6 Mechanical Ventilation Nursing Care Plans

6 Mechanical Ventilation Nursing Care Plans
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Mechanical ventilation can partially or fully replace spontaneous breathing. Its main purpose is to improved gas exchange and decreased work of breathing by delivering preset concentrations of oxygen at an adequate tidal volume. An artificial airway (endotracheal tube) or tracheostomy is needed to a client requiring mechanical ventilation. This therapy is used most often in clients with hypoxemia and alveolar hypoventilation. Although the mechanical ventilator will facilitate movement of gases into and out of the pulmonary system, it cannot guarantee gas exchange at the pulmonary and tissue levels. Caring for a client on mechanical ventilation has become an indispensable part of nursing care in critical care or general medical-surgical units, rehabilitation facilities, and the home care settings. Ventilator-associated pneumonia (VAP) is a significant nosocomial infection that is associated with endotracheal intubation and mechanical ventilation.
Nursing Care Plans
The major goals for a client receiving mechanical ventilation include improvement of gas exchange, maintenance of a patent airway, prevention of trauma, promoting optimal communication, minimizing anxiety, and absence of cardiac and pulmonary complications.
Here are six (6) nursing care plans (NCP) for patients who are under mechanical ventilation:
1. Impaired Spontaneous Ventilation
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Impaired Spontaneous Ventilation: Decreased energy reserves results in an individual’s inability to maintain breathing adequate to support life.
May be related to
• - Acute respiratory failure
• - Metabolic factors
• - Respiratory muscle fatigue
Possibly evidenced by
• - Adventitious breath sounds
• - Apnea
• - Apprehension
• - Arterial ph less than 7.35
• - Decreased tidal volume
• - Decreased oxygen saturation (Sao₂ <90%)
• - Decreased Pao₂ level (>50 to 60 mm Hg)
• - Diminished lung sounds
• - Dyspnea
• - Forced vital capacity less than 10 mL/kg
• - Increased Paco₂ level (50 to 60 mm Hg or higher)
• - Increased or decreased respiratory rate
• - Inability to maintain airway (emesis, depressed gag, depressed cough).
• - Restlessness
Desired Outcomes
• - Client will maintain spontaneous gas exchange resulting in reduced dyspnea, normal oxygen saturation, normal arterial blood gases (ABGs) within client parameters.
• - Client will demonstrate an absence of complications from the mechanical ventilation.
Nursing Interventions	Rationale
Prior intubation assessment:
Observe for changes in the level of consciousness.	Early signs of hypoxia include disorientation, irritability, and restlessness. While lethargy, stupor, and somnolence are considered as late signs.
Assess the client’s respiratory rate, depth, and pattern, including the use of accessory muscles.	Changes in the respiratory rate and rhythm are early signs of possible respiratory distress. As moving air in and out of the lungs becomes more difficult, the breathing pattern changes to include the use of accessory muscles to increase chest excursions.
Assess the client’s heart rate and blood pressure.	Tachycardia may result from hypoxia; Increased in blood pressure happen in the initial phases then followed by lowered blood pressure as the condition progresses.
Auscultate the lung for normal or adventitious breath sounds.	Adventitious breath sounds such as wheezes and crackles are an indication of respiratory difficulties. Quick assessment allows for early detection of deterioration or improvement.
Assess the skin color, examine the lips and nailbeds for cyanosis.	Bluish discoloration of the skin (cyanosis) indicates an excessive concentration of deoxygenated blood and that breathing pattern is ineffective to maintain adequate tissue oxygenation.
Monitor oxygen saturation using pulse oximetry.	Pulse oximetry is useful in detecting early changes in oxygen. Oxygen saturation levels should be between 92% and 98% for an adult without any respiratory difficulties.
Monitor arterial blood gases (ABGs) as indicated.	Increasing Paco2 and decreasing PaO2 indicates a respiratory failure. If the client’s condition begins to fail, the respiratory rate and depth decreases and Paco2 begin to rise.
