Dysfunctional adult ventilatory weaning response

Domain 4. Activity-rest
Class 4. Cardiovascular-pulmonary responses
Diagnostic Code: 00318
Nanda label: Dysfunctional adult ventilatory weaning response
Diagnostic focus: Ventilatory weaning response

Nursing diagnosis is an important part of providing care to patients. In the case of dysfunctional adult ventilatory weaning response, it is important to accurately diagnose the problem in order to offer the best treatment options. A nursing assessment will include a thorough physical exam and appropriate laboratory tests in order to determine the underlying cause of the dysfunctional response. By accurately diagnosing the problem, nurses can create an effective plan of care that will reduce the risk of complications and help the patient recover as quickly as possible.

NANDA Nursing Diagnosis Definition

NDx00391 Dysfunctional Adult Ventilatory Weaning Response is revealed when a patient's progress toward weaning from mechanical ventilation is adversely affected due to inadequate physiological and respiratory responses. This condition puts the patient at risk for prolonged periods of assisted ventilation, impaired oxygenation, and potential pneumonic complications.

Defining Characteristics

Subjective: The patient may report difficulty breathing, a feeling of not being able to breathe properly, chest tightness, increased heart rate and tachypnea (excessively rapid breathing).

Objective: The patient's arterial blood levels may show hypoxemia (low levels of oxygen in the blood) or elevated carbon dioxide levels. Respiratory rate may be excessively rapid, and SpO2