Part 07

738 PART SEVEN – COMMUNITY-BASED HEALTH
IMPAIRED SPONTANEOUS VENTILATION

related to home ventilation therapy
Definition
Decreased energy reserves result in an individual’s inability to maintain breathing adequate
to support life
Assessment
• Age and sex
• Health history, including previous respiratory problems, neurologic or neuromuscular
disease, and recent hospitalization
• Respiratory status, including rate and depth of respiration, chest excursion and symme-
try, presence of cyanosis, use of accessory muscles for respiration, effectiveness of cough,
suctioning demands, and sputum characteristics
• Neuromuscular strength and endurance
• Mental and emotional status, including cognitive state and ability to follow directions
• Functional status, including ability to perform ADLs
• Family status, including usual coping patterns, family roles, communication patterns,
financial resources, effect of patient’s illness on family, and beliefs and attitudes about
health, illness, death, and other issues
• Home environment, including electrical safety, availability of hot water, house layout,
lighting, and fire hazards
• Knowledge of safety precautions
Defining Characteristics
• Apprehension
• Decreased arterial oxygen saturation
• Decreased cooperation
• Decreased partial pressure of oxygen
• Decreased tidal volume
• Dyspnea
• Increased metabolic rate
• Increased partial pressure of arterial carbon dioxide
• Increased restlessness
• Increased use of accessory muscles of respiration
• Tachycardia
Expected Outcomes
• Patient will exhibit clear breath sounds.
• Patient won’t exhibit signs of respiratory distress or infection.
• Patient will incorporate mechanical ventilation into ADLs and family life.
• Patient will demonstrate adequate use of communication aids.
• Patient will remain free from complications.
11651_part07.indd 738 20/05/10 12:03 PM

Impaired Spontaneous Ventilation 739
• Caregiver will demonstrate ease in using equipment and procedures to keep patient
comfortable and free from infection.
• Caregiver will implement and maintain safety measures for using oxygen in home.
Suggested NOC Outcomes

Respiratory Status: Gas Exchange; Respiratory Status: Ventilation; Vital Signs
Interventions and Rationales

• Ascertain what the patient and family members know about home ventilation therapy
to determine what the patient needs to learn. Building on current knowledge enhances
learning.
• Teach the patient and family members the setup, use, and care of all parts of the equip-
ment to promote independence and decrease anxiety.
• Explain the meanings of ventilator alarms and what to do if alarms sound to help reduce
anxiety and minimize complications.
• Explain how to get help in case of emergency to decrease the potential for injury.
• Emphasize the importance of the patient’s involvement in family activities, even though
he’s on mechanical ventilation, to increase the patient’s sense of well-being.
• Emphasize to family members that the patient needs to be attended to at all times to
ensure ongoing care.
• Demonstrate to family members how to clean and disinfect equipment to ensure that the
patient doesn’t develop an infection.
• Teach home oxygen safety to avoid fire or injury to the patient and family members.
• Inform the patient and family members about signs and symptoms of complications, such
as atelectasis, fluid overload, respiratory infection, and tension pneumothorax. Encour-
age immediate reporting of complications to ensure early intervention for respiratory
distress.
Suggested NIC Interventions

Airway Management; Mechanical Ventilation; Respiratory Monitoring; Vital Signs
Monitoring
Evaluations for Expected Outcomes

• Patient has clear breath sounds.
• Patient doesn’t exhibit respiratory distress or infection.
• Patient incorporates mechanical ventilation into daily life.
• Patient demonstrates use of communication aids.
• Patient remains free from complications.
• Caregiver demonstrates ease in using equipment and procedures to keep patient comfort-
able and free from infection.
• Caregiver implements and maintains safety measures for using oxygen in home.
Documentation
• Assessment results, such as vital signs and breath sounds
• Checks of ventilator settings, alarms, and backup equipment
11651_part07.indd 739 20/05/10 12:03 PM

740 PART SEVEN – COMMUNITY-BASED HEALTH
• Arterial blood gas analysis results

• Patient’s response to respiratory treatment
• Patient’s response to nursing interventions
• Patient teaching and patient’s and family members’ responses to teaching
• Evaluations for expected outcomes
REFERENCE
Ballangrud, R., et al. “Clients’ Experiences of Living at Home with a Mechanical Ventilator,” Journal of
Advanced Nursing 65(2):425–34, February 2009.
11651_part07.indd 740 20/05/10 12:03 PM

Part 07

Uploaded by

Copyright:

Available Formats

Part 07

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Part 07

Uploaded by

Copyright:

Available Formats

738 PART SEVEN – COMMUNITY-BASED HEALTH

IMPAIRED SPONTANEOUS VENTILATION

11651_part07.indd 738 20/05/10 12:03 PM

Suggested NOC Outcomes

Interventions and Rationales

Suggested NIC Interventions

Evaluations for Expected Outcomes

11651_part07.indd 739 20/05/10 12:03 PM

• Arterial blood gas analysis results

11651_part07.indd 740 20/05/10 12:03 PM

You might also like