Page 69 - Critical Care Nursing Demystified

54 CRITICAL CARE NURSING DeMYSTIFIED

Nursing Care Planning for the MV Patient

Nursing Diagnoses Expected Outcomes
Ineffective airway clearance, The airway will remain open and clear
risk for
Aspiration, risk for The patient will have a clear chest x-ray
The patient will have baseline ABGs
The patient will have normal breath sounds
Ventilation, impaired spon- The patientʼs respiratory status will be within
taneous five spontaneous breaths of baseline
Gas exchange, impaired Arterial blood gases will return to baseline
Cardiac output decreased The vital signs will be within normal limits
The urine output will be >30 mL/hr
Infection, risk for The patient will have a clear chest x-ray
The patient will have normal sputum cultures

Nursing Interventions and Rationales for the Patient During MV

1. Ongoing respiratory assessments: inspection, palpation, percussion, and
auscultation. Assess the ventilator settings at the beginning of the shift Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission.
and ensure they are as prescribed. Assess tubing for fluid buildup and
drain, as well as humidification and temperature.
Observe for s/s of respiratory distress. Assess serial blood gases. Monitor
the color, amount, and thickness of secretions. Assess for aspiration.
Monitor for tracheal deviation (tension pneumothorax) and subcutane-
ous emphysema to prevent complications.
Check for placement of ETT tube by verifying mark at the end of the
tube is as per intubation record to prevent sliding down or out of proper
alignment above the carina.
Check for minimal leak technique by auscultating a small leak at the
side of the trachea during the height of inspiration to prevent tracheal
necrosis balloon from overinflation and ensure correct tidal volumes (Vt).
Ensure that the ETT is taped securely to prevent accidental extubation.
Ensure that the patient is not biting down on the ETT to prevent kinking
and increasing pressure to give ventilator breaths.
2. Perform frequent suctioning with closed suctioning or individual suction
kits. Perform continuous subglottic aspiration of secretions to prevent
infection and aspiration.
3. Turn to prevent skin breakdown, pneumonia.