Mechanically Ventilated Patient

“Nursing Care Plan for Mechanically Ventilated Patient”

Alexandra Diaz

ITT Technical Institute

NU270

NURSING CARE PLAN

Assessment: Mechanically ventilated patient requiring sedation as evidenced by patient’s increased agitation.

Nursing Diagnosis: Ineffective Airway Clearance r/t presence of artificial airway.

Planning/Interventions:

• Auscultate lung sounds bilaterally q1 to 4 hours. “Breath sounds are normally clear or scattered fine crackles at bases, which clear with deep breathing. The presence of coarse crackles during late inspiration indicates fluid in the airway, wheezing indicates airway obstruction.”

• Assure the patient’s airway is free of secretions by monitoring respiratory patterns including rate depth and effort. “With secretions in the airway, the respiratory rate will increase”

• Suction patient and perform oral care every two hours or as often as needed.

• Explain the process of suctioning beforehand and ensure the patient is not overly anxious or agitated. “Suctioning can be a frightened experience; an explanation along with needed sedation can reduce stress and anxiety.

• Hyperoxygenate before and between endotracheal suction sessions. “Studies have demonstrated that hyper oxygenation helps prevent oxygen desaturation in a suctioned client.”

• Suction for less than 15 seconds. “Studies have demonstrated that because of a drop in the partial pressure of oxygen with suctioning, that preferably no more than 10 seconds be used actually suctioning, with the entire procedure taking 15 seconds (Pedersen, 2009)

• Assess patient for increased levels of agitation.

• Prevent patient from pulling the tube by securing patient’s hands with soft wrist restraints if needed once ordered from the physician.

• Assess patients’ agitation level after sedative-hypnotics have been administered.

Evaluation:

The Endotracheal tube is secured and in place. Patient maintains an open and clear of secretions airway. Patient agitation levels diminish considerably compared upon admission to ICU.