NURSING DIAGNOSIS: RISK FOR DYSFUNCTIONAL VENTILATORY WEANING RESPONSE

RISK FACTORS MAY INCLUDE Sleep disturbance Limited or insufficient energy stores Pain or discomfort Adverse environment, such as inadequate monitoring or support Client-perceived inability to wean; decreased motivation History of extended weaning POSSIBLY EVIDENCE BY (Not applicable; presence of signs and symptoms establishes an actual diagnosis) DESIRED OUTCOMES/EVALUATION CRITERIA-CLIENT WILL

RESPIRATORY STATUS: VENTILATION Actively participate in the weaning process. Reestablish independent respiration with ABGs with acceptable range and free of signs of respiratory failure. Demonstrate increased tolerance for activity and participate in self-care within level of ability.

INDEPENDENT Assess physical factors involved in weaning as follows: Stables heart rate/rhythm, blood pressure (BP), and clear breath sounds

Fever Nutritional status and muscle strength

The heart has to work harder to meet increased energy needs associated with weaning. Physician may defer weaning if tachycardia, pulmonary crackles, or hypertension are present. Increase of 1oF (0.6o) in body temperature raises metabolic rate and oxygen demands by 7%. Weaning is hard work. Client not only

Determine psychological readiness

Explain weaning techniques, for example, spontaneous breathing trial (SBT), Tpiece, pressure support ventilation (PSV), and spontaneous intermittent maximal ventilation (SIMV). Discuss individual plan and expectations.

Provide undisturbed rest and sleep periods. Avoid stressful procedures or situations and nonessential activities.

Evaluate and document clients progress. Note restlessness; changes in BP, heart rate; use of accessory muscles; discoordinated breathing with ventilator; increased concentration on breathing (mild dysfunction); clients concerns about possible machine malfunction; inability to cooperate or respond to coaching; and color changes. Recognize and provide encouragement for clients efforts. Monitor cardiopulmonary response to activity COLLABORATIVE Consult with dietitian and nutritional support team for adjustments in

must be able to withstand the stress of weaning but also must have the stamina to breathe spontaneously for extended periods. Weaning provokes anxiety for client regarding concerns about ability to breathe on own and long term need oh ventilator. Assist client to prepare for weaning process, helps limit fear of unknown, promotes cooperation, and enhances likelihood of a successful outcome. NOTE: current guidelines recommended SBT as the preferred method of weaning as it withdraws ventilator support while oxygenation is continued. The simplest form of SBT is the T-piece trial. In PSV weaning, all breaths are spontaneous and combined with enough pressure support to ensure that each breath is a reasonable tidal volume. findings from randomized trials suggest that SIMV weaning delays extubation compared with PSV and SBT and that it should not be the primary mode of weaning in most clients (Byrd et al, 2006). Maximizes energy for weaning process; limits fatigue and oxygen consumption. NOTE: it takes approximately 12 to 14 hours of respiratory rest to rejuvenate tired respiratory muscles. For clients on AC, raising the rate to 20 breaths per minute can also provide respiratory rest. Indicators that client may require slower meaning and an opportunity to stabilize, or may need to stop program. NOTE: moving from pressure/volume (such as assist/control) ventilator to T-piece may precipitate a flash form of heart failure requiring prompt intervention. Positive feedback provides reassurance and support for continuation of weaning process. Excessive oxygen consumption and demand increase the possibility of failure. Reduction of carbohydrates and fats may be required to prevent excessive

composition of diet. Monitor CBC, serum albumin and prealbumin, transferring, total ironbinding capacity and electrolytes, especially potassium, calcium, and phosphorus. Review chest x-ray and ABGs.

production of CO2, which could alter respiratory drive. Verifies that nutrition is adequate to meet energy requirements for weaning.

Chest x-ray should show clear lungs or marked improvement in pulmonary congestion or infiltrates. ABGs should document satisfactory oxygenation on a Fio2 of 40% or less.

IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS INDEPENDENT GENERAL Assess nutritional status continually during daily nursing