These ventilators deliver a predetermined volume of air with each breath. Once the set volume is administered, the ventilator cycles off, and exhalation occurs passively. This type ensures consistent tidal volume delivery.
• Pressure-cycled ventilators: These ventilators deliver air until a preset pressure is reached, then cycle off, allowing for passive expiration. The volume of air delivered can vary based on the patient’s airway resistance and lung compliance.
• High-frequency oscillatory ventilators: These specialized ventilators deliver very rapid, small breaths at high frequencies (180-900 breaths per minute). They are often used in neonatal and pediatric intensive care and in adults with severe lung injury, facilitating gas exchange with minimal lung distension.
• Non-invasive positive-pressure ventilation (NIPPV): NIPPV delivers positive pressure ventilation through a facemask, nasal mask, or nasal pillows, avoiding the need for intubation. It is used for patients with less severe respiratory distress, such as those with COPD exacerbations or sleep apnea, and reduces the risk of ventilator-associated infections.

Negative-Pressure Ventilators:

Negative-pressure ventilators operate by applying negative pressure externally to the chest, causing the chest wall to expand and air to be drawn into the lungs. While less common today, they were historically significant.

• Iron Lung (Tank Ventilators): The iron lung is a large, chamber that encases the patient’s body, with only the head exposed. By cyclically decreasing and increasing the pressure within the tank, it mimics the physiological process of breathing.
• Cuirass Ventilator: A smaller, more portable version of the iron lung, the cuirass ventilator is a shell-like device fitted to the chest. It applies negative pressure to the thorax to facilitate breathing.
• Exovent Ventilator: A modern iteration of the cuirass ventilator, developed recently.
• Jacket Ventilator: Also known as poncho or raincoat ventilator, this is a lighter version using airtight material and suction to create negative pressure.

The mode of ventilation dictates how breaths are delivered by the ventilator, with common modes including controlled mechanical ventilation, assist-control (A/C), intermittent mandatory ventilation (IMV), synchronized intermittent mandatory ventilation (SIMV), pressure support ventilation, and airway pressure release ventilation, each tailored to specific patient needs and respiratory conditions.

Nursing Care Plans & Management

The primary goals of nursing care for patients on mechanical ventilation with endotracheal intubation or tracheostomy are to enhance gas exchange, maintain a clear airway, prevent trauma and complications, promote communication, minimize anxiety, and prevent cardiac and pulmonary complications. A well-structured nursing care plan is crucial to achieving these goals and ensuring optimal patient outcomes.

Nursing Problem Priorities

Nursing priorities for patients receiving mechanical ventilation include:

1. Ensuring a patent airway and verifying correct endotracheal tube placement to facilitate effective ventilation and prevent airway obstruction.
2. Monitoring and managing respiratory status, including regular assessment of lung sounds, oxygen saturation levels, and end-tidal carbon dioxide (EtCO2) monitoring to detect changes and ensure effective gas exchange.
3. Managing sedation and pain control to ensure patient comfort, promote synchrony with the ventilator, and minimize agitation.
4. Assessing for and managing potential complications, such as tube displacement, pneumothorax, or airway obstruction, and promptly initiating appropriate interventions to mitigate risks and ensure patient safety.
5. Preventing ventilator-associated complications, such as ventilator-associated pneumonia (VAP) and ventilator-induced lung injury (VILI), through diligent infection control measures and appropriate ventilator settings.
6. Collaborating with the healthcare team to optimize ventilator settings, implement weaning protocols, and conduct extubation readiness assessments, while providing continuous patient and family education and support to facilitate informed decision-making and reduce anxiety.

