NANDA-Nursing Plan Area4 activity/rest

NANDA-Nursing Plan 00034 Dysfunctional ventilatory weaning response

Note: This article was translated from Japanese using translation software. Please use at your own risk, as there may be unnatural points in the content or differences in content due to cultural differences.

Area 4 Activity/Rest
production, storage, consumption, or balance of energy resources
Class 4 Cardiovascular/Pulmonary Response: Circulatory Support for Activity/Rest – Respiratory Mechanism

Dysfunctional ventilatory weaning response 00034

Nursing Diagnosis: Dysfunctional ventilatory weanig response
Definition: Interrupted and prolonged weaning due to inability to reduce the level of ventilatory support on the ventilator.

Weaning is a gradual intervention to wean the patient off the ventilator and allow them to breathe on their own.
Students may find it hard to believe that a patient on a ventilator can be taken off the ventilator. When I was a student, I also thought, “Aren’t artificial respirators worn by people who can’t breathe on their own?”
When should you use a ventilator temporarily? If you study it, you will understand.
Let’s learn together in any case.

1. Adaptation for ventilator

Who should wear a respirator?
Let’s take a look at its target audience

1) What is a ventilator?

Ventilation is performed artificially (mechanically) when sufficient ventilation cannot be achieved by self-breathing.
There are assisted ventilation (helps spontaneous breathing) and mandatory ventilation (machines change into humans and perform ventilation).

2) adaptation

There are no clear criteria for ventilator initiation, and it is left to the discretion of the physician.
(1) Ventilation disorder
・ Problems with respiratory movement (apnea, respiratory muscle weakness)
・Difficult to secure airway
②Oxygenation disorder
・Hypoxemia that does not improve with treatment other than artificial respiration
③ Excessive work of breathing (increase in oxygen consumption → exhaustion of respiratory muscles)
・Increase in tidal volume due to accelerated metabolism
・ Pathological conditions in which lung compliance decreases
・ Pathological conditions in which airway resistance increases
④Instable circulatory dynamics
・ Severe arrhythmia
⑤ Surgery (use of anesthesia machine)

3) Guideline for starting artificial respiration

① Abnormal respiratory rate: slow breathing ≤ 5 times/minute or tachypnea ≥ 40 times/minute
② Consciousness disorder: Hypoxemia, CO2 narcosis
③ Hypoxemia not improved by oxygen inhalation: acute PaO2 ≤ 60 mmHg, chronic PaO2 ≤ 50 mmHg
④ Hypercapnia: Acute PaCo2 ≥ 50 mmHg, chronic PaCo2 ≥ 70 mmHg

2. About artificial ventilation

Artificial ventilation uses a machine to push air and oxygen into the lungs when you are unable to breathe on your own.
There are those that control the amount of air (quantitative type) and those that control the amount of air while observing the airway pressure (low-pressure type).
In addition, as for the timing of inhalation, there are those that forcibly inject at a predetermined timing and those in which inhalation is assisted at the timing of spontaneous respiration. There is also a mode that uses both.
Low pressure (PEEP) can also be applied to prevent alveolar collapse at the end of exhalation.
In more detail, you can inflate more alveoli by devising whether to shorten the time spent on inspiration. If the rise time is lengthened, the alveoli can be inflated for a long time.
These modes are selected according to the pathology of the lungs and airways.
There are a lot of modes, and a lot of detailed settings that go along with them, and it can get confusing.
Different manufacturers have different names for the same mode. It is also a source of confusion.
You can’t learn and master everything at once, so let’s review it over and over again and learn little by little.
The more I see respiratory patients, the more I understand.

1) Classification by drive part and ventilation method

2) Classification by presence or absence of invasiveness

IPPV and NIV are classified according to the presence or absence of invasiveness.
IPPV stands for “Invasive Positive Pressure Ventilation” and uses endotracheal intubation or tracheostomy.
NIV stands for “Non-Invasive Positive Pressure Ventilation” and uses a mask.
Since the name of the mode differs depending on the manufacturer, it is necessary to check each one.

3) mode

Whether there is spontaneous breathing or not. Is the spontaneous breathing rate within the normal range?
Depending on the state of spontaneous breathing, perform forced ventilation or assisted ventilation. Then, detailed settings are made taking into consideration lung stiffness (compliance) and breathing patterns.