After intubation assessment:
Assess for correct endotracheal (ET) tube placement through: - Observation of a symmetrical rise of both chest sides. - Auscultation of bilateral breath sounds. - X-ray confirmation.	Correct ET tube placement is important for effective mechanical ventilation.
Assess for client’s comfort and the ability to cooperate while on mechanical ventilation.	Client discomfort may be secondary to incorrect ventilator settings that result in insufficient oxygenation. Once intubated and breathing on the mechanical ventilator, the client should be breathing easily and not “fighting or bucking” the ventilator.
Assess the ventilator settings and alarm system every hour.	Assessment ensures that settings are accurate and alarms are functional.
Therapeutic interventions prior intubation:
Maintain the client’s airway. Use the oral or nasal airway as needed.	An artificial airway is used to prevent the tongue from occluding the oropharynx.
Maintain client in a High-Fowler’s position as tolerated. Frequently check the position.	This position promotes oxygenation via maximum chest expansion and is implemented during events of respiratory distress. Do not let the client slide down; this causes the abdomen to compress the diaphragm, which could cause respiratory change.
Encourage deep breathing and coughing exercises.	Deep breathing facilitates oxygenation. A deep cough is effective in clearing mucus out of the lungs.
Use nasotracheal suction as needed if coughing and deep breathing are not useful.	Suctioning is needed to clients who are unable to remove secretions from the airway by coughing.
Preparation for endotracheal intubation:
Notify the respiratory therapist to bring a mechanical ventilator.	Mechanical ventilators are classified according to the method by which they support ventilation. The two types are negative-pressure and positive-pressure ventilators (used most frequently).
If possible, before intubation, explain to the client the steps and purpose of the procedure and the temporary inability to speak (due to the ET tube passing through the vocal chords).	Preparatory information can decrease anxiety and promote cooperation with intubation.
Prepare the following equipment:
- ET tubes of different sizes.	Endotracheal tubes come in various sizes and shapes. Adult sizes range from 7 to 9 mm. Selection is based on the client’s size.
- Blades, laryngoscope, and stylet	Blades and scopes facilitate the opening of the upper airway and visualization of the vocal cords for placement of oral ET tubes. A stylet makes the ET tube firmer and gives additional support to direction during intubation.
- Syringe, benzoin, and waterproof tape or other securing materials.	A syringe is used to inflate the balloon (cuff) after the ET tube is in position. Tape and benzoin are used to secure the ET tube.
- Local anesthetic agent (e.g., Xylocaine spray or jelly, benzocaine spray, cocaine, lidocaine, and cotton-tipped applicators.	These anesthetic agents suppress the gag reflex and promote general comfort.
Administer sedation as ordered.	Sedation facilitates comfort and ease of intubation.
Assist with intubation:
Place the client in a supine position, hyperextending the neck unless contraindicated and aligning the client’s oropharynx, posterior oropharynx, and trachea.	This position is necessary to promote visualization of landmarks for accurate tube insertion.
Apply cricoid pressure as directed by the physician.	Use of cricoid pressure to prevent passive regurgitation during rapid sequence intubation. It may also prevent passive regurgitation of gastric and oesophageal contents.
Provide oxygenation and ventilation using an Ambu bag and mask as needed before and after each intubation attempt. If intubation is difficult, the physician will stop periodically so that oxygenation is maintained with artificial ventilation by the Ambu bag and mask.	This provides assisted ventilation with 100% oxygen before intubation. Increasing oxygen tension in the alveoli may result in more oxygen diffusion into the capillaries.
Therapeutic interventions after intubation:
Assist with the verification of correct ET tube placemen. Use a carbon dioxide detector as indicated.	Correct placement is needed for effective mechanical ventilation and to prevent complications associated with malpositioning such as vomiting, hypoxia, gastric distention, lung trauma. The carbon dioxide detector is attached to the ET tube immediately after intubation to verify tracheal intubation. Other capnography devices that provide numerical measurements of end-tidal carbon dioxide (normal value is 35 to 45 mm Hg) and capnograms may also be used.