Nursing Assessment

Comprehensive assessment is vital for identifying patient needs and guiding nursing interventions. Key assessment areas for patients on mechanical ventilation include:

Subjective and Objective Data:

• Respiratory Status:

  • Adventitious breath sounds (wheezes, crackles, rhonchi)
  • Apnea or changes in breathing pattern
  • Dyspnea or increased work of breathing
  • Increased or decreased respiratory rate
  • Diminished lung sounds
  • Abnormal breath sounds
  • Ineffective cough
  • Excessive secretions

• Oxygenation & Ventilation:

  • Decreased oxygen saturation (SpO2 < 92%)
  • Decreased PaO2 level (< 60 mm Hg)
  • Arterial pH less than 7.35
  • Increased PaCO2 level (> 50 mm Hg)
  • Decreased tidal volume
  • Forced vital capacity less than 10 mL/kg

• Neurological & General Status:

  • Apprehension, restlessness, or anxiety
  • Disorientation or changes in level of consciousness
  • Increased peak airway pressure

• Airway & Tube Related:

  • Inability to maintain airway (emesis, depressed gag, depressed cough)
  • ET tube position and security

Factors Related to Mechanical Ventilation:

• Underlying Medical Conditions:

  • Acute respiratory failure
  • Noncompliant lung tissue (e.g., ARDS, pulmonary fibrosis)
  • Respiratory muscle weakness or paralysis
  • Altered V/Q ratio
  • Infection (Pneumonia, Bronchitis)

• Ventilator & Intubation Related:

  • Endotracheal intubation or tracheostomy
  • Stasis of secretions due to artificial airway
  • Decreased energy and fatigue related to respiratory effort and critical illness

Patient on Mechanical Ventilator

Nursing Diagnosis

Based on a thorough assessment, relevant nursing diagnoses for patients on mechanical ventilation may include:

• Impaired Gas Exchange related to altered oxygen supply, alveolar-capillary membrane changes, and ventilation-perfusion mismatch, as evidenced by abnormal arterial blood gases, decreased oxygen saturation, and dyspnea.
• Ineffective Airway Clearance related to presence of artificial airway, decreased cough reflex, and increased secretions, as evidenced by adventitious breath sounds, ineffective cough, and excessive secretions.
• Risk for Infection related to invasive procedures (endotracheal intubation, tracheostomy), suppressed immune response, and stasis of secretions.
• Ineffective Breathing Pattern related to mechanical ventilation, pain, anxiety, and underlying respiratory conditions, as evidenced by changes in respiratory rate, depth, and rhythm.
• Anxiety related to inability to communicate, dependence on mechanical ventilator, fear of suffocation, and critical care environment, as evidenced by restlessness, verbalization of fear, and physiological signs of anxiety.
• Impaired Verbal Communication related to endotracheal intubation or tracheostomy, mechanical ventilation, and physical barriers.
• Risk for Injury related to ventilator malfunction, dislodgement of endotracheal tube, and complications of mechanical ventilation (e.g., barotrauma, volutrauma).
• Imbalanced Nutrition: Less Than Body Requirements related to increased metabolic demands, inability to eat orally, and critical illness.
• Deficient Knowledge (for patient and family) related to mechanical ventilation, care procedures, and home management if applicable.
• Decreased Cardiac Output related to increased intrathoracic pressure from mechanical ventilation and underlying cardiac conditions.

Nursing Goals

The overarching goals for nursing care are to ensure optimal gas exchange, maintain a patent airway, prevent complications, promote comfort and communication, and facilitate weaning when appropriate. Specific goals and expected outcomes include:

• The patient will maintain optimal gas exchange, as evidenced by improved arterial blood gases within patient-specific parameters, SpO2 ≥ 92%, and reduced dyspnea.
• The patient will maintain a clear and patent airway, evidenced by clear breath sounds after suctioning and effective secretion management.
• The patient will remain free from ventilator-associated complications, such as VAP, barotrauma, and unplanned extubation.
• The patient will participate in the weaning process as appropriate for their condition and demonstrate progress towards spontaneous breathing.
• The patient will demonstrate effective alternative communication methods to express needs and reduce frustration.
• The patient will exhibit reduced anxiety and increased comfort, evidenced by a calm demeanor and cooperative behavior.
• The patient and caregiver will demonstrate understanding of ventilator care, potential complications, and home management if applicable.