A. Friends of IPPV (Invasive Positive Pressure Ventilation)

(1) CMV: Continuous active ventilation
A mode for people without spontaneous breathing. Forced ventilation enters at equal intervals by the machine.
① CMV (controlled forced ventilation)
② AMV (auxiliary forced ventilation)

(2) IMV: Intermittent forced ventilation
When there is spontaneous breathing, but sufficient ventilation cannot be maintained. Provide assisted ventilation for spontaneous breathing,
When time becomes vacant until the next spontaneous-respiration, the active-ventilation enters in time.
① SIMV (synchronous intermittent mandatory ventilation)

(3) Spontaneous ventilation mode
Mode for people with spontaneous breathing
① PSV (pressure support ventilation)
② CPAP (continuous positive airway pressure)

B. Companion of NIV (Non-Invasive Positive Pressure Ventilation)

(1) NPPV (non-invasive positive pressure ventilation)
(2) maskCPAP (continuous positive airway pressure)

4) Control method

There are two types: quantitative type and low pressure type.
・Quantitative formula: Feeds a preset amount of gas
・Constant pressure type: Injects gas into the airway to reach a preset airway pressure

3. weaning

The process of switching from forced ventilation by artificial respiration to spontaneous breathing.

1) Road to withdrawal

① The cause of artificial respiration is improved *For the cause, see 1. 2) Refer to adaptation
② Satisfy the conditions to proceed to withdrawal (conditions to proceed to withdrawal are explained below)
③ Cleared the spontaneous breathing trial (the spontaneous breathing trial will be explained next)
④ Extubation

《Conditions for proceeding to withdrawal from the ventilator》

Those who meet the following conditions while on a ventilator proceed to weaning (spontaneous breathing trial).
・Proper oxygenation:
When FiO2 ≤ 40%, SPO2 ≥ 90%
・No respiratory acidosis or electrolyte abnormalities
・Stable hemodynamics: HR ≤ 120 beats/min, stable blood pressure
Adequate mental status: alert, no persistent sedatives
Produce less phlegm or can cough adequately to expel phlegm

《Spontaneous Breathing Trial (SBT)》

The spontaneous breathing trial is to check whether breathing is stable even after switching from active ventilation mode to spontaneous breathing mode.
Active ventilation modes include CMV, AMV, A/C, and SIMV.
There are PSV and CPAP in spontaneous breathing modes.

《Conditions for judging successful spontaneous breathing trial》

When the ventilator mode is changed from active-ventilation to spontaneous-breathing mode, the trial is judged to be successful if the following conditions are achieved.
Adequate oxygenation: SPO2 ≥ 90% maintained, no respiratory acidosis or PaCO2 retention
A stable breathing pattern. Breathing rate < 30 breaths/min. No labored breathing is seen.
・Stable hemodynamics: stable heart rate, stable blood pressure, no appearance of arrhythmia
・Appropriate mental state: No disturbance of consciousness or strong discomfort.

Now that you’ve come this far, you’ve come to see the target of this nursing diagnosis, “Difficult reaction to withdrawal from artificial ventilation.”
The target of “difficult reaction to withdrawal from artificial ventilation” is
Although he was adapted to a ventilator and was put on a ventilator, his condition improved and the conditions for withdrawal were met. You can say that.

4. Adaptation for “difficult reaction to withdrawal from artificial ventilation”

1) A state in which the conditions for success of the spontaneous breathing trial cannot be met

Inability to provide adequate oxygenation:
・SPO2≧90% cannot be maintained
・ Respiratory acidosis
・There is storage of PaCO2
Unstable breathing pattern.
・Respiration rate ≤ 30 times/min
・ Forced breathing is observed.
・Instable hemodynamics
Instability of heart rate,
Instability of blood pressure,
・Appearance of arrhythmia
・Not in the right mental state
・Consciousness disorder
・I have a strong sense of discomfort.

2) Symptoms of the underlying disease remain

① Ventilation problem
・ Problems with respiratory movement (apnea, respiratory muscle weakness)
・Difficulty securing the airway due to accumulation of sputum
② Excessive work of breathing (increase in oxygen consumption → exhaustion of respiratory muscles)
・Increase in tidal volume due to accelerated metabolism
・ Pathological conditions in which compliance (ease of lung expansion) decreases: severe pneumonia, pulmonary fibrosis
・ Pathological conditions in which airway resistance increases: COPD, asthma

5. aim setting

1) Goal setting by linkage (published in the second half of NOC)

*Linkage has the role of connecting NANDA (diagnosis) and NOC (results).
・Ventilation withdrawal reaction (adult)
・Respiratory status: gas exchange, ventilation, airway patency
The level of debilitating fatigue
・Tissue circulation: lung/peripheral
・vital signs

2) Goal

The goal is to make the patient the subject.
Instead of saying “Nurses can do XX”,
For example, “The patient will be able to do ○○.”

