Impaired spontaneous ventilation r/t immersion syndrome (Assesment: (pH:…
Impaired spontaneous ventilation r/t immersion syndrome
temperature: 32.6 C (90.7 F)
SpO2 = 75%
RR --> apneic
pH: 7.29 (acidic) and PaCO2: 70 (high)
indicating respiratory acidosis
Patient will effectively mobilize secretions throughout hospital stay.
"Nurse will position the client in a semicumbent with the head of the bed at 30-45 degree angle to decrease the aspiration of gastric, oral and nasal secretions" (Ackley, Ladwig, & Makic, 843).
Historically, evidence shows that mechanically ventilated clients have a decreased incidence of VAP if the client is placed in a 30-45 degree angle as opposed to supine position.
Nurse will use endotracheal tubes that allow for the continuous aspiration of subglottic secretions (Ackley, Ladwig, & Makic, 843).
Subglottic secretion drainage during mechanical ventilation results in a significant reduction in VAP, including late onset VAP.
Patient will maintain an oxygen saturation of above 70% throughout hospital stay.
Nurse will analyze and respond to arterial blood gas results, end tidal CO2 levels, and pulse oximetry values.
Ventilatory support must be closely monitored to ensure adequate oxygenation and acid-base balance.
Nurse will ensure that ventilator are appropriate to meet the client's minute ventilation requirements (Ackley, Ladwig, & Makic, 841).
Ventilator setting should be adjusted to prevent hyperventilation or hypo-ventilation . A variety of new modes of ventilation are currently available that are responsive to patient effort.
Goal 1/ Outcome evaluation:
met goal and was able to mobilize secretions, continue plan.
Goal 2/ Outcome Evaluation:
Patient maintained an O2 sat. above 70% throughout hospital stay, continue plan as is. Goal met.