Nursing Interventions and Actions

Nursing interventions for mechanically ventilated patients are multifaceted and require a combination of technical skills, vigilant monitoring, and compassionate patient care.

1. Managing Mechanical Ventilation

Effective management of mechanical ventilation requires continuous assessment, appropriate ventilator settings, and proactive management of potential issues.

Prior to Intubation Assessment and Interventions:

1. Investigate the etiology of respiratory failure. Determine the underlying cause (e.g., pneumonia, COPD exacerbation, ARDS) to guide treatment and ventilator management.
2. Observe changes in the level of consciousness. Monitor for early signs of hypoxia (disorientation, restlessness) and late signs (lethargy, stupor).
3. Assess respiratory rate, depth, and pattern. Note use of accessory muscles, nasal flaring, and abnormal breathing patterns.
4. Assess heart rate and blood pressure. Monitor for tachycardia (hypoxia) and blood pressure changes (initial increase followed by decrease in severe hypoxia).
5. Auscultate lungs for breath sounds. Identify adventitious sounds (wheezes, crackles, absent sounds) to assess airway and lung status.
6. Assess skin color and examine lips and nailbeds for cyanosis. Cyanosis indicates severe hypoxemia.
7. Monitor oxygen saturation using pulse oximetry. Maintain SpO2 within prescribed parameters (usually 92-98%).
8. Monitor arterial blood gases (ABGs). Evaluate PaO2, PaCO2, pH, and bicarbonate levels to assess oxygenation, ventilation, and acid-base balance.

Post-Intubation Assessment and Interventions:

9. Assess for correct endotracheal (ET) tube placement. Observe for symmetrical chest rise, auscultate bilateral breath sounds, and confirm placement with chest X-ray.
10. Assess patient comfort and ability to cooperate. Address discomfort and agitation, ensuring ventilator synchrony.
11. Assess ventilator settings and alarms hourly. Verify correct settings and functional alarms (oxygen, low volume, high pressure, apnea). Never turn off alarms.
12. Count patient respirations for a full minute. Compare with set ventilator rate and patient effort.
13. Maintain airway patency. Use oral or nasal airway as needed to prevent tongue obstruction.
14. Maintain High-Fowler’s position. Elevate head of bed to 30-45 degrees to promote lung expansion and prevent aspiration.

Preparation for Endotracheal Intubation:

15. Notify respiratory therapist to bring mechanical ventilator. Ensure ventilator is available and set up for immediate use.
16. Prepare intubation equipment. Gather ET tubes (various sizes), laryngoscope, blades, stylet, syringe, securing materials, and local anesthetic agents.
17. Administer sedation as ordered. Sedation facilitates intubation and patient comfort.

Assisting with Intubation:

18. Position patient supine with neck hyperextended (unless contraindicated). Align oropharynx, posterior oropharynx, and trachea for optimal visualization.
19. Apply cricoid pressure (Sellick maneuver) as directed. Assist provider in applying cricoid pressure to prevent aspiration during intubation.
20. Preoxygenate patient. Administer 100% oxygen via non-rebreather mask for 3 minutes before intubation.
21. Assist with verification of correct ET tube placement. Use end-tidal CO2 detector (capnometry) to confirm placement in trachea.
22. Continue manual Ambu-bag ventilation until ET tube is secured. Maintain oxygenation until ventilator is connected.
23. Document ET tube position. Note centimeter marking at the lip line for future reference.
24. Institute mechanical ventilation with prescribed settings. Initiate ventilation with ordered mode, tidal volume, rate, FiO2, and PEEP.
25. Anticipate need for nasogastric/orogastric suction. Suction to decompress stomach and prevent aspiration.
26. Administer muscle-paralyzing agents, sedatives, and opioid analgesics as ordered. Manage pain and agitation and facilitate ventilator synchrony.
27. Examine cuff volume. Ensure proper cuff inflation to prevent air leaks and aspiration (cuff pressure 20-30 mm Hg).
28. Position patient with head of bed elevated. Maintain semi-recumbent position to reduce aspiration risk.
29. Inflate ET tube cuff properly. Check cuff inflation every 4-8 hours.
30. Note inspired humidity and temperature. Use heated humidification to prevent drying of airway and secretions.