Continue with manual Ambu bag ventilation until the ET tube is stabilized. Assist in securing the ET tube once tube placement is confirmed.	Stabilization is necessary before initiating mechanical ventilation.
Document the ET tube position, noting the centimeter reference marking on the ET tube.	Documentation provides a reference for determining possible tube displacement, usually 21 cm for the women and 23 cm at the lips for men.
Insert an oral airway and/or bite block for the orally intubated client.	An oral airway and/or block prevents the client from biting down on the ET tube.
Use bilateral soft wrist restraints as needed, explaining the purpose of their use.	These restraints may prevent self-extubation of the ET tube. Although all clients do not require restraints to prevent extubation, many do.
Institute mechanical ventilation with prescribed settings.	Modes for ventilating (assist/control, synchronized intermittent mandatory ventilation), tidal volume, rate per minute, fraction of oxygen in inspired gas (FIO2), pressure support, positive end-expiratory pressure, and the like must be preset and carefully evaluated for response.
Institute aseptic suctioning of the airway.	Suction helps remove secretions. A Yankaeur suction device should be available. Suctioning procedures should not be done frequently but as needed only in order to lessen the risk for infection and airway trauma.
Anticipate the need for nasogastric and/or oral gastric suction.	Abdominal distention may indicate gastric intubation and can also occur after cardiopulmonary resuscitation when the air is inadvertently blown or bagged into the esophagus, as well as the trachea. Suction prevents abdominal distention. Oral gastric suctioning may also reduce the risk for sinusitis.
Administer muscle-paralyzing agents, sedatives, and opioid analgesics as ordered.	These medications decrease the client’s work of breathing, decrease myocardial work, and may facilitate effective gas exchange.
Examine the cuff volume by checking whether the client can talk or make sounds around the tube or whether exhaled volumes are significantly less than volumes delivered. To correct, slowly reinflate the cuff with air until no leak is detected. Notify the respiratory therapist to check cuff pressure.	Cuff pressure should be maintained at 20 to 30 mm Hg. Maintenance of low-pressure cuffs prevents many tracheal complications formerly associated with ET tubes. Notify the physician if the leak persists. The ET tube cuff may be defective, requiring the physician to change the tube.
Respond to alarms, noting that high-pressure alarms may be of client resistance or the client’s need for suctioning. A low-pressure alarm may be a ventilator disconnection. If the source of the alarm cannot be located, ventilate the client with an Ambu bag until assistance arrives.	The key is that the client receives oxygenation support at all times until mechanical ventilation is no longer required.
2. Ineffective Airway Clearance
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Ineffective Airway Clearance: Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway.
May be related to
• - Decreased energy and fatigue
• - Endotracheal intubation
• - Stasis of secretions
Possibly evidenced by
• - Abnormal breath sounds
• - Anxiety
• - Dyspnea
• - Excessive secretions
• - Increased peak airway pressure
• - Ineffective cough
• - Restlessness
Desired Outcomes
• - Client will maintain clear, open airways, as evidenced by normal breath sounds after suctioning.
Nursing Interventions	Rationale
Observe the color, odor, quantity, and consistency of sputum.	Thick, tenacious secretions increase airway resistance and the work of breathing. A sign of infection is discolored odoriferous sputum.
Auscultate the lungs for the presence of normal or adventitious breath sounds.	Diminished lung sounds or the presence of adventitious sounds may indicate an obstructed airway and the need for suctioning.
Monitor oxygen saturation prior and after suctioning using pulse oximetry.	This assessment provides an evaluation of the effectiveness of therapy.
Assess arterial blood gases (ABGs).	Signs of respiratory compromise including decreasing Pao2 andincreasing Paco2.
