Effective
Careplanning for Someone on a Ventilator
Careplan
development for a ventilator-dependent person should be the Roadmap
for clinicians, families, and the individual. If careplanning is
approached as a team-based function, designed to map the successful
liberation of the Resident from the ventilator; it becomes an
evergreen document created to adapt to the Resident’s changing
needs and ultimate success.
People find themselves requiring the need for a ventilator for a
myriad of reasons; including respiratory failure, lung disease,
heart disease, post-surgical support, and post traumatic injury. It
is essential to describe the underlying cause or need for the
ventilator in your careplan.
In this article we will demonstrate careplan development for a
fictional person, John Doe. We will start with a brief case study,
followed by suggested goals and interventions that an
interdisciplinary treatment team could use in the treatment of Mr.
Doe.
Case Study
Mr. John Doe is a 58 year old white male with a long-standing
history of smoking; he noted starting smoking at approximately age
16 and averaging one and half packs per day for a smoke year history
of 63 years.
He reported developing shortness of breath with regular daily
activity approximately 5 years ago and was diagnosed with chronic
obstructive pulmonary disease (COPD). At that time he underwent
pulmonary function studies that revealed a significantly reduced
forced expiratory volume (1 second). During this testing,
bronchodilator administration was performed and he showed
significant improvement in expiratory volume. He was subsequently
started on a medication regime of inhaled bronchodilators.
He has presented to his doctor today and is complaining of increased
shortness of breath, sputum production, fever, and general malaise.
Chest x-ray reveals a right lower lobe pneumonia and pulse oximetry
is noted at 85% on room air. Mr. Doe is directly admitted from the
doctor’s office to the hospital for aggressive treatment and
monitoring.
Once admitted to the hospital, baseline arterial blood gases are
drawn on room air and noted as follows: Ph 7.289, PaCO2 57.4, PaO2
58.2 . Oxygen therapy is initiated at 2 lpm, and Mr. Doe is
monitored. Pulse oximetry reveals saturations levels well above 90,
but Mr. Doe is now lethargic and confused. Repeat arterial blood
analysis reveal severe CO2 retention and decrease in his Ph. Based
on the overall clinical picture, Mr. Doe is intubated and mechanical
ventilation is instituted to assist him through this crisis.
After mechanical ventilation is started, repeated arterial blood
gases reveal normal values: Ph 7.410, PaCO2 47, PaO2 89. During his
complicated hospital stay numerous attempts are made to wean him
from the ventilator, without success. With each attempt, Mr. Doe’s
respiratory rate elevates into the high 30’s and his heart rate
increases into the 120’s, with a noted drop in his pulse oximetry
values. After numerous unsuccessful attempts to wean Mr. Doe, it was
deemed necessary for him to proceed to a Long-Term Care (LTC)
ventilator program.
On admission to the LTC program, Mr. Doe was noted to be very
anxious, but easily distracted. He had a good sense of humor and
voiced his desire to come off the ventilator. During his initial
assessments he told the doctor he still had the desire to smoke,
although he knew it was not possible. Mr. Doe was deconditioned, and
had not walked since his hospital admission, and reports that his
daily walking was limited due to his shortness of breath. He also
reports neglecting daily grooming, for the same reason.
After gathering their initial data and assessments the LTC
interdiciplinary treatment team gathered for a careplan development
meeting. A marker board was utilized to collect the pertinent data
for easy viewing by the entire team.
The team, with the input of Mr. Doe, and his family, identified the
issues, barriers, and successes required for Mr. Doe’s ultimate
weaning from the ventilator. The team then developed the written
plan of care based on these items. The careplan also reflects the
progression and/or difficulties Mr. Doe may encounter during his
progression in weaning.
The careplan will reflect the issues related to the Mr. Doe’s
condition which are what the team assesses have to be addressed in
order to meet the goal of weaning.
Problems, Concerns, and Opportunities
The team assessed Mr. Doe’s issues to be -
- COPD
- Smoker -
quit upon hospitalization; still reports desire to smoke
- Decreased
strength and endurance
- Anxiety
- Inability
to speak, secondary to tracheostomy tube
- CO2
retention that rises with oxygen administration
- Eating
through a gastrostomy tube
- Below
ideal body weight
- Currently
on work disability; would like to return to work (autoparts
store clerk)
- Supportive
family
- Supportive
community
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These issues are the
start of the treatment plan for Mr. Doe and are written into the
careplan based on the team assessment. Note again that this is a
fictional case study. Each Resident’s issues and presenting
problems may be different.
Goals:
- John Doe
will have an incremental decrease in ventilator support,
per own tolerance, with clear open airway. AEB pulse ox
>=90%
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In this example the
goal is developed through the team assessment, the defining of the
issue. Because the introduction of a mechanical ventilator is based
on medically complex reasons, goals will be different for each
individual.
Individualized Interventions and Approaches
- Wean per
protocol.
- Monitor
for signs of intolerance; such as, increased HR, RR,
sweating, and/or decrease pulse oximetry or LOC. Report
changes to MD, RN and RT.
- Provide
rescue/back up ventilator settings when s/s of intolerance
develop
- Airway
management and care per protocol.
- Monitor
secretions for change in color, consistency, odor, and
volume. Report changes to MD, RN and RT.
- Provide
diversional activities when s/s of anxiety present -
general conversation, reading, music, TV, card playing.
- Provide
repeated opportunities for engagement in motivational
self-discovery programs (Art, Music, Writing, per general
Resident protocol).
- Instruct
family and visitors on successful ways to assist John Doe
in relaxation and diversion methods.
- Provide
anti-anxiety medications per MD order.
- Rehab
services to improve strength and endurance.
- Provide
smoking cessation program including nicotine replacement,
if desired, and if ordered by MD.
- Dietary
consult to promote weight gain.
- Speech
Therapy for progression to by-mouth diet.
- Trial of
Passy Muir Valve for audible speech.
- Per
Resident’s request, discuss weaning progress and
ventilator settings only in general terms and incorporate
adjustments to ventilator into scheduled ventilator checks
to reduce Resident fear and anxiety.
- Monitor
for s/s of CO2 retention - increased confusion,
sleepiness.
- Monitor
for safe oxygen use within hi environment.
- Monitor
Pulse oximetry per protocol.
- Give
medications per MD order(s).
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The interventions are
designed to meet the goals, as defined by the issue. These suggested
interventions are based on our fictional case study and
individualized on that example. The success of any careplan rests on
the interdisciplinary team assessment and individualizing the goals
and interventions to meet the individual needs of the person.
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