2. Promoting Patent Airway Clearance

Maintaining airway patency is crucial for effective ventilation and preventing complications.

1. Assess airway patency. Monitor for signs of obstruction (secretions, mucous plugs, tube kinking).
2. Observe sputum characteristics. Note color, odor, quantity, and consistency of secretions.
3. Auscultate lungs for breath sounds. Assess for diminished or adventitious breath sounds indicating need for suctioning.
4. Monitor oxygen saturation before and after suctioning. Evaluate effectiveness of suctioning and patient tolerance.
5. Assess arterial blood gases (ABGs). Monitor PaO2 and PaCO2 for signs of respiratory compromise.
6. Monitor peak airway pressures and airway resistance. Increased pressures may indicate secretions or airway obstruction.
7. Monitor ET tube placement. Ensure tube remains in correct position and has not migrated.
8. Note signs of increased secretions. Observe for excessive coughing, dyspnea, high-pressure alarms, and visible secretions in the ET tube.
9. Explain suctioning procedure and reassure patient. Reduce anxiety associated with suctioning.
10. Encourage deep breathing and coughing exercises. Promote secretion mobilization and lung expansion (if patient is able and weaning).
11. Turn patient every two hours. Mobilize secretions and prevent atelectasis.
12. Institute airway suctioning as indicated. Suction based on assessment findings, not routine schedule. Avoid over-suctioning.
13. Use closed in-line suction system. Reduce infection risk and maintain oxygenation during suctioning.
14. Hyperoxygenate before suctioning. Prevent hypoxia during suctioning procedure.
15. Instruct patient in coughing techniques. Teach effective coughing methods (splinting, step-cough) to enhance secretion clearance (if patient is able and weaning).
16. Administer IV fluids and aerosol bronchodilators as indicated. Hydration and bronchodilators help thin secretions and improve airway patency.
17. Administer humidified oxygen as prescribed. Prevent drying of airway and secretions.
18. Consult respiratory therapist for chest physiotherapy. Consider postural drainage and chest percussion to mobilize secretions.

A nurse is shown performing airway suctioning on a patient, highlighting the procedure to clear secretions and maintain airway patency in ventilated individuals.

3. Reducing Anxiety and Fear

Mechanical ventilation can be a frightening experience, and addressing anxiety is essential for patient well-being.

1. Assess patient’s understanding of mechanical ventilation. Determine patient’s perception of the situation and identify misconceptions.
2. Assess for signs of anxiety. Monitor for restlessness, rapid breathing, and verbal expressions of fear.
3. Observe physical responses to anxiety. Note repetitive movements, changes in vital signs, and agitation.
4. Assess previous coping strengths. Identify patient’s and family’s past coping mechanisms to build upon.
5. Encourage expression of fears. Allow patient and family to verbalize concerns and anxieties.
6. Reduce distracting stimuli. Provide a quiet environment and minimize noise. Explain ventilator alarms and reassure patient about staff responsiveness.
7. Educate patient and family about safety precautions. Discuss backup power, oxygen supplies, and emergency equipment.
8. Display a confident, calm manner. Provide reassurance and support, explaining care and progress regularly.
9. Provide relaxation techniques. Offer music therapy, guided imagery, or other relaxation methods.
10. Encourage sedentary diversional activities. Provide activities like TV, music, reading, or handicrafts.
11. Encourage visits from family and friends. Support system is crucial for emotional well-being.
12. Promote spiritual care as appropriate. Offer chaplain services or spiritual resources if desired.
13. Reinforce education about cognitive behavioral therapy (CBT). Consider CBT techniques to manage anxiety.
14. Refer to psychiatric liaison or chaplain as needed. Seek specialized support for severe anxiety or emotional distress.

