00034 Dysfunctional Ventilatory Response To Weaning

Domain 4: activity/rest
Class 4: cardiovascular/pulmonary responses
Diagnostic Code: <00034
Nanda label: Dysfunctional ventilatory response to weaning
Diagnostic focus: ventilatory response to weaning
approved 1992 • Revised 2017

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « Dysfunctional ventilatory response to weaning is defined as: inability to adapt to the reduction of mechanical ventilation levels, which interrupts and prolongs the weaning period. /p>

Definite characteristics

Mild

  • discomfort when breathing
  • Express heat sensation
  • Fatigue
  • Fear of machine malfunction
  • Increased concentration in breathing
  • Light increase in respiratory rate on the basal
  • Perception of increasing need of oxygen
  • Psychomotor agitation

Moderate

  • Abnormal skin color
  • apprehension
  • Increase in blood pressure compared to basal (<20 mmhg)
  • Decrease in air entry during auscultation
  • Diaphoresis
  • Difficulty cooperating
  • Difficulty responding to training
  • Facial expression of fear
  • Increase in heart rate with respect to the basal (<20 pulsations/minute)
  • Hypervigilance of activities
  • Discreet use of breathing accessory muscles
  • Moderate increase in respiratory rate on the basal

Severe

  • Abnormal respiratory sounds
  • Asynchronous breathing with the fan
  • Increase in blood pressure compared to basal (? 20 mmHg)
  • Deterioration of arterial gasometry with respect to the basal
  • Panting breathing
  • Increase in heart rate with respect to the basal (? 20 pulsations/minute)
  • Paradoxical abdominal breathing
  • Profuse diaphoresis
  • Superficial breathing
  • Significant increase in respiratory rate on the basal
  • Intense use of accessory muscles

Related factors

Physiological factors

  • Alteration of the sleep-vigilia cycle
  • Ineffective cleaning of the airways
  • Malnutrition
  • Pain

psychological

  • Anxiety
  • Decreased motivation
  • Fear
  • Desperateness
  • Inappropriate knowledge about the weaning process
  • Inadequate trust in the health professional
  • Low self -esteem
  • Impotence
  • Uncertainty about weaning ability

Situational

  • ATRACIONES OF THE ENVIRONMENT
  • Inappropriate rhythm in the weaning process
  • Episodic and uncontrolled energy demands

Risk population

  • People with a history of weaning without success
  • People with a history of fan dependence> 4 days

Associated problems

  • Decrease in the level of consciousness

Suggestions of use

  • The dysfunctional ventilatory response to weaning refers specifically to the patient’s responses to the separation of the mechanical fan. Other respiratory diagnoses may also be presented during weaning, for example, ineffective cleaning of respiratory tract, ineffective respiratory pattern and deterioration of gas exchange. These diagnostic labels do not include the causes of weaning problems.
  • If the etiology of the dysfunctional ventilatory response is unknown to weaning, “unknown etiology” must be noted.

Suggested alternative diagnostics

Other examples

  • Achieve the objectives established for weaning
  • It is physiologically stable for the weaning process
  • It is psychologically stable for the weaning process
  • Presents symmetric chest expansion

NIC Interventions

  • Ventilation assistance: Promotion of an optimal spontaneous respiratory pattern, which provides the maximum possible oxygen exchange and carbon dioxide in the lungs
  • Respiratory control and monitoring: Patient data collection and analysis to ensure the permeability of the respiratory tract and an appropriate gas exchange
  • Weaning of mechanical ventilation: patient assistance to breathe without the help of the respirator
  • Preparatory sensory information: description, in concrete and objective terms, of typical experiences and sensory events, associated with an imminent stressful medical procedure or treatment
  • Mechanical ventilation management: Invasive: Help the patient to receive artificial breathing through an apparatus inserted in the trachea
  • Anxiety reduction: minimum reduction of apprehension, fear, feeling or discomfort, related to an anticipated danger of unknown origin
  • Surveillance of vital signs: Collection and analysis of cardiovascular, respiratory and body temperature data, to determine and prevent complications

