About
Decreased gas exchange as a result of thickened and scarred alveoli and lung tissue.
Assess
Ventilator dependant for weeks to months, irreversible lung changes; late Acute Respiratory Distress Syndrome.
Complications
Damage to the lungs- monitor settings of ventilation frequently; monitor lung sounds frequently.
Malnutrition- monitor fluid volume status; administer parenteral or enteral nutrition as ordered. Consult dietary or nutrition services.
Fluid retention; Impaired skin integrity; Infection
Acid- base imbalance- monitor ABG's.
Diagnosis
- Ineffective breathing pattern related to stiffening and decreased elasticity of lung tissue
- Impaired gas exchange related to scarring and decreased functioning lung tissue
Goals
- The client will express concerns regarding treatment course.
- The client will be able to state reasons for ventilator.
- The client will be able to identify three signs that might indicate possible weaning from ventilator.
- The client will have adequate oxygenation.
Interventions
- Monitor vitals, ABG's, ET tube placement, skin integrity, tracheostomy site every four hours, or more frequently if necessary.
- Monitor the lungs sounds every 30 to 60 minutes after ventilator initiation.
- Monitor for signs and symptoms of infection.
- Monitor nutrition status and implement strategies to increase nutrition to meet metabolic needs.
- Suction, as needed.
- Turn the client every two hours while bed bound.
- Encourage the client to express fears, anxieties, concerns through non-verbal communication techniques.
- Monitor for cardiac and lung complications associated with mechanical ventilation.
- Encourage active range of motion techniques, and perform passive range of motion exercises every shift.
- Teach the client about the ventilator, the settings, and the course of treatment.
- Explain all procedures to client and keep apprised of plan of care.
- Monitor for signs/ symptoms of complications.
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