4. Administering Medications and Pharmacological Support

Medications play a critical role in managing pain, agitation, and respiratory function in ventilated patients.

1. Induction agents (Etomidate, Ketamine). Administer for rapid loss of consciousness during intubation.
2. Paralyzing agents (Succinylcholine, Rocuronium). Administer to facilitate intubation and ventilator synchrony. Remember these agents do not provide sedation or analgesia.
3. Opioids (Morphine, Fentanyl). Administer for pain relief and sedation. Monitor closely for respiratory depression.
4. Diuretics. Administer to manage fluid balance and edema.
5. Vasopressors and Inotropes. Administer to support cardiac output and blood pressure.
6. Broad-spectrum antibiotics (Ceftriaxone, Cefepime). Administer to treat or prevent bacterial infections.
7. Vancomycin and Linezolid. Administer for MRSA infections.
8. Antifungal agents. Administer if fungal infection is suspected or confirmed.

5. Preventing Respiratory Injury Risk

Preventing ventilator-induced lung injury (VILI) is a primary concern in mechanically ventilated patients.

1. Review ventilator settings hourly. Pay special attention to tidal volume and plateau pressures. Notify respiratory therapy of discrepancies.
2. Assess respiratory rate and rhythm. Ensure patient is synchronized with ventilator and not “bucking” it.
3. Assess arterial blood gas results and oxygen saturation. Guide ventilator settings to maintain optimal oxygenation and ventilation while minimizing VILI risk.
4. Assess for signs of barotrauma. Monitor for crepitus, subcutaneous emphysema, altered chest excursion, tracheal deviation, and pneumothorax signs.
5. Auscultate breath sounds. Decreased breath sounds on one side may indicate pneumothorax.
6. Monitor chest X-ray reports daily. Obtain stat chest X-ray if barotrauma is suspected.
7. Monitor plateau pressures with respiratory therapist. Maintain plateau pressures < 30 cm H2O to reduce barotrauma risk.
8. Ensure ventilator alarms are on. Verify alarms are active and audible.
9. Listen for alarms and troubleshoot. Understand alarm ranges and appropriate responses for apnea, low volume, high pressure, etc.
10. Suction only when necessary. Avoid routine suctioning; suction based on assessment findings.
11. Lower tidal volume settings as indicated. Use lung-protective ventilation strategies with lower tidal volumes (6-8 mL/kg predicted body weight).
12. Provide early nutritional support. Address nutritional needs to maintain respiratory muscle strength.
13. Ensure proper sedation and pain management. Minimize patient-ventilator dyssynchrony and agitation.
14. Assist in performing tube thoracostomy or needle thoracostomy. Prepare for and assist with procedures to manage pneumothorax.
15. Observe for air leaks in water-seal chamber. Monitor chest tube drainage system for air leaks.
16. Clamp tubing to determine air leak origin. Differentiate between pleural air leak and system leak.

6. Optimizing Cardiac Function

Mechanical ventilation can affect cardiac function due to increased intrathoracic pressure.