・ Participate in respiratory rehabilitation.
・ Able to self-excrete.
・Describe how to use safe oxygen and use it safely in practice.
・Able to maintain ADL by incorporating life rehabilitation.

*Nurse goals include:

・Maintain cleanliness of the oral cavity, care for expectoration, and maintain airway clearance.
・During spontaneous breathing trials, closely observe respiratory rate, SPO2, dyspnea, pulse rate, etc., and strive for early detection of abnormalities.
・Listen to the patient’s complaints and try to alleviate their anxiety.
• Help patients use oxygen safely.
・Strive to maintain ADL.

6. nursing plan

1) Observation Plan 《OP》

・Medical history, current disease history
・ Heart disease, valve disease, arrhythmia, shock
・ Lung disease: asthma, COPD, pulmonary fibrosis, severe pneumonia
・Ventilator: ventilation mode, setting
・Presence or absence of spontaneous breathing, frequency of spontaneous breathing, pattern of spontaneous breathing
・Presence or absence of abnormal breathing (gasping, groaning, depression, tail, pursed lips)
・Dyspnea (at rest, during exertion)
・vital signs
・Blood pressure, pulse pressure, left-right difference, pulse deficit
・Heart rate (bradycardia, tachycardia), pulse rate (bradycardia, tachycardia), difference between heartbeat and pulse
・ Auscultation: lung murmur (pulmonary edema), heart murmur (valve disease 3.4 sounds)
・ Breathing: number of times, pattern
・Breathing sound: left-right difference, secondary noise
・Physical findings
・Edema, cyanosis, peripheral coldness
・Subjective symptoms:
・Difficulty breathing
・Chest pain
・Disturbance of consciousness
・Image inspection
・XP, CT: pleural effusion, ascites, fracture, etc.
・Sputum: properties, amount, presence or absence of spontaneous sputum
・Venous blood data
・ Anemia: Hb, RBC
・ Cardiac function: BNP, proBNP
・ Renal function (secondary renal dysfunction due to cardiac dysfunction): BUN, Cr
・ Neutral fat, total cholesterol, HDL, LDL
・symptoms indicating high blood pressure
・ Nose bleeding, headache, increased blood pressure, etc.
Cardiogenic shock symptoms
・Low blood pressure, loss of consciousness, decreased urine output, etc.
・ Oral medicine (Try following the 6Rs. Check what you are taking and what risks you are taking.)
・Cyanosis, cold sensation
・Treatment plan
・Oral medicine
・Cognitive impairment, compliance
・Pain scale
・Sedation Scale (RASS)

2) Action plan 《TP》

・Provide care that considers safety, comfort, and independence.
・Minimize the use of the monitor, and early detection of abnormalities such as arrhythmia when wearing the monitor.
・Arrange tubes so that they are not bent or pulled out.
・While wearing a ventilator, check the setting value of the ventilator, breakage of the circuit, and the amount of oxygen (if possible, double check) when changing shifts (according to the rules of the facility).
・Adequate suction of airway secretions to maintain airway clearance.
・Provide phlegm care. Postural drainage, squeezing, tapping, etc.
・Mouth care during intubation should be performed by two people, paying attention to extubation. The tape fixation should be changed alternately on the left and right sides every other day, and attention should be paid to the appearance of skin troubles.
・Adjust the cuff pressure of the intubation tube and tracheostomy tube.
・Arrange the environment so that the degree of rest can be maintained.
・Check the drip route from the injection site along the route. Be especially careful when handling sedatives, narcotics, and circulatory agents, and follow the 6Rs.
・Recheck the syringe pump usage and replacement procedure, and pay attention to free flow.
・Help and manage internal medicines.
・After extubation, when getting out of bed for the first time after surgery, perform step-by-step from the gap up while paying attention to the pulse, oxygen saturation, complexion, and the appearance of discomfort.
・When using oxygen, check the oxygen administration device, dosage, and state of consciousness. Follow the route to make sure oxygen is being administered. Prepare the environment so that it will not be pulled.
・Perform passive exercise (joint range of motion exercise) to maintain good limb position.
・In order to prevent a decline in ADL, from the viewpoint of daily life rehabilitation, we will have them do what they can do by themselves, and create an environment where they can do it by themselves.
・Perform ROM training to maintain ADL and good leg position.
・Check for painful symptoms (dyspnea, pain) and try to alleviate the pain. If there is anxiety, listen carefully and try to reduce anxiety.
・Compensate for self-care that is no longer possible due to illness or treatment.
Provide assistance according to the symptoms according to the progress of the spontaneous breathing trial.

