Many patients on ventilators are now being transferred from the intensive care unit (ICU) to medical-surgical units with problems including (1) neuromuscular deficits, such as quadriplegia with phrenic nerve injury or high C-spine injuries, Guillain-Barré syndrome, and amyotrophic lateral sclerosis (ALS); (2) COPD with respiratory muscle atrophy and malnutrition (inability to wean); and (3) restrictive conditions of chest or lungs, such as kyphoscoliosis and interstitial fibrosis.
The expectation is that the majority of patients will be weaned before discharge. That is the focus of this plan of care. However, some patients are either unsuccessful at weaning or are not candidates for weaning. For those patients, portions of this plan of care would need to be modified for the discharge care setting, that is, an extended care facility or home.
Types of Ventilators
Volume-cycled ventilators are the primary choice for long-term ventilation of patients whose permanent changes in lung compliance and resistance require increased pressure to provide adequate ventilation (e.g., COPD).
Pressure-cycled ventilators are desirable for patients with relatively normal lung compliance who cannot initiate or sustain respiration because of muscular/phrenic nerve involvement (e.g., quadriplegics).
CARE SETTING
Patients on ventilators may be cared for in any setting; however, weaning is usually attempted/accomplished in the acute, subacute, or rehabilitation setting.
RELATED CONCERNS
Cardiac surgery: postoperative care
Chronic obstructive pulmonary disease (COPD) and asthma
Hemothorax/pneumothorax
Spinal cord injury (acute rehabilitative phase)
Total nutritional support: parenteral/enteral feeding
Psychosocial aspects of care
Patient Assessment Database
Gathered data depend on the underlying pathophysiology and/or reason for ventilatory support. Refer to the appropriate plan of care.
Discharge plan
DRG projected mean length of inpatient stay: 9.5 days (or more)
If ventilator-dependent, may require changes in physical layout of home, acquisition of
equipment/supplies, provision of a backup power source, instruction of SO/caregivers, provision for continuation of plan of care, assistance with transportation, and coordination of resources/support systems
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Pulmonary function studies: Determine the ability of the lungs to exchange oxygen and carbon dioxide, and include but are not limited to the following:
Vital capacity (VC): Is reduced in restrictive chest or lung conditions; normal or increased in COPD; normal to decreased in neuromuscular diseases (Guillain-Barré syndrome); and decreased in conditions limiting thoracic movement (kyphoscoliosis).
Forced vital capacity (FVC): Measured by spirometry, is reduced in restrictive conditions and in asthma, and is normal to reduced in COPD.
Tidal volume (VT): May be decreased in both restrictive and obstructive processes.
Negative inspiratory force (NIF): Can be substituted for vital capacity to help determine whether patient can initiate a breath.
Minute ventilation (VE): Measures volume of air inhaled and exhaled in 1 min of normal breathing. This reflects muscle endurance and is a major determinant of work of breathing.
Inspiratory pressure (Pimax): Measures respiratory muscle strength (less than -20 cm H2O is considered insufficient for weaning).
Forced expiratory volume (FEV): Usually decreased in COPD.
Flow-volume (F-V) loops: Abnormal loops are indicative of large and small airway obstructive disease and restrictive diseases, when far advanced.
ABGs: Assesses status of oxygenation, ventilation, and acid-base balance.
Chest x-ray: Monitors resolution/progression of underlying condition (e.g., adult respiratory distress syndrome [ARDS]) or complications (e.g., atelectasis, pneumonia).
Nutritional assessment: Done to identify nutritional and electrolyte imbalances that might interfere with successful weaning.
NURSING PRIORITIES
1. Promote adequate ventilation and oxygenation.
2. Prevent complications.
3. Provide emotional support for patient/SO.
4. Provide information about disease process/prognosis and treatment needs.
DISCHARGE GOALS
1. Respiratory function maximized/adequate to meet individual needs.
2. Complications prevented/minimized.
3. Effective means of communication established.
4. Disease process/prognosis and therapeutic regimen understood (including home ventilatory support if indicated).
5. Plan in place to meet needs after discharge.
The expectation is that the majority of patients will be weaned before discharge. That is the focus of this plan of care. However, some patients are either unsuccessful at weaning or are not candidates for weaning. For those patients, portions of this plan of care would need to be modified for the discharge care setting, that is, an extended care facility or home.
Types of Ventilators
Volume-cycled ventilators are the primary choice for long-term ventilation of patients whose permanent changes in lung compliance and resistance require increased pressure to provide adequate ventilation (e.g., COPD).
Pressure-cycled ventilators are desirable for patients with relatively normal lung compliance who cannot initiate or sustain respiration because of muscular/phrenic nerve involvement (e.g., quadriplegics).
CARE SETTING
Patients on ventilators may be cared for in any setting; however, weaning is usually attempted/accomplished in the acute, subacute, or rehabilitation setting.
RELATED CONCERNS
Cardiac surgery: postoperative care
Chronic obstructive pulmonary disease (COPD) and asthma
Hemothorax/pneumothorax
Spinal cord injury (acute rehabilitative phase)
Total nutritional support: parenteral/enteral feeding
Psychosocial aspects of care
Patient Assessment Database
Gathered data depend on the underlying pathophysiology and/or reason for ventilatory support. Refer to the appropriate plan of care.
Discharge plan
DRG projected mean length of inpatient stay: 9.5 days (or more)
If ventilator-dependent, may require changes in physical layout of home, acquisition of
equipment/supplies, provision of a backup power source, instruction of SO/caregivers, provision for continuation of plan of care, assistance with transportation, and coordination of resources/support systems
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Pulmonary function studies: Determine the ability of the lungs to exchange oxygen and carbon dioxide, and include but are not limited to the following:
Vital capacity (VC): Is reduced in restrictive chest or lung conditions; normal or increased in COPD; normal to decreased in neuromuscular diseases (Guillain-Barré syndrome); and decreased in conditions limiting thoracic movement (kyphoscoliosis).
Forced vital capacity (FVC): Measured by spirometry, is reduced in restrictive conditions and in asthma, and is normal to reduced in COPD.
Tidal volume (VT): May be decreased in both restrictive and obstructive processes.
Negative inspiratory force (NIF): Can be substituted for vital capacity to help determine whether patient can initiate a breath.
Minute ventilation (VE): Measures volume of air inhaled and exhaled in 1 min of normal breathing. This reflects muscle endurance and is a major determinant of work of breathing.
Inspiratory pressure (Pimax): Measures respiratory muscle strength (less than -20 cm H2O is considered insufficient for weaning).
Forced expiratory volume (FEV): Usually decreased in COPD.
Flow-volume (F-V) loops: Abnormal loops are indicative of large and small airway obstructive disease and restrictive diseases, when far advanced.
ABGs: Assesses status of oxygenation, ventilation, and acid-base balance.
Chest x-ray: Monitors resolution/progression of underlying condition (e.g., adult respiratory distress syndrome [ARDS]) or complications (e.g., atelectasis, pneumonia).
Nutritional assessment: Done to identify nutritional and electrolyte imbalances that might interfere with successful weaning.
NURSING PRIORITIES
1. Promote adequate ventilation and oxygenation.
2. Prevent complications.
3. Provide emotional support for patient/SO.
4. Provide information about disease process/prognosis and treatment needs.
DISCHARGE GOALS
1. Respiratory function maximized/adequate to meet individual needs.
2. Complications prevented/minimized.
3. Effective means of communication established.
4. Disease process/prognosis and therapeutic regimen understood (including home ventilatory support if indicated).
5. Plan in place to meet needs after discharge.
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