1. Assess level of consciousness, blood pressure, heart rate, and hemodynamic parameters. Monitor for signs of decreased cardiac output (hypotension, tachycardia, decreased LOC).
2. Assess capillary refill, skin temperature, and peripheral pulses. Evaluate peripheral perfusion and cardiac output.
3. Monitor for dysrhythmias. Assess ECG for arrhythmias related to hypoxia or decreased perfusion.
4. Auscultate heart sounds. Listen for changes in heart sounds indicating decreased cardiac output.
5. Monitor fluid balance and urine output. Assess hydration status and renal perfusion.
6. Assess patient response to activity and promote rest. Balance activity and rest to minimize cardiac workload.
7. Monitor liver function test results. Evaluate for hepatic dysfunction secondary to decreased cardiac output.
8. Maintain optimal fluid balance. Manage fluid intake and output to optimize cardiac preload.
9. Provide small, easily digested meals and limit caffeine. Reduce myocardial workload and prevent cardiac stimulation.
10. Measure cardiac output parameters as appropriate. Use non-invasive or invasive monitoring to assess cardiac function.
11. Notify healthcare provider of signs of decreased cardiac output. Report hypotension, decreased output, and anticipate ventilator adjustments.
12. Assist in inserting Swan-Ganz catheter and perform PEEP studies. Assist with advanced hemodynamic monitoring to optimize PEEP and cardiac function.
13. Administer medications as ordered (diuretics, inotropes). Administer cardiac medications to support function.

7. Facilitating Weaning Process

Weaning from mechanical ventilation is a gradual process requiring careful assessment and patient preparation.

1. Assess vital signs. Ensure stable vital signs before initiating weaning.
2. Assess nutritional status and muscle strength. Optimize nutrition to support respiratory muscle function.
3. Determine psychological readiness for weaning. Address patient anxiety and fear related to weaning.
4. Note signs of weaning intolerance. Monitor for restlessness, changes in vital signs, accessory muscle use, and desaturation.
5. Monitor cardiopulmonary response to activity. Assess tolerance to increased respiratory effort.
6. Monitor laboratory tests. Review CBC, electrolytes, and nutritional markers.
7. Review chest radiograph and ABGs. Ensure improved lung status and adequate oxygenation on lower FiO2.
8. Clarify weaning techniques for patient and family. Explain weaning process and expected steps.
9. Schedule undisturbed rest and sleep periods. Maximize energy for weaning process.
10. Provide encouragement and recognition of efforts. Positive reinforcement is crucial during weaning.
11. Collaborate with dietitian for diet adjustments. Optimize nutrition to support weaning.
12. Terminate weaning if adverse reactions occur. Stop weaning and return to prior support level if patient decompensates.

8. Promoting Communication & Alternative Communication Methods

Effective communication is vital for ventilator patients who are unable to speak normally.

1. Assess ability to communicate by alternative means. Evaluate patient’s cognitive and physical abilities to communicate.
2. Evaluate need for talking tracheostomy tube. Consider if appropriate for patient’s condition.
3. Assess communication barriers. Identify factors hindering communication for intubated patients.
4. Establish a means of communication. Use eye contact, yes/no questions, gestures, letter boards, or picture boards.
5. Educate patient and family about communication systems. Introduce augmentative and alternative communication (AAC) methods.
6. Plan form of communication before IV line placement. Consider IV placement to facilitate writing hand.
7. Place call light within reach and answer promptly. Ensure patient can easily signal for assistance.
8. Inform staff that patient is unable to speak. Alert all staff to communicate directly at bedside.
9. Encourage family to talk to patient. Maintain social and emotional connection through family communication.
10. Consult speech therapist. Obtain expert guidance on communication strategies and AAC devices.

9. Initiating Measures for Infection Control & Management

Preventing ventilator-associated pneumonia (VAP) is a critical nursing responsibility.

