MACHANICAL VENTILATOR PATIENT NURSING CARE PLAN
Nursing Action
Preparatory phase
Obtain baseline samples for blood gas
determinations (pH, PaO2, PaCO2,
HCO3-) and chest X-ray.
Performance phase
Give a brief explanation to the patient
and family.
Premedicate as needed
Establish the airway by means of a
cuffed ET or tracheostomy tube
Prepare the ventilator. (Respiratory
therapist does this in many facilities.)
Set up desired circuitry.
Connect oxygen and compressed air
source.
Turn on power
Set VT (usually 6 to 8 mL/kg body
weight “Morton”).
Set oxygen concentration.
Set ventilator sensitivity
Set rate at 12 to 14 breaths/minute
(variable).
Set inspiratory-expiratory (I:E) times
(varies depending on the ventilator).
Adjust flow rate (velocity of gas flow
during inspiration). Usually set at 40
to 60 L/minute. Depends on rate and
VT.
Select mode of ventilation.
Rationale
Baseline measurements serve as a guide in determining
progress of therapy
Emphasize that mechanical ventilation is a temporary
measure. The patient should be prepared psychologically
for weaning at the time the ventilator is first used.
To promote cooperation through mild sedation.
A closed system between the ventilator and patient's
lower airway is necessary for positive pressure ventilation
To have all equipment and settings in place before
applying to patient
Adjusted according to pH and PaCO2.
Adjusted according to PaO2.
This setting approximates normal ventilation. These
machines' settings are subject to change according to the
patient's condition and response, and the ventilator type
being used.
The slower the flow, the lower the peak airway pressure
will result from set volume delivery. This results in lower
intrathoracic pressure and less impedance of venous
return. However, a flow that is too low for the rate
selected may result in inverse I:E ratios.
Check machine function—measure VT,
rate, I:E ratio, analyze oxygen, check
all alarms.
Couple the patient's airway to the
ventilator.
Assess patient for adequate chest
movement and rate. Note peak airway
pressure and PEEP.
Set airway pressure alarms according
to patient's baseline
High pressure alarm
Low pressure alarm
Assess frequently for change in
respiratory status by evaluation of
ABGs, pulse oximetry, spontaneous
rate, use of accessory muscles, breath
sounds, and vital signs. Other means
of assessing are through the use of
exhaled carbon dioxide or “oxygen
saturation monitoring,”
Monitor and troubleshoot alarm
conditions. Ensure appropriate
ventilation at all times.
Ensures safe function.
Make sure all connections are secure. Prevent ventilator
tubing from “pulling” on artificial airway, possibly
resulting in tube dislodgement or tracheal damage.
Ensures proper function of equipment.
High airway pressure is set at 10 to 15 cm H2O above peak
inspiratory pressure. An alarm sounds if airway pressure
selected is exceeded. Alarm activation indicates decreased
lung compliance (worsening pulmonary disease);
decreased lung volume (such as pneumothorax, tension
pneumothorax, hemothorax, pleural effusion); increased
airway resistance (secretions, coughing, bronchospasm,
breathing out of phase with the ventilator); loss of patency
of airway (mucus plug, airway spasm, biting or kinking of
tube).
Low airway pressure alarm set at 5 to 10 cm H2O below
peak inspiratory pressure. Alarm activation indicates
inability to build up airway pressure because of
disconnection or leak, and changing compliance and
resistance.
Priority is ventilation and oxygenation of the patient. In
alarm conditions that cannot be immediately corrected,
disconnect the patient from mechanical ventilation and
manually ventilate with resuscitation bag.
Check for secure stabilization of Reduces risk of inadvertent extubation.
artificial airway.

Positioning:
Turn patient from side to side every 2
hours, or more frequently if possible.
Consider kinetic therapy as early
intervention to improve outcome.
For patients on long-term ventilation, this may result in
sleep deprivation. Follow a turning schedule best suited to
a particular patient's condition. Repositioning may
improve secretion clearance and reduce atelectasis.