Monitor for peak airway pressures and airway resistance.	Increases in these parameters signal the accumulation of secretions or fluid and the potential for ineffective ventilation.
Explain the suctioning procedure to the client; give reassurance throughout the procedure.	Suctioning can be frightening to the client. Reinforce the need to maintain a patent airway. Provide sedation and pain relief as indicated.
Turn the client every 2 hours.	Turning mobilizes secretions and helps prevent ventilator-associated pneumonia.
Institute airway suctioning as indicated based on the presence of adventitious breath sounds and/or increased ventilatory pressure.	The frequency of suctioning should be based on the client’s clinical status, not on a preset routine such as every 2 hours. Oversuctioning can cause hypoxia and injury to bronchial and lung tissue.
Use closed in-line suction.	This technique decreases the infection rate, may reduce hypoxia, and is often less expensive. Sterile technique is a priority.
Avoid saline instillation before suctioning.	Saline instillation before suctioning has an adverse effect on oxygen saturation.
Hyperoxygenated as ordered.	Hyperoxygenation before, during, and after endotracheal suctioning decreases hypoxia and cardiac dysrhythmias related to the suctioning procedure.
Silence any ventilator alarms during suctioning. Reset the alarms after suctioning.	Silencing alarms decrease the frequency of false alarms during suctioning and reduces stressful noise to the client. Alarms need to be turned on again after suctioning to ensure safety.
Administer an adequate fluid intake (IV and nasogastric, as appropriate).	Maintaining hydration increases ciliary action to remove secretions and reduces a viscosity of secretions. It is easier to mobilize thinner secretions with coughing
Administer pain medications, as appropriate, before suctioning.	These medications decrease peak periods of pain and assist with an effective cough needed to clear secretions.
Consult a respiratory therapist for chest physiotherapy as indicated.	Chest physiotherapy includes the techniques of postural drainage and chest percussion to loosen and mobilize secretions.
3. Anxiety
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Anxiety: Vague uneasy feeling of discomfort or dread accompanied by an autonomic response.
May be related to
• - Change in health status
• - Change in environment
• - Inability to communicate verbally
• - Inability to breathe adequately without support
• - Inability to maintain adequate gas exchange
• - Unknown outcome
Possibly evidenced by
• - Facial tension
• - Focus on self
• - Restlessness
• - Tachypnea
• - Uncooperative behavior
• - Vigilant watch on equipment
• - Withdrawal
Desired Outcomes
• - Client will use effective coping mechanism.
• - Client will describe a reduction in level of anxiety experienced.
• - Client will demonstrate reduced anxiety as evidenced by calm manner and cooperative behavior.
Nursing Interventions	Rationale
Assess the client’s understanding of the need for mechanical ventilation.	Accurate appraisal can facilitate the development of appropriate treatment strategies.
Assess the client for signs of anxiety.	Being on a mechanical ventilator can be a drastic change that will produce a high level of anxiety. Anxiety can affect the respiratory rate and pattern, resulting in rapid, shallow breathing and leading to arterial blood gas abnormalities and the client “fighting or bucking” the ventilator.
Reduce distracting stimuli. Inform the client of alarms on the ventilatory system, and reassure the client about the close proximity of health care personnel to respond to alarms.	Decreasing stimuli provides a quiet environment that enhances rest. Anxiety may escalate with excessive noise, conversation, and equipment around the client. An informed client who understands the treatment plan will be more cooperative.
Display a confident, calm manner and understanding attitude. Be available to the client for support, as well as for explanations of the client’s care and progress.	The presence of a trusted person may be helpful during periods of anxiety. An ongoing relationship establishes a basis for comfort in communicating anxious feelings.
Provide relaxation techniques.	Using anxiety-reduction techniques enhances the client’s sense of personal mastery and confidence.
Encourage sedentary diversional activities.	These activities enhance the client’s quality of life and help pass time.