1. Identify risk factors for infection. Recognize factors increasing VAP risk (intubation, suppressed immunity).
2. Assess sputum characteristics. Monitor for purulent, odorous sputum indicating infection.
3. Auscultate breath sounds. Assess for rhonchi and wheezes suggesting retained secretions and potential infection.
4. Assess for signs of pulmonary infection. Monitor temperature, secretions, WBC count, cultures, and chest X-ray.
5. Obtain sputum culture as indicated. Collect specimens to identify pathogens and guide antibiotic therapy.
6. Encourage hand hygiene. Promote hand washing among staff, patient, and family.
7. Encourage deep breathing and coughing exercises. Facilitate secretion mobilization and prevent atelectasis.
8. Provide oral hygiene every two hours. Use oral antibiotic rinse to reduce oral bacterial flora.
9. Limit visitors and avoid contact with respiratory infections. Protect patient from exposure to pathogens.
10. Keep head of bed elevated 30-45 degrees. Reduce aspiration risk and promote lung expansion.
11. Use continuous subglottic suction ET tube. Prevent secretion accumulation above the cuff.
12. Use sterile suctioning procedures. Minimize introduction of microorganisms into airway.
13. Promote humidifiers or heat moisture exchangers. Reduce ventilator circuit colonization.
14. Attempt spontaneous awakening trial. Reduce sedation and ventilator days to minimize VAP risk.
15. Administer antibiotics or antifungals as prescribed. Treat confirmed or suspected infections promptly.

10. Promoting Optimal Nutrition Balance

Maintaining adequate nutrition is crucial for recovery and weaning success.

1. Weigh patient regularly. Monitor for weight loss indicating catabolism and malnutrition.
2. Evaluate ability to eat. Determine if oral feeding is possible or if enteral/parenteral nutrition is needed.
3. Observe for muscle wasting and loss of subcutaneous fat. Assess for signs of malnutrition.
4. Auscultate bowel sounds and measure abdominal girth. Monitor GI function and distention.
5. Monitor gastric residual volumes. Assess tolerance to enteral feedings and prevent aspiration.
6. Offer desired foods when oral intake resumes. Encourage oral intake with preferred foods.
7. Provide small, frequent meals of soft, easily digested foods. Enhance intake and reduce gastric distress.
8. Encourage increased oral fluid intake. Maintain hydration to prevent dehydration and constipation.
9. Provide diet to meet respiratory needs. Adjust macronutrient ratios (lower carbohydrate, adequate protein) as needed.
10. Administer early enteral feedings as needed. Initiate enteral nutrition within 24-48 hours if possible.
11. Provide parenteral feedings if enteral feedings are not tolerated. Consider parenteral nutrition if enteral route is contraindicated or not tolerated.

11. Providing Patient Education & Health Teachings

Education is essential for patients and families, especially if long-term ventilation or home care is anticipated.

1. Assess patient and caregiver understanding of mechanical ventilation. Identify knowledge gaps and educational needs.
2. Assess readiness and ability to learn. Tailor education to patient’s cognitive and physical limitations.
3. Encourage expression of feelings and questions. Facilitate open communication and address concerns.
4. Schedule teaching sessions during quiet times. Enhance learning by providing education in a calm, focused environment.
5. Provide materials in multiple formats. Use books, pamphlets, videos, demonstrations, and written instructions.
6. Encourage evaluation of lifestyle impact of ventilator dependence. Discuss long-term implications and support needs.
7. Explain importance of vital signs, breath sounds, and ventilator checks. Empower patient and family to monitor and report changes.
8. Explain inability to talk while intubated and alternative communication methods. Reduce frustration and facilitate communication.
9. Explain inability to eat or drink while intubated and alternative nutrition. Reassure patient about nutritional support.
10. Explain ventilator alarms and staff proximity. Reduce anxiety related to alarms.
11. Explain need for suctioning. Educate on purpose and procedure of suctioning.
12. Explain weaning process and extubation. Prepare patient for weaning and positive outcomes.
13. Discuss long-term ventilator care management and referrals. Plan for home care or long-term ventilator facilities if needed.
14. Recommend caregiver CPR training. Enhance preparedness for emergencies at home.
15. Ensure all safety concerns are addressed and equipment in place. Predischarge planning for safe home environment.

Recommended Resources

Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care

Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)

Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales

Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care

All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health

See Also

• Impaired Gas Exchange Nursing Care Plan
• Ineffective Airway Clearance Nursing Care Plan
• Risk for Infection Nursing Care Plan
• Anxiety Nursing Diagnosis and Nursing Care Plan

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