Nursing Activities

Valuations

  • Evaluate patient preparation for weaning, considering the following respiratory indicators:
    • Stable arterial gases with PA02> Pac02 in 40 to 60% oxygen
    • Maximum inspiratory force> -20 cm H, 0, so that autonomous breathing can begin
    • Autonomous current volume> 5 ml/kg ideal body weight
    • Vital capacity> 13 ml/kg ideal body weight
    • Stable spontaneous respiratory rate <30 breaths per minute
    • cough effective enough to handle secretions
    • Amount of time with the fan
  • Evaluate the patient’s arrangement for weaning, considering the following respiratory indicators:
    • Absence of constipation, diarrhea or ileus
    • Absence of fever and infection
    • Adequate nutritional status, manifested by acceptable serum levels of albumin and transferrin, and average muscular circumference of the arm> Percentile 15 ?
    • REST AND SLEEP APPROPRIATE
    • Hemoglobin and hematocrit within normal limits
    • Increase in body strength and resistance
    • Normal blood pressure
    • Psychological and emotional preparation
    • satisfactory balance of liquids and electrolytes
    • Stable heart rate and rhythm
    • Tolerable pain or level of discomfort
  • Determine why the previous attempts of weaning failed, if it is pertinent
  • Monitor the patient’s response to current medications and relate the response to weaning goals
  • (NIC) weaning of mechanical ventilation:
    • Monitor the factors that predict the ability to tolerate wean )
    • Monitor the signs of muscle respiratory fatigue (for example, abrupt increase in PAC02; rapid and superficial ventilation, and non -common abdominal wall movements), hypoxemia and tissue hypoxia during the weaning process

Patient and family education

  • Instruct the patient and his family about the process and weaning goals, which should include:
    • The feelings of the patient over the course of the process
    • Family participation
    • The required participation of the patient
    • What the patient can expect from the nursing professional
    • The reasons why weaning is necessary
  • (NIC) Weaning of mechanical ventilation: helping the patient to distinguish spontaneous breathing from mechanics or assisted.

Collaboration activities

  • Dialogue with the doctor and staff that provide respiratory care about the process and objectives of weaning, including the current situation of the patient and pre -existing medical conditions
  • (NIC) Weaning of mechanical ventilation: collaborating with other members of the health team to optimize the patient’s nutritional status, ensuring that 50% of the non -protein calorie source of the diet are fat instead of carbohydrates

Others

  • Promote self -care to increase the sensation of control and participation
  • Normalize daily life activities at the patient tolerance level
  • Establish a relationship that fosters the patient’s confidence in nursing staff for the weaning process
  • Establish effective communication methods between the patient and others (for example, in writing, with flickers and hand tights)
  • Start the weaning process with the following actions:
    • Verify that the equipment is connected to oxygen and that the installation is correct
    • Verify that there are bilateral respiratory sounds
    • Verify that there are no knots or too much moisture in the piped
    • Monitor vital signs and the patient every 5 to 15 minutes to detect fatigue or lack of tolerance indicators
    • Document the weaning process and patient tolerance
    • Explain the procedure to the patient and his family
    • Measure and register the normal respiratory rate, heart rate, blood pressure, rhythm (electrocardiogram), pulmonary sounds, vital capacity, ordinary volume, inspiratory force and oxygen saturation, by means of pulseioximeter
    • Preoxigenar, hyperinflar, aspirate and reoxygenar the patient before weaning
    • Provide a quiet environment during weaning
    • Provide some entertainment, such as a TV or a radio
    • Sit the patient vertically to reduce abdominal pressure on the diaphragm, and thus allow greater lung expansion
    • Start the moment of weaning when the patient has rested, and be awake and alert
    • Stay with the patient during weaning to give guidance and safety
    • Understand the foundations of the indications for wean /li>
  • Reconnect the patient to the fan according to the configuration prior to weaning, in case of intolerance
  • Document in the nursing care plan the strategies that allow a successful weaning process to guarantee consistency (for example, the method of communication with the patient, family participation and guidance methods)
  • (NIC) weaning of mechanical ventilation:
    • Alternate weaning attempts with enough rest and sleep periods
    • Avoid the delay of the reconnection to the mechanical ventilation of a patient who has respiratory muscle fatigue
    • Establish a schedule to coordinate weaning attempts with other patient care activities
    • Apply relaxation techniques, as required

At home

  • Evaluate whether it is practical (economically, psychologically, physically) withdraw the patient from the fan at home
  • If weaning is done at home, have an emergency plan for temporary ventilation while restoring mechanical ventilation

Older people

  • Older adults over 80 years of age require a longer period for weaning