Mechanical ventilation CM PDF

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NURS3301 Concept Map DISEASE: Patient receiving mechanical ventilation

CLINICAL MANIFESTATIONS:

LABS/ DIAGNOSTICS/ TESTS:

Name:________________________________________

Date:____________

ETIOLOGY:

ASSESSMENT:

-assess coping with mechanical ventilation -respiratory assessment: - vital signs, respiratory rate and pattern, breath sounds, evaluation of spontaneous ventilator effort, potential evidence of hypoxia (i.e skin color), increased adventitious breath sounds (need for suctioning) -nurse evaluates settings and functioning of mechanical ventilator -assess neurologic status -assess lung sounds every 2-4 hours -assess GI system and nutritional status because weaning requires adequate nutrition -assess ABG’s.

MEDICAL MANAGEMENT:

MEDICATIONS:

NURSING INTERVENTIONS: pg 531

NURSING DIAGNOSES:

-impaired gas exchange -ineffective airway clearance -risk for trauma and infection -impaired physical mobility -impaired verbal communication

- keep patients head 30 degrees or higher to prevent aspiration and VAP -enhancing gas exchange - promoting effective airway clearance -preventing trauma & infection -promoting optimal level of mobility -promoting optimal communication -promoting coping ability -monitoring potential complications -promoting home based, transitional care

PATIENT EDUCATION:

NURS3301 Concept Map

Name:________________________________________

Date:____________

Nursing Interventions  enhancing gas exchange  promoting effective airway clearance  preventing trauma & infection  promoting optimal level of mobility  promoting optimal communication  promoting coping ability  monitoring potential complications  promoting home based, transitional care  Potential complications  Alterations in cardiac function o Can occur due to positive pressure ventilation, the positive intrathoracic pressure compresses the heart and great vessels = reducing venous return and cardiac output o Observe for signs of hypoxia: restlessness, apprehension, confusion, tachycardia, tachypnea, pallor progressing to cyanosis, diaphoresis, transient hypertension, decreased urine output  Barotrauma and pneumothorax o Excessive positive pressure can cause laung damage (barotrauma) = spontaneous pneumothorax, which can quickly develop into tension pneumothorax. Assess for sudden changes in O2 stat.  Pulmonary infection o High risk for infection! Report fever, change in color or odor of sputum o Patients that are going to be intubated for longer than 72 hours will benefit from endotracheal tube with subglottic suction port.  Delirium o ABDE bundle  A: awakening  Breathing  Coordination  Delirium monitoring and management  Early mobility  Goal of this bundle is to improve communication among members of health care team, standardize care related to assessment and use of sedation, provide nonpharmacologic interventions in management of delirium and provide early exercise and ambulation...