00318 Dysfunctional Ventilatory Response To The Weaning Of The Adult

Domain 4: activity/rest
Class 4: cardiovascular/pulmonary responses
Diagnostic Code: 00318
Nanda label: Dysfunctional ventilatory response to the weaning of the adult
Diagnostic focus: ventilatory response to weaning
approved 2020 • Evidence level 3.2

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « dysfunctional ventilatory response to the wean pass successfully to spontaneous ventilation.

Definite characteristics

Early answer (<30 minutes)

  • Abnormal respiratory sounds
  • Audible secretions on the airway
  • Decrease in blood pressure (<90 mmHg or> 20 % reduction over the basal)
  • Decrease in heart rate (> 20 % reduction over basal)
  • Decrease in oxygen saturation (<90 % when inspired oxygen fraction ratio is> 40 %)
  • Express apprehension
  • Express distress
  • Express fear of machine malfunction
  • Express heat sensation
  • Hypervigilance of activities
  • Increase in blood pressure (systolic tension> 180 mmHg or> 20% on the basal)
  • Increase in heart rate (> 140 pulsations/minute or> 20% on the basal)
  • Increased respiratory rate (> 35 rpm or> 50 % on the basal)
  • Nasal flutter
  • Paseo
  • Paradoxical abdominal breathing
  • Perception of increasing need of oxygen
  • Psychomotor agitation
  • Superficial breathing
  • Intense use of accessory muscles
  • Very open eye appearance

IMMEDIATE ANSWER (30-90 minutes)

  • PH decrease (<7.32 or> 0.07 reduction on basal)
  • Diaphoresis
  • Difficulty to cooperate with instructions
  • hypercapnia (> 50 mmHg of increase in partial pressure of carbon dioxide or> 8 mmhg on the basal)
  • Hypoxemia (partial pressure of 50% oxygen or oxygen> 6 l/min)

Late answer (> 90 minutes)

  • Cardiorespiratory arrest
  • Cianosis
  • Fatigue
  • Recent start of arrhythmias

Related factors

  • Alteration of the sleep-vigilia cycle
  • Excessive secretions on the airway
  • ineffective cough
  • Malnutrition

Risk population

  • People with a history of failure in the attempt to weate
  • People with a history of lung diseases
  • People with a history of prolonged fan dependence
  • People with an unplanned extubation history
  • People with unfavorable pre-extubation indices
  • Older adults

Associated problems

  • Acid-base imbalance
  • Anemia
  • Cardiogenic shock
  • Decrease in the level of consciousness
  • Diaphragm dysfunction acquired in the Intensive Care Unit
  • Endocrine system diseases
  • heart disease
  • High acuity affection
  • Hyperthermia
  • hypoxemia
  • Infections
  • Neuromuscular diseases
  • Pharmacological preparations
  • Electrolytes-water imbalance