00034 Dysfunctional ventilatory weaning response

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00034 Dysfunctional ventilatory weaning response

Definition of the NANDA label

State in which the individual cannot adapt to lower levels of assisted mechanical ventilatory support, which prevents the interruption of ventilation and prolongs the weaning period.

Inability to adjust to lowered levels of mechanical ventilator support that interrupts and prolongs the weaning process.

Defining characteristics

In the severe dysfunctional response, the patient responds to lower levels of ventilatory support with:
• Agitation.
• Alterations in arterial blood gas analysis.
• Increase in blood pressure & gt; 20 mmHg.
• Increased heart rate & gt; 20 beats / min.
• Significant increase in respiratory rate.
• Diaphoresis.
• Cyanosis.
• Important use of accessory respiratory muscles.
• Longing shallow breathing.
• Paradoxical abdominal breathing.
• Uncoordinated breathing with the fan.
• Decreased level of consciousness.
• Auscultation of breath sounds (secretions in the respiratory tract).

In the moderate dysfunctional response, the patient responds to lower levels of ventilatory support with:
• Slight increase in blood pressure <20 mmHg.
• Slight increase in heart rate <20 beats / min.
• Increase in respiratory rate <5 breaths / min.
• State of maximum alert.
• Inability to respond to instructions.
• Difficulty cooperating.
• Apprehension.
• Diaphoresis.
• Facies with bulging eyes.
• Decreased air intake on auscultation.
• Changes in skin color (paleness, slight cyanosis).
• Participation of the accessory respiratory muscles.

In the mild dysfunctional response, the patient responds to lower levels of ventilatory support with:
• Slight increase in respiratory rate.
• Agitation.
• Feeling of the need for increased oxygen.
• Discomfort when breathing, fatigue and heat.
• Suspected ventilation malfunctions.
• Greater concentration to breathe.

Related factors

Environmental (situations)

• Lack of control in episodic energy demands.
• Inadequate decrease in the rhythm of ventilatory support.
• Adverse environment (annoying noises, excessive activity, negative situations in the room, inadequate nurse / patient relationship, absence of health personnel, presence of personnel
unusual, inadequate social support).
• History of fan dependency & gt; to 1 week.
• History of failed multiple attempts to disconnect ventilation.

Physiological

• Ineffective cleaning of the airways.
• Inadequate nutrition.
• Uncontrolled pain or discomfort.
• Altered sleep pattern.

Psychological

• Lack of knowledge about assisted mechanical ventilation.
• Perception of difficulties in assisted mechanical ventilation.
• Decreased motivation.
• Decreased self-esteem.
• Anxiety: moderate, intense.
• Fear, hopelessness and helplessness.
• Mistrust in health personnel.

Associated condition

• History of unsuccessful weaning attempt
• History of ventilator dependence > 4 days

NOC

• Control of anxiety.
• Status of vital signs.
• Respiratory state: gas exchange.
• Respiratory status: ventilation.

NIC

• Decreased anxiety.
• Preparatory sensory information.
• Monitoring of vital signs.
• Respiratory monitoring.
• Helps with ventilation.
• Mechanic ventilation.
• Weaning from mechanical ventilation.

This diagnosis will retire from the NANDA-I Taxonomy in the 2021-2023 edition unless additional work is completed to bring it up to a level of evidence 2.1 or higher.

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