Ventilator care plan

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1. NURSING SERVICES DEPARTMENT TITLE: Mechanical Ventilation
PATIENT CARE PLAN DIAGNOSIS:
DISCHARGE CRITERIA:
1 The patient will : Maintain adequate mechanics of
PERTINENT INFORMATION:
.
ventilation as demonstrated by ABGs within normal limits
2 Indwelling or attached medical devices will
remain intact until discontinued
3 Patient will be extubated following Weaning Procedure

INITIATED RESOLVED
DATE RN
NURSING PROBLEMS
DIAGNOSES
EXPECTED OUTCOMES CHECK
POINT
TARGET
DATE
INTERVENTIONS
DATE RN

1. Potential for injury
related to external
factors:

• Unfamiliar
environment
• Ventilator support

Patient & family will
understand the need for
intubation

Endotube will remain
patent until extubated by
medical staff



Successful
weaning
from Vent



• Reorient and increase
observation
• Sedation per protocol to obtain
RASS score of ( ___ )
• Explain extubation goals and
potential time frames to patient
and family



2. Alteration in Cognitive
or Perceptual function
related to:
• Altered mental
status
• Effects of
medication





Patient will return to
previous level of mental
awareness and function





• Maintain quiet work
environment
• Explain all inventions prior to
starting
• Allow long sleep intervals and
schedule patient care
accordingly

• Follow:
( ) Lorazepam Protocol
( ) Midazolam Protocol

• Document sedation level hourly
and prn with vital signs using
Richmond Agitation-Sedation
Scale (RASS)

2. Mechanical Ventilation
Page 2 of 4



INITIATED RESOLVED
DATE RN
NURSING PROBLEMS
DIAGNOSES
EXPECTED OUTCOMES CHECK
POINT
TARGET
DATE
INTERVENTIONS
DATE RN

3. Alteration in
respiratory function
related to:
• Pain
• Noxious stimuli
• Secretions
• Respiratory status
and disease
pathophysiology



Patient will exhibit
adequate ventilation as
exhibited by ABG values
within normal limits

Successful
weaning
from Vent

• Decrease or remove sources of
discomfort, noxious stimuli.
• Medicate with narcotic as
ordered, observe for desired
effect and possible side effects
• Suction patient with in-line
suction setup. Oxygenate with
100% FIO2 before and after
suctioning
• Adjust ventilator alarms to
match patient’s mechanics
• Assess patient’s chest x-ray,
ABGs and mechanics



4. Potential or actual risk
of injury related to
medical devices:

• Dislodging
Endotracheal tube

• Mechanical
ventilation support










Endotracheal tube will
remain patent

SpO
2
will remain greater
or equal to 90%

Ventilator settings
appropriate for patient
condition

Ventilator alarms will
function appropriately

Patient will maintain
adequate respiratory
status post extubation





Successful
weaning
from Vent










Assess the following:
• Lung sounds
• Endotube position
• Security of endotube holder
• Continuous SpO
2
monitoring
• Ventilation adequacy
• Airway suctioning
• Sedation level
• Patient’s level of
understanding
• Vent settings and alarm
function assessed every hour
• Wean and extubate per
protocol when criteria met

3. Mechanical Ventilation
Page 3 of 5

INITIATED RESOLVED DATE RN
NURSING PROBLEMS
DIAGNOSES
EXPECTED OUTCOMES CHECK
POINT
TARGET
DATE
INTERVENTIONS
DATE RN
5. Potential or actual risk
for ventilator-
associated
complications

• Aspiration
pneumonia

• Deep vein
thrombosis
formation






• Peptic ulcer
disease
X-ray reports will remain
or return to normal






Patient will remain free
of deep vein thrombosis







Gastric mucosa will
remain intact


Successful
weaning
from Vent


• Maintain head of bed 30-45
degrees
• Oral care q 4hrs with 0.12 %
chlorhexidine solution and
brush teeth q 12 hrs
• Daily reduction of sedation
levels to evaluate readiness
to wean and extubate


• Evaluate for positive
Homan’s q 4 hrs
• Ted stocking as ordered
• Sequential compression
devices as ordered
• DVT prophylactic
anticoagulation as ordered


• H
2
receptor inhibitor
administered as ordered

4. Mechanical Ventilation
Page 4 of 5
WEANING PROCEDURE:



Prior to and during weaning trial:
• Obtain and document baseline mechanical & spontaneous measurements
• Evaluate baseline vital signs & changes with each vent change
• Titrate sedation to optimal level
• Explain procedure to patient and family
• Document mechanical and spontaneous efforts along with response

Slow Wean

(Patient sleepy but ready to wean)
Moderate Wean
(Patient awake but occasionally needs stimulation)

Quick Wean
(Patient very awake and cooperative)


1) Decrease respiratory rate to 6/min, PSV 15 for 30
minutes

2) Decrease respiratory rate to 4/min for 30 minutes
(Do not change PSV pressures)

3) Decrease respiratory rate to 0/min for 30 minutes,
patient in PSV Mode. (Do not change PSV
pressures)

4) Decrease PSV to 10 for 30 minutes

5) Continue to wean to PSV 5 unless endotube size is
less than 7.5 mm. (If less than 7.5mm keep PSV at
10)

6) Obtain and spontaneous parameters and document.
Evaluate patient readiness for extubation using
Burn’s Wean Assessment Program

7) Obtain ABG and spontaneous parameters and
report results to physician for extubation and
oxygen orders

8) Provide supplemental nasal cannula oxygen after
extubation


1) Decrease respiratory rate to 4/min, PSV 15 for 30
minutes

2) Decrease respiratory rate to 0/min for 30 minutes,
patient in PSV Mode. (Do not change PSV
pressures)

3) Decrease PSV to 10 or 5 for 30 minutes

4) Continue to wean to PSV 5 unless endotube size is
less than 7.5 mm. (If less than 7.5mm keep PSV at
10)

5) Obtain and spontaneous parameters and document.
Evaluate patient readiness for extubation using
Burn’s Wean Assessment Program)

6) Obtain ABG and spontaneous parameters and
report results to physician for extubation and
oxygen orders

7) Provide supplemental nasal cannula oxygen after
extubation

1) Decrease respiratory rate to 4/min, PSV 10
for 30 minutes. (If endotube is less than
7.5mm keep PSV at 10)

2) Decrease respiratory rate to 0/min PSV 5 for
30 minutes, patient in PSV Mode (If
endotube is less than 7.5mm keep PSV at 10)

3) Obtain and spontaneous parameters and
document. Evaluate patient readiness for
extubation using Burn’s Wean Assessment
Program

4)
Obtain ABG and spontaneous parameters
and report results to physician for extubation
and oxygen orders

5) Provide supplemental nasal cannula oxygen
after extubation
Sedation levels must be closely observed during the weaning
period. Decreases in mechanical ventilation may result in
hypoventilation if the patient is too sedate or is medicated with
narcotics. Patients may need to be occasionally stimulated
during weaning but if excessive stimulation is needed to
maintain ade
q
uate rate
,
the
p
atient is not read
y
to wean.

5. Mechanical Ventilation
Page 5 of 5


Patient Care Plan Reviewed






APPROVAL: _____________________________________

Vice President, Nursing



______________________________________

President, Medical Staff



DATE ISSUED: DATE REVIEWED: DATE REVISED:


FILE NAME: Mechanical Ventilator Care Plan








Date


Signature