Encourage visiting family and friends.	The presence of significant others reinforces feelings of security for the client.
If impaired communication is the problem, provide the client with word-and-phrase cards, a writing pad, and pencil, or a picture board.	These tools broaden the opportunity for communicating which may reduce frustrations.
Refer to the psychiatric liaison clinical nurse specialist, psychiatrist, or hospital chaplain, as appropriate.	Specialty expertize may provide a wider range of treatment options and may be needed to achieve successful outcomes.
4. Deficient Knowledge
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Deficient Knowledge: Absence or deficiency of cognitive information related to specific topic.
May be related to
• - Cognitive limitation
• - Decreased motivation to learn
• - New treatment
• - New environment
Possibly evidenced by
• - Anxiety
• - Expressing inaccurate information
• - Questioning members of health care team
Desired Outcomes
• - Client or significant others demonstrate knowledge of mechanical ventilation and care involved.
Nursing Interventions	Rationale
Assess the client’s perception and understanding of mechanical ventilation.	This information provides an important starting point in education.
Assess the client’s readiness and ability to learn.	Educational interventions must be designed to meet the learning limitations, motivation, and needs of the client. Clients in acute care may not be able to take in much information because of fatigue, pain, sensory overload, hypoxemia, and the like.
Encourage the client or significant others to express feelings and ask questions.	Questions facilitate open communication between the client and health care professionals and allow the verification of understanding and the opportunity to correct misconceptions.
Explain the importance of frequent assessment of vital signs, auscultation of breath sounds, ventilation checks.	This information also helps reduce anxiety by providing a basis for actions.
Explain to the client the reason for the inability to talk while intubated. Explain alternative efforts for communicating.	The endotracheal tube passes through the vocal cords and attempts to talk can cause more trauma to the cords. However, clients must understand how to use supplementary methods for communication such as paper, pen, pictures.
Explain that the client will not be able to eat or drink while intubated but assure him or her that alternative measures (IV fluids, gastric feedings, or hyperalimentation) will be taken to provide nourishments.	The risk for aspiration is high if the client eats or drinks while intubated. In long-term care settings, clients may be allowed to eat and drink after a swallow evaluation.
Explain that alarms may periodically sound off, which may be normal, and that the staff will be in close proximity.	Explaining expected events can help reduce anxiety.
Explain the need for suctioning as needed.	This information can help reduce anxiety associated with the procedure.
Explain the weaning process and explain that extubation demonstrates adequate respiratory function and a decrease in pulmonary secretions.	This information aids the client in maintaining some control.
If long-term ventilation is anticipated, discuss or plan for long-term ventilator care management and use appropriate referrals: long-term ventilator facilitates versus home care management.	Continuity of care is facilitated through the use of specialty resources.
5. Risk for Ineffective Protection
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Risk for Ineffective Protection: At risk for a decrease in the ability to guard self against internal or external threats such as illness or injury.
May be related to
• - Decreased pulmonary compliance
• - Improper alarm settings
• - Improper ventilator settings
• - Increased secretions
• - Positive-pressure ventilation
• - Ventilator dependency
• - Ventilator disconnection
Possibly evidenced by
• [not applicable]
Desired Outcomes
• - Client will remain free of injury as evidenced by proper ventilator settings and arterial blood gases (ABGs) within normal limits for client.
• - Client will have a decreased potential for injury from barotrauma and ventilator-associated pneumonia (VAP) by continuous assessments and early interventions.
Nursing Interventions	Rationale
Review the ventilator settings every hour. Notify the respiratory unit of any discrepancy in the ventilator settings immediately:	Frequent assessment guarantees that the client is receiving correct mode, rate, tidal volume, FIo2,positive end-respiratory pressure (PEEP) and pressure support. Important attention to details can prevent problems.
- Rate of mechanical breaths	The usual rate is between 10 to 14 breaths per minute.
- Pressure support (PS)	Pressure support (PS) produces positive airway pressure during the inspiratory cycle of a spontaneous inspiratory effort.
