Vent Patient Nursing Diagnosis

[DecafMom]

I spent my clinical day on Monday at a long-term care facility for kids. My patient was a 23 month old female on a ventilator. She was born at 26 weeks. I'm looking over the nursing diagnoses and I'm so confused! I thought this would be one of the easiest ones to come up with, but I'm having a hard time. It seems as if the diagnoses pertain to someone prior to being placed on a vent, not someone who is already on one. I think that impaired spontaneous ventilation would still be good because this is still true even though she's on the vent. But what about impaired gas exchange, or ineffective breathing patterns? What would be the priority? ABGs are used to determine the effectiveness of gas exchange, but there were none in her chart. I know the vent forces ventilation but cannot force respiration. As you can see, I keep going in circles. Thanks for your help!

[SteveNNP, MSN, NP]

I work as an RN in a level III NICU where I deal with babies on vents all the time. Here are a few suggestions for nsg dx's:

Dysfunctional ventilatory weaning response - basically you can't get them off the vent.

Risk for infection - ALWAYS, esp with an artificial airway

Risk for aspiration - babies don't have cuffed ETT's, saliva and other stuff can still get to the lungs.

You mentioned impaired gas exchange, ineffective ventilation...these are good, and can be measured by ABG's, Spo2, color, airway pressures etc.....Also you can determine from the vent how often the baby is breathing on her own.

Pain is a biggie, all kids on vents should be sedated and medicated for pain. Bad abg's, fluctuating Spo2, increased o2 requirements, can all indicate pain

I hope these help....BTW I LOVE nicu, you should try to do a preceptorship there. I'll bet you'd love it!

Steve

[sailornurse]

I teach med surg II students that are in the ICu with ventilator patients. We teach by Maslow's priorities so for vent patients that are being suctioned, this is what I like to see in the nursing dx:1. Airway 2. Breathing 3. Circulation

1. Ineffective Airway clearance as pt is being suctioned

then I would go with any of the ones Steve mentions also. as he covered #2, breathing very nicely. 3. circulation -Try ineffective tissue perfusion or cardiac output or fluid volume issues might be applicable depending on the patho.

Good luck,

Sailor Nurse

[Gompers, BSN, RN]

Well, if she was in long term care, she has to have had a trach, and most likely a G-tube as well?

I wouldn't say pain would be an issue here. The trach site would have been long healed before she went to the long term care facility.

Once a baby is in a place like that, they don't usually do labs on a regular basis. It's usually when they are getting sick, and then they transfer them to a hospital anyways. The reason they don't have ABGs in the chart is that the baby was monitored closely in the hospital for a long time before they decided on her vent settings - on our unit, an older baby who is going home or to a LTC facility has to stay on the exact same vent settings and oxygen level for 30 days before being discharged. So yes, gas exchange is an issue, but you really can only go by vital signs and O2 sats to assess how she's doing.

Risk for infection r/t artificial airway is definitely a good one.

Alteration in nutrition if she does not take food orally (or if she doesn't take enough) and has a G-tube. Babies who eat by mouth usually take what their body tells them they need - but if you're giving G-tube feedings you have to make sure they are getting enough fluid and calories on their current ordered

diet.

I'd say the BIGGEST issue with a 2 year old in LTC on a vent would be developmental care. This baby is probably behind developmentally after being so premature and being hospitalized basically her entire life. She needs to have goals made (sitting, standing, crawling, etc.) and therapy working with her to make sure she is making her milestones.

[DecafMom]

I work as an RN in a level III NICU where I deal with babies on vents all the time. Here are a few suggestions for nsg dx's:

Dysfunctional ventilatory weaning response - basically you can't get them off the vent.

Risk for infection - ALWAYS, esp with an artificial airway

Risk for aspiration - babies don't have cuffed ETT's, saliva and other stuff can still get to the lungs.

You mentioned impaired gas exchange, ineffective ventilation...these are good, and can be measured by ABG's, Spo2, color, airway pressures etc.....Also you can determine from the vent how often the baby is breathing on her own.

Pain is a biggie, all kids on vents should be sedated and medicated for pain. Bad abg's, fluctuating Spo2, increased o2 requirements, can all indicate pain

I hope these help....BTW I LOVE nicu, you should try to do a preceptorship there. I'll bet you'd love it!

