A priority concern for this patient would be OXYGENATION (Documentation of…
A priority concern for this patient would be
Impaired Gas Exchange (Ackley, Ladwig & Makic, 2017)
The patient will develop clear lung fields. (Ackley et al., 2017)
Demonstrate improved ventilation and adequate oxygenation as evidenced by blood gas levels within normal parameters for that client (Ackley et al., 2017)
Risk for Aspiration (Ackley et al., 2017)
The patient will complete his stay at the hospital and have not aspirated during his time.
Maintain patent airway
Ineffective Airway Clearance (Ackley et al., 2017)
The patient will complete his hospital stay without developing ventilator-associated pneumonia (VAP).
Pt will demonstrate clear breath sounds (Ackley et al., 2017)
Maintain a patent airway at all times (Ackley et al., 2017)
Documentation of Data Related to Nursing Diagnosis
Fentanyl IV 2.5 mL/hr (1000 mg/100 mL) ; Midazolam 1 mL/hr (1000 mg/100 mL)
Hemoglobin: 7.9 (Low levels can decrease the uptake of oxygen in the blood stream)
Patient is sedated
Pt is on a ventilator
Pt has an endotracheal tube (ET) placement
Rhonchi bilaterally in lungs
Pt on mechanical ventilation
Respiratory rate 46 without sedation; respiratory rate 18-20 with sedation
Current Medical Diagnoses
Tissue Perfusion Alteration
Acute Congestive Heart Failure
Altered Mental Status
Interventions for Impaired Gas Exchange
Auscultate breath sounds every 1-2 hours. (Ackley et al., 2017) - In order to hear if any lung sounds have changed (improved or diminished)
Evaluation: Establish a baseline for lung sound at the beginning of your shift, and then compare the lung sounds you hear throughout the day to discern whether the sounds are improving, getting worse, or staying the same.
Monitor the effects of sedation and analgesics on the patients respiratory pattern (Ackley et al., 2017) - These can depress the respiratory rate. However, in this patient, the sedation was being used to depress his RR. When the healthcare providers began to take the patient off of sedation, his respiratory rate jumped to 46 breaths per minute.
Evaluation: The patient's respiration rate would stay in the normal range of 12 -20 breaths per minute. (Lewis, Bucher, Heitkemper, Harding, Kwong, Roberts, 2017).
Monitor oxygen saturation continuously using pulse oximetry (Ackley et al., 2017). The oxygen saturation should stay within a normal range in order to ensure proper oxygenation.
Evaluation: SpO2 should be greater than or equal to 94% (Lewis et al. 2017). Compare the pt's SpO2 to this one.
Interventions for Risk for Aspiration
Check the pH of the Endotracheal Tube before feeding or flushing to ensure placement (Ackley et al., 2017) It is possible for the tube to slide out of it's position and into the wrong place. By verifying placement, it helps to ensure that the patient will not aspirate due to misplacement.
Evaluation: If the pH is less than 4, it is probably in the stomach. (Ackley et al., 2017).
Maintain endotracheal cuff pressures at an appropriate level to prevent leakage of secretions around the cuff. (Ackley et al., 2017). By preventing fluids from getting into the airway, aspiration is being prevented, which could also prevent pneumonia.
Evaluation: Cuff pressure should be maintained for an ET at "20-25 cm H20." (Lewis et al., 2017). Monitor cuff pressure q 8 hours by using the minimal occluding volume technique or the minimal leak technique. (Lewis et al., 2017)
Provide meticulous oral care. (Ackley et al., 2017). Providing good oral care by brushing teeth and suctioning secretions can help to get rid of bacteria in the mouth. This bacteria could possibly be aspirated if left unattended. This could lead to pneumonia.
Evaluation: Perform oral care as often as your policy dictates. This can be evaluated by checking to see if the secretions have all been suctionined and if the proper oral care has been done and documented at the correct times.
Interventions for Ineffective Airway Clearance
Position the client to optimize respiration (e.g. HOB elevated to 30 to 45 degrees) (Ackley et al., 2017). With the HOB raised, it allows for maximal lung expansion with help from the ventilator. In this pt, who is ventilator dependent, it "decreases the risk of ventilator associated pneumonia" (Ackley et al., 2017)
Evaluation: Seeing if SpO2 stays within normal range and if the patient develops ventilator-associated pneumonia by the end of the hospital stay.
Suction the patient prn. (Ackley et al., 2017). This can help to clear the airway and to help prevent ventilator-associated pneumonia, which could cause even more problems for oxygenation if it develops.
Evaluation: Observe the color and consistency of the secretions. See if the patient does not develop ventilator-associated pneumonia. Evaluate if you have maintained a patent airway.
Reposition the patient q 2 hours (Ackley et al., 2017) This can help to decrease the development of pneumonia and the pooling of secretions. Repositioning the patient can also help to improve their SpO2.
Evaluation: Similar to the other interventions, monitor to see if the patient develops VAP. This intervention can also be evaluated by assessing the SpO2 and seeing if stays with normal range. While not the main goal of this intervention, it will also help to prevent skin breakdown.
Ackley, B. J., Ladwig, G. B., & Makic, M. B. F. (2017). Nursing diagnosis handbook: an evidence-based guide to planning care (11th ed.). St. Louis, MO: Elsevier.
Lewis, S. M., Bucher, L., Heitkemper, M. M. L., Harding, M., Kwong, J., & Roberts, D. (2017). Medical surgical nursing: assessment and management of clinical problems (10th ed.). St. Louis: Elsevier.