Lateral turns are desirable; from right

semiprone to left semiprone
Sit the patient upright at regular
intervals if possible
Consider prone positioning to
improve oxygenation
Carry out passive range-of-motion
exercises of all extremities for patients
unable to do so.
Assess for need of suctioning at least
every 2 hours
Assess breath sounds every 2 hours:
Listen with stethoscope to the chest in
all lobes bilaterally.
Upright posture increases lung compliance.
Proning has been shown to have some beneficial effects or
the improvement of oxygenation in certain populations,
such as patients with ARDS.
To prevent contractures.
Patients with artificial airways on mechanical ventilation
are unable to clear secretions on their own. Suctioning
may help to clear secretions and stimulate the cough
reflex.
Auscultation of the chest is a means of assessing airway
patency and ventilatory distribution. It also confirms the
proper placement of the ET or tracheostomy tube

Determine whether breath sounds are

present or absent, normal or
abnormal, and whether a change has
occurred.
Observe the patient's diaphragmatic
excursions and use of accessory
muscles of respiration.
Humidification.
Check the water level in the
humidification reservoir to ensure
that the patient is never ventilated
with dry gas. Empty the water that
condenses in the delivery and
exhalation tubing into a separate
receptacle, not into the humidifier.
Always wash hands before and after
emptying fluid from ventilator
circuitry. Humidification may also be
achieved using a moisture enhancer.
Assess airway pressures at frequent
intervals.
Water condensing in the inspiratory tubing may cause
increased resistance to gas flow. This may result in
increased peak airway pressures. Warm, moist tubing is a
perfect breeding area for bacteria. If this water is allowed
to enter the humidifier, bacteria may be aerosolized into
the lungs. Emptying the tubing also prevents introduction
of water into the patient's airways.
Monitor for changes in compliance, or onset of conditions
that may cause airway pressure to increase or decrease.

Measure delivered VT and analyze To ensure that patient is receiving the appropriate
oxygen concentration every 4 hours ventilatory assistance.
or more frequently if indicated.
(Respiratory therapist performs this
in most facilities.)

Monitor cardiovascular function.

Assess for abnormalities.
Monitor pulse rate and arterial BP; Arterial catheterization for intra-arterial pressure
intra-arterial pressure monitoring monitoring also provides access for ABG samples.
may be carried out.
Use pulmonary artery catheter to Intermittent and continuous positive pressure ventilation
monitor pulmonary capillary wedge may increase the PAP and decrease cardiac output
pressure (PCWP), mixed venous
oxygen saturation (SvO2), and cardiac
output (CO).

Provide mouth care every 1-4 hours

and assess for development of
pressure areas from ET tubes.
Monitor for systemic signs and For comfort and reduced risk of infection.
symptoms of pulmonary infection
(pulmonary physical examination
findings, increased heart rate,
increased temperature, increased
count).
Evaluate need for sedation or muscle Sedatives may be prescribed to decrease anxiety, or to
relaxants. relax the patient to prevent “competing” with the
ventilator. At times, pharmacologically induced paralysis
may be necessary to permit mechanical ventilation.
Use “ventilator bundle” protocol, as
directed, to prevent ventilator-
associated complications.
Elevate the head of the bed to
between 30 and 45 degrees.
Daily “sedative interruption” and daily
assessment of readiness to extubate.
Peptic ulcer disease prophylaxis
Deep vein thrombosis prophylaxis
(unless contraindicated
Report intake and output precisely
and obtain an accurate daily weight to
monitor fluid balance.
Monitor nutritional status
Monitor GI function
Test all stools and gastric drainage for
occult blood (if part of facility
protocol).
Provide for care and communication
needs of patient with an artificial
airway.
Provide psychological support.
Assist with communication
Orient to environment and function of
mechanical ventilator.
To reduce the risk of aspiration, peptic ulcer, and deep
vein prophylaxis; and to reduce sedation that may
interfere with assessment.
Positive fluid balance resulting in increase in body weight
and interstitial pulmonary edema is a frequent problem in
patients requiring mechanical ventilation. Prevention
requires early recognition of fluid accumulation. An
average adult who is dependent on parenteral nutrition
can be expected to lose 12 lb (0.25 kg) per day; therefore,
constant body weight indicates positive fluid balance.
Patients on mechanical ventilation require inflation of
artificial airway cuffs at all times. Patients with
tracheostomy tubes may eat, if capable, or may require
enteral feeding tubes or parenteral nourishment. Patients
with ET tubes are to receive nothing by mouth (the tube
splints the epiglottis open) and must be entirely tube fed
or parenterally nourished.
Mechanically ventilated patients are at risk for
development of stress ulcers.
Stress may cause some patients requiring mechanical
ventilation to develop GI bleeding
Mechanical ventilation may result in sleep deprivation and
loss of touch with surroundings and reality
Ensure that the patient has adequate
rest and sleep.
Follow-up phase
Maintain a flow sheet to record Establishes means of assessing effectiveness and progress
ventilation patterns, ABGs, venous of treatment
chemical determinations, hemoglobin
and hematocrit, status of fluid balance,
weight, and assessment of the
patient's condition. Notify appropriate
personnel of changes in the patient's
condition.
Change ventilator circuitry per facility Prevents contamination of lower airways.
protocol; assess ventilator's function
every 4 hours or more frequently if
problem occurs.