3) Education plan 《EP》

・Explain the purpose, goals, and treatment course of the treatment plan.
・While confirming the degree of understanding of the course of treatment and the purpose, supplementary explanations will be provided if the patient does not understand. Engage in convincing treatment.
・Do not discontinue taking the medicine on your own and take the prescribed medicine.
・Please let us know if you have any subjective symptoms (pain, palpitations, shortness of breath, breathing difficulty, etc.).
・Explain that pain should not be tolerated and should be reported. Explain that analgesics can be used if needed.
・If there is a need to improve lifestyle habits, check the policies of doctors, nutritionists, and physical therapists, and provide support and explanations in accordance with the policies.
・Explain the dangers associated with removal of tubes, and explain treatment methods that prevent removal.
・Explain that fire is strictly prohibited when oxygen is used.
・Explain how to connect to an oxygen cylinder and how to use it.
– When using oxygen at home, the same applies to fire bans, and explain that it is necessary to keep at least 2 meters away from fire.
・Give advice on adapting to lifestyle changes.
・Consult with a social worker or care manager so that you can receive the services you need to live at home.  


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Yutaka Okaniwa. (2003). Disease can be seen VOL.2 Cardiology. Medic Media Co., Ltd.
Yutaka Okaniwa. (2007). Illness can be seen VOL.4 Respiratory organs. Medic Media Co., Ltd.
Yuko Kuroda (Translation). (2015). Nursing Outcome Classification (NOC) Original 5th Edition Indicators and Measurement Scales for Measuring Outcomes. Elsevier Japan K.K.
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Thank you for staying with us so far (*゚▽゚*) It would be very encouraging if you could send us your comments. Also, if you have any improvements or suggestions, please let us know in the comments section as well.

Well, there are several nursing plans related to this time’s artificial ventilation. We also have nursing care plans for ventilation and gas exchange disorders that cause weaning to fail, so please refer to them.

“impaired spontaneous ventilation”, “impaired gas exchange”, “ineffective breathing pattern” and “ineffective airway clearance”.

1) Spontaneous ventilation failure

Breathing consists of ventilation and gas exchange.

If you have a problem with “ventilation”, please refer to “spontaneous ventilation failure” and “ineffective breathing pattern”.
Nursing Diagnosis: Impaired Spontaneous Ventilation
Definition: Inability to sustain life-sustaining self-respiration due to reduced energy reserves
Spontaneous ventilatory failure care plan – Florence lamp care plan ( %80%e7%9c%8b%e8%ad%b7%e8%a8%88%e7%94%bb #NOC

2) Ineffective Breathing Patterns

Nursing Diagnosis: Ineffective Breathing Patterns
Definition: Inadequate ventilation of inspiration and/or expiration %91%e3%82%bf%e3%83%bc%e3%83%b3%e3%80%80%e7%9c%8b%e8%ad%b7%e8%a8%88%e7%94%bb ?preview_id=1147&preview_nonce=a58d9aa2c3&preview=true&_thumbnail_id=1155

Looking at the NOC, intervention plans for impaired spontaneous ventilation and ineffective breathing patterns are similar and overlap to a large extent.
From the definition, it seems that severe ventilatory failure related to life support corresponds to spontaneous ventilatory failure. Please compare the diagnostic indicators and select the one that is more appropriate.

3) Impaired gas exchange

Breathing consists of “ventilation” and “gas exchange”, but for disorders of “gas exchange”, refer to the nursing diagnosis “gas exchange disorder”.
Impaired gas exchange refers to problems in gas exchange due to the following factors:
(1) Diffusion obstruction: interstitial pneumonia (hardening of alveolar walls), pulmonary edema (water enters between alveoli and capillaries, hindering diffusion)
(2) Shunt: atelectasis (air does not enter the alveoli), pneumonia (cannot spread due to inflammation of the alveolar walls), pulmonary arteriovenous fistula (venous blood flows into arterial blood without passing through capillaries) and lose the chance of gas exchange)
(3) Ventilation and blood flow imbalance: thromboembolism (alveoli are expanding, but blood flow is interrupted)
④ Alveolar hypoventilation: Respiratory center depression, neuromuscular disease, chest wall disease %80%e7%9c%8b%e8%ad%b7%e8%a8%88%e7%94%bb

4) ineffective airway clearance

Please refer to “Ineffective Airway Clearing” for difficult sputum production. %84%e5%8c%96

Thank you for staying with us.
If you have any opinions or impressions, please use the comment section below.



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