- Tidal volume (TV)	Typical ranges for TV are 6 to 8 mL/kg of ideal body weight. Research supports lower standard TVs to reduce barotrauma.
- PEEP	PEEP serves to improve gas exchange and prevent atelectasis.
- FIO2	The amount of oxygen prescribed depends on the client’s condition and ABG results.
Mode:
- Assist control (AC)	Assist control (AC) delivers full ventilatory support by providing a preset tidal volume for each client-initiated breath.
- Controlled mandatory ventilation (CMV)	CMV ensures a preset rate with no sensitivity to the client’s respiratory effort. The client cannot initiate breaths or alter the pattern.
- Synchronized intermittent mandatory ventilation (SIMV)	SIMV ensures a preset rate in synchronization with the client’s own spontaneous breathing.
Make sure that the ventilator alarms are on.	The alarm alert the caregiver in cases of ventilation problems. A quick response to alarm ensures the correction of problems and maintenance of adequate ventilation.
Assess respiratory rate and rhythm including the work of breathing.	It is important to maintain the client in synchrony with the ventilator and not permit “bucking” it.
Assess arterial blood gases results and monitor oxygen saturation.	Objective data guide the ventilator settings and appropriate interventions.
Assess for the signs of pulmonary infection including increased temperature, purulent secretions, elevated white blood cell count, positive bacterial cultures, and evidence of pulmonary infection on chest X-ray studies.	VAPs occur in up to 28% of clients on ventilators. Mortality rates of 40% to 50% have been reported for these clients. Most ventilator-associated infections are caused by bacterial pathogens, with gram-negative bacilli being common.
Assess for the signs of barotrauma: the client with crepitus, subcutaneous emphysema, altered chest excursion, asymmetrical chest, abnormal ABGs, a shift in trachea, restlessness, evidence of pneumothorax on chest x-ray studies.	Barotrauma is damage to the lungs from positive pressure as seen in clients with an acute respiratory disease when high pressures are needed to ventilate stiff lungs or when PEEP is used. Frequent assessments are needed because barotrauma can occur at any time and the client will not show signs of dyspnea, shortness of breath, or tachypnea if heavily sedated to maintain ventilation.
Monitor chest x-ray reports daily and obtain a stat portable chest x-ray film if barotrauma is suspected.	Vigilant monitoring helps reduce complications.
Monitor plateau pressures with the respiratory therapist.	Monitoring for barotrauma can involve measuring plateau pressure, which is the pressure after delivery of the tidal volume but before the client is allowed to exhale. The ventilator is programmed so that after delivery of the tidal volume the client is not allowed to exhale for a half second. Therefore pressure must be maintained to prevent exhalation. Elevation of plateau pressures increases both the risk and incidence of barotrauma when the client is on mechanical ventilation. There has been less occurrence of barotrauma since guidelines have recommended lower standard tidal volumes.
Listen for alarms. Know the range in which the ventilator will set off the alarm and how to troubleshoot:	The ventilator is a life-sustaining treatment that requires prompt response to alarms:
- Apnea alarm	The apnea alarm is indicative of a disconnection or absence of spontaneous respirations.
- Low exhale volume	The low exhale alarm indicates that the client is not returning delivered TV (through disconnection or leak).
- Low-pressure alarm	The low-pressure alarm indicates a possible disconnection or mechanical ventilator malfunction.
- High peak pressure alarm	The high peak pressure alarm indicates bronchospasm, retained secretions, obstruction of ET tube, atelectasis, acute respiratory distress syndrome (ARDS), or pneumothorax, among others.
Institute measures to reduce VAP.	Nosocomial infections are a leading cause of mortality.
- Keep the head of bed elevated to 30 to 45 degrees or perform subglottic suctioning unless it is medically contraindicated.	Elevation promotes better lung expansion. It also reduces gastric reflux and aspiration.