WEANING THE PATIENT FROM

MECHANICAL VENTILATION

PROCEDURE
Preparatory phase
For weaning to be successful, the Provides baseline; ensures that patient is capable of
patient must be physiologically having adequate neuromuscular control to provide
capable of maintaining spontaneous adequate ventilation.
respirations. Assessments must
ensure that:
The underlying disease process is
significantly reversed, as evidenced by
pulmonary examination, ABGs, chest
X-ray.
The patient can mechanically perform
ventilation. Should be able to generate
a negative inspiratory pressure less
than -20 cm H2O; have a vital capacity
10 to 15 mL/kg; have a resting minute
ventilation less than 10 L/minute; and
be able to double this; have a
spontaneous respiratory rate of less
than 25 breaths/minute; without
significant tachycardia; be
normotensive; have optimal
hemoglobin for condition; have
adequate nutritional status.

Assess for other factors that may Weaning is difficult when these conditions are present
cause respiratory insufficiency
Acid-base abnormality
Nutritional depletion
Electrolyte abnormality
Fever
Abnormal fluid balance
Hyperglycemia
Infection
Pain
Sleep deprivation
Decreased LOC
Assess psychological readiness for Patient must be physically and psychologically ready for
weaning. weaning.
Performance phase
Ensure psychological preparation. Explaining procedure to patient will decrease patient
Explain procedure and that weaning is anxiety and promote cooperation. The patient should not
not always successful on the initial be discouraged if weaning is unsuccessful on the first
attempt. attempt.
Prepare appropriate equipment.
Position the patient in sitting or semi- Increases lung compliance, decreases work of breathing.
Fowler's position.
Pick optimal time of day, preferably The patient should be rested.
early morning.
Perform bronchial hygiene necessary The patient should be in best pulmonary condition for
to ensure that the patient is in best weaning to be successful.
condition (postural drainage,
suctioning) before weaning attempt.
T-Piece
This system provides oxygen enrichment and humidity to a patient with an ET or tracheostomy
tube while allowing completely spontaneous respirations

Discontinue mechanical ventilation Stay with the patient during weaning time to decrease
and apply T-piece adapter. patient anxiety and monitor for tolerance of procedure

Monitor the patient for factors Indicates intolerance of weaning procedure

indicating need for reinstitution of
mechanical ventilation.
Monitor the patient for factors
indicating need for reinstitution of
mechanical ventilation.
BP increase or decrease greater than
20 mm Hg systolic or 10 mm Hg
diacstolic

Heart rate increase of 20

beats/minute or greater than 110
Respiratory rate increase greater than
10 breaths/minute or rate greater
than 30
Respiratory rate increase greater than
10 breaths/minute or rate greater
than 30
VT less than 250 to 300 mL (in adults)
Appearance of new cardiac ectopy or
increase in baseline ectopy
PaO2 less than 60, PaCO2 greater than
55, or pH less than 7.35 (may accept
lower PaO2 and pH, and higher PaCO2
in patients with COPD)

Increase time off ventilator with each
weaning attempt as the patient's
condition indicates. Evaluate for
toleration before moving to the next
increment.
The patient will progress as he becomes mentally and
physically able to perform adequate spontaneous
ventilation.

When patient tolerates 40 to 60

minutes of continuous weaning,
weaning increments can increase
rapidly.
When the patient can maintain
spontaneous ventilation throughout
day, begin night weaning.
CPAP weaning
The principles and techniques for
continuous positive airway pressure
(CPAP) weaning are the same as for T-
piece weaning.
CPAP weaning
The principles and techniques for This weaning technique is preferred for patients prone to
continuous positive airway pressure atelectasis when placed on a T-piece.
(CPAP) weaning are the same as for T-
piece weaning.
The patient breathes with CPAP at low
level (2.5 to 5 cm H2O), rather than
with the T-piece, for periods that
increase in length.

IMV or SIMV weaning

Set ventilator to IMV or SIMV mode.
Set rate interval. This determines the time interval between
machinedelivered breaths, during which the patient will
breathe on his own.
If the patient is on continuous flow The gas flow rate into the bag must be adequate to prevent
IMV circuitry, observe reservoir bag to the bag from collapsing during inspiration. Flow rates of 6
be sure that it remains mostly inflated to 10 L/minute are usually adequate.
during all phases of ventilation.

If gas for the patient's spontaneous Aids in decreasing work of breathing necessary to open
breath is delivered via a demand valve demand valve.
regulator, ensure that machine
sensitivity is at maximum setting.

Evaluate for tolerance of procedure. If the patient does not tolerate the procedure, the PaCO2
Monitor for factors indicating need for will rise and pH will fall.
increase or decrease of mandatory
respiratory rate (see step 3 of T-piece
adapter section above). In rapid
weaning, changes may be made
approximately every 20 to 30
minutes.
If PaCO2 and pH levels remain stable, May be done as frequently as every 20 to 30 minutes with
then continue to decrease mandatory ABG monitoring, pulse oximetry, documentation of
rate as patient tolerates. successful weaning.

Pressure support
May be beneficial adjunct to IMV or
SIMV weaning.
The amount of pressure support (cm
H2O) provided to the airway is
progressively decreased over time,
allowing the patient to increase role in
supporting own spontaneous
ventilation.
Follow-up phase
Record at each weaning interval: heart Provides record of procedure and assessment of progress.
rate, BP, respiratory rate, FiO2, ABG,
pulse oximetry value, respiratory and
ventilator rate (if IMV or SIMV), or
length of time off ventilator (if T-piece
weaning).

EXTUBATION:
EQUIPMENT:
Tonsil suction (surgical suction
instrument)
10 mL syringe
Resuscitation bag and mask with
oxygen flow
Face mask connected to large-bore
tubing, humidifier, and oxygen source
Suction catheter
Suction source
Gloves
Face shield

Preparatory phrase
Monitor heart rate, lung expansion, VT, VC, and NIF are measured to assess respiratory muscle
and breath sounds before extubation. function and adequacy of ventilation.
Record tidal volume (VT), vital
capacity (VC), negative inspiratory
pressure (NIP).

Assess the patient for other signs of Adequate muscle strength is necessary to ensure muscle
adequate muscle strength. strength for spontaneous breathing and coughing.

Instruct the patient to tightly squeeze the index and

middle fingers of your hand. Resistance to removal of your
fingers from the patient's grasp must be demonstrated.

Ask the patient to lift head from the pillow and hold for 2
to 3 seconds.
Performance phase
Obtain orders for extubation and Do not attempt extubation until postextubation oxygen
postextubation oxygen therapy. therapy is available and functioning at the bedside.

Explain the procedure to the patient: Increases patient cooperation.

Artificial airway will be removed. a.

Suctioning will occur before extubation.
Deep breath should be taken on command.
Instruction will be given to cough after extubation.
Prepare necessary equipment. Have
ready for use tonsil suction, suction
catheter, 10-mL syringe, bag-mask
unit, and oxygen by way of face mask.
Place the patient in sitting or semi- Increases lung compliance and decreases work of
Fowler's position (unless breathing. Facilitates coughing.
contraindicated).

Put on face shield. Spraying of airway secretions may occur.

Put on gloves. Loosen tape or ET tube-

securing device.
Suction ET tube.
Suction oropharyngeal airway above Secretions not cleared from above the cuff will be
the ET cuff as thoroughly as possible. aspirated when the cuff is deflated.

Extubate the patient:

Ask the patient to take as deep a At peak inspiration, the trachea and vocal cords will dilate,
breath as possible (if the patient is not allowing a less traumatic tube removal.
following commands, give a deep
breath with the resuscitation bag).
At peak inspiration, deflate the cuff b.
completely and pull the tube out in the
direction of the curve (out and
downward).
Once the tube is fully removed, ask the Frequently, old blood is seen in the secretions of newly
patient to cough or exhale forcefully to extubated patients. Monitor for the appearance of bright
remove secretions. Then suction the red blood due to trauma occurring during extubation.
back of the patient's airway with the
tonsil suction.

Apply oxygen therapy as ordered.

Evaluate immediately for any signs of Immediate complications:
airway obstruction, stridor, or difficult
breathing. If the patient develops any Laryngospasm may develop, causing obstruction of the
of these problems, attempt to airway.
ventilate the patient with the
resuscitation bag and mask and Edema may develop at the cuff site. Signs of narrowing
prepare for reintubation. (Nebulized airway lumen are high-pitched crowing sounds, decreased
treatments may be ordered to avoid air movement, and respiratory distress.
having to reintubate the patient.)
Follow-up phase
Note patient tolerance of procedure, Establishes a baseline to assess
upper and lower airway sounds improvement/development of complications.
postextubation, description of
secretions.

Observe the patient closely Tracheal or laryngeal edema develops postextubation (a

postextubation for any signs and possibility for up to 24 hours). Signs and symptoms
symptoms of airway obstruction or include high-pitched, crowing upper airway sounds and
respiratory insufficiency. respiratory distress.
Observe character of voice and signs Hoarseness is a common postextubation complaint.
of blood in sputum. Observe for worsening hoarseness or vocal cord paralysis.

Provide supplemental oxygen using

face mask.