Problem

Interventions

Rationale

Ineffective breathing pattern

Observe changes in respiratory rate and depth;

observe for breathing difficulty and use of accessory muscles.

An increase in the work of breathing will add to fatigue; may indicate patient fighting ventilator.

Observe for tube misplacement.

Indicates correct position to provide adequate ventilation.

Prevent accidental extubation by taping tube securely, checking q2h.; restraining/sedating as needed.

Avoid trauma from accidental extubation, prevent inadequate ventilation and potential respiratory arrest.

Inspect thorax for symmetry of movement.

Determines adequacy of breathing pattern; asymmetry may indicate hemothorax or pneumothorax.

Measure tidal volume and vital capacity.

Indicates volume of air moving in and out of lungs.

Monitor chest x-rays.

Shows extent and location of fluid or infiltrates in lungs.

Elevate head of bed 60-90 degrees.

This position moves the abdominal contents away from the diaphragm, which facilitates its contraction.

Impaired gas exchange related to alveolar-capillary membrane changes

Monitor arterial blood gas analysis.

Determines acid-base balance and need for oxygen.

Monitor Hb.

Indicates the oxygen carrying capacity available.

Observe for tube obstruction; suction prn; ensure adequate humidification.

May result in inadequate ventilation or mucous plug.

Potential altered nutritional status

Monitor albumin.

Indicates adequate visceral protein.

Nutrition by the enteral route is always preferable.

Calories, minerals, vitamins, and protein are needed for energy and tissue repair.

Provide good oral care q. 4 h.; suction when need indicated using sterile technique; handwashing with antimicrobial for 30 seconds before and after patient contact; do not empty condensation in tubing back into cascade.

Measures aimed at prevention of nosocomial infections.

Assess for GI problems. Preventative measures include relieving anxiety, antacids or H2 receptor antagonist therapy, adequate sleep cycles, adequate communication system.

Most serious is stress ulcer. May develop constipation.

Observe skin integrity for pressure ulcers; preventative measures include turning patient at least q. 2 h.; keep HOB < 30 degrees with a 30 degree side-lying position; use pressure relief mattress or turning bed if indicated; follow prevention of pressure ulcers plan of care; maintain nutritional needs.

Patient is at high risk for developing pressure ulcers due to immobility and decreased tissue perfusion.