- Wash hands before and after suctioning, touching ventilator equipment, and/or coming into contact with respiratory secretions.	An artificial airway bypasses the normal protective mechanisms of the upper airways. Handwashing reduces germ transmission.
- Brush teeth two to three times per day with a soft toothbrush. Chlorhexidine-based rinses may also be incorporated into oral care protocols.	Oral care reduces colonization of the oropharynx with respiratory pathogens that can be aspirated into the lungs.
- Use a continuous subglottic suction endotracheal (ET) tube for intubation that is expected to be longer than 24 hours.	This intervention prevents the accumulation of secretions that can be aspirated.
- Use sterile suctioning procedures.	This technique decreases the introduction of microorganisms into the airway.
Notify the physician of signs of barotrauma immediately; anticipate the need for chest tube placement, and prepare the client as needed.	If barotrauma is suspected, intervention must follow immediately to prevent tension pneumothorax.
6. Risk for Decreased Cardiac Output
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Risk for Decreased Cardiac Output: At risk for inadequate blood pumped by the heart to meet metabolic demands of the body.
May be related to
• - Mechanical ventilation
• - Positive-pressure ventilation
Possibly evidenced by
• [not applicable]
Desired Outcomes
• - Client will maintain adequate cardiac output, as evidenced by systolic BP within 20 mm Hg of baseline; HR to 60 to 100 beats per minute with regular rhythm; strong peripheral pulses; urine output greater than 30 ml/hour, warm, and dry skin; and normal level of consciousness.
Nursing Interventions	Rationale
Assess the client’s level of consciousness, blood pressure, heart rate and hemodynamic parameters if in place (central venous pressure, pulmonary artery diastolic pressure (PADP), and pulmonary capillary wedge pressure, cardiac output).	Mechanical ventilation can produce decreased venous return to the heart, resulting in decreased BP, compensatory increased heart rate, and decreased cardiac output. This may happen abruptly with ventilator changes: rate, tidal volume, or positive-pressure ventilation. The level of consciousness will decrease if cardiac output is severely compromised. Therefore close monitoring during ventilator changes is imperative.
Assess the capillary refill, skin temperature, and peripheral pulses.	Pulses are weak with reduced stroke volume and cardiac output. Capillary refill is slow with reduced cardiac output. Cold, pale, clammy skin is secondary to compensatory sympathetic nervous system stimulation and associated with low cardiac output and oxygen desaturation.
Monitor for dysrhythmias.	Cardiac dysrhythmias may result from the low perfusion state, acidosis, or hypoxia.
Monitor fluid balance and urine output.	Optimal hydration status is needed to maintain effective circulating blood volume and counteract the ventilatory effects on cardiac output. With positive pressure ventilation, pressure from the diaphragm decreases blood flow to the kidneys and could result in a drop in urine output. The brain is very sensitive to a decrease in blood flow and may respond by releasing antidiuretic hormone (ADH) (to increase water and sodium retention), further reducing urine output. After the initial decrease in venous return to the heart, volume receptors in the right atrium signal a decrease in volume, which triggers an increase in the release of ADH from the posterior pituitary and retention of water by the kidneys.
Notify the physician immediately of signs of a decrease in cardiac output, and anticipate possible ventilator setting changes.	Vigilant monitoring reduces the risk for complications. Hypotension and decreased cardiac output may be related to positive-pressure ventilator itself or use of positive end-expiratory pressure (PEEP) mode.
Maintain an optimal fluid balance.	Volume therapy may be required to maintain adequate filling pressures and optimize cardiac output. However, if PADP and/or pulmonary capillary wedge pressure rises and cardiac output remains low, fluid restriction may be necessary.
Administer medications as ordered (diuretics, inotropic agents).	Diuretics may be useful to maintain fluid balance if fluid retention is a problem. Inotropic agents may be useful to increase cardiac output.
References and Sources : nurse labesnurseslabs.com