Steve

Awesome, thank you Steve! She is on ativan and valium, but is not receiving pain medicine. I would like to get some time in at a NICU. I'm working on scheduling 16 hours of my own clinical hours. I currently work in the nursery of an OB unit, but we do not keep babies that are really sick. Generally we have only bili babies or those needing O2 or antibiotics.

[DecafMom]

I teach med surg II students that are in the ICu with ventilator patients. We teach by Maslow's priorities so for vent patients that are being suctioned, this is what I like to see in the nursing dx:1. Airway 2. Breathing 3. Circulation

1. Ineffective Airway clearance as pt is being suctioned

then I would go with any of the ones Steve mentions also. as he covered #2, breathing very nicely. 3. circulation -Try ineffective tissue perfusion or cardiac output or fluid volume issues might be applicable depending on the patho.

Good luck,

Sailor Nurse

Thanks! See, this is where I get confused. Would you use Ineffective Airway Clearance as the top priority? I'm going to call the facility today and see if I can talk to her nurse and get some more input. We just didn't get enough time there and I feel useless!!

[DecafMom]

Well, if she was in long term care, she has to have had a trach, and most likely a G-tube as well?

I wouldn't say pain would be an issue here. The trach site would have been long healed before she went to the long term care facility.

Once a baby is in a place like that, they don't usually do labs on a regular basis. It's usually when they are getting sick, and then they transfer them to a hospital anyways. The reason they don't have ABGs in the chart is that the baby was monitored closely in the hospital for a long time before they decided on her vent settings - on our unit, an older baby who is going home or to a LTC facility has to stay on the exact same vent settings and oxygen level for 30 days before being discharged. So yes, gas exchange is an issue, but you really can only go by vital signs and O2 sats to assess how she's doing.

Risk for infection r/t artificial airway is definitely a good one.

Alteration in nutrition if she does not take food orally (or if she doesn't take enough) and has a G-tube. Babies who eat by mouth usually take what their body tells them they need - but if you're giving G-tube feedings you have to make sure they are getting enough fluid and calories on their current ordered

diet.

I'd say the BIGGEST issue with a 2 year old in LTC on a vent would be developmental care. This baby is probably behind developmentally after being so premature and being hospitalized basically her entire life. She needs to have goals made (sitting, standing, crawling, etc.) and therapy working with her to make sure she is making her milestones.

Developmental issues are most definitely a concern. She suffers from profound MR. She was sleeping the whole time I was there so I did not get to see her abilities when awake. I have thought about going back down there to spend some more time with her if I could.

She does have a G-tube, so nutrition was going to be one of my diagnoses, but I know that respiratory needs to be number one. Thanks so much for your input. I really appreciate it!!!

[NRSKarenRN, BSN, RN]

a irway

breathing

c irculation

n utrition/hydration

d evelopmental status

these are areas you want to focus on with your diagnosis for peds patient.

excelelnt resources for children with trach is aaron's tracheostomy page although it deals more with homecare. also might give you some ideas.

[DecafMom]

a irway

breathing

c irculation

n utrition/hydration

d evelopmental status

these are areas you want to focus on with your diagnosis for peds patient.

excelelnt resources for children with trach is aaron's tracheostomy page although it deals more with homecare. also might give you some ideas.

thanks! i have visited that page...i found it the same day as my clinical experience at the facility. i know that airway is first, but what my issue was decided exactly which diagnosis to use. after all, if they aren't breathing, they aren't living. :)

[Gompers, BSN, RN]

Thanks! I have visited that page...I found it the same day as my clinical experience at the facility. I know that airway is first, but what my issue was decided exactly which diagnosis to use. After all, if they aren't breathing, they aren't living. :)

Then I'd definitely go with airway clearance. You won't be doing blood gasses on this baby or changing her vent settings. Unless she gets sick, that stuff is kind of set already. So what you would focus on is keeping that trach clear so she gets the ordered volumes from the vent.

It's good that she's on sedation - but I wonder if they're giving her too much if she sleeps all the time? Then again, depending on how severe her MR is, she might be constantly trying to pull out her trach or G-tube when awake, so maybe that is why she's sedated.

She shouldn't need the pain medication. Her trach and G-tube incisions were most likely healed well before she left the hospital for the nursing facility. It's more when someone has an endotracheal tube that they need pain management because it is much larger and more uncomfortable than a trach tube. Having a trach itself shouldn't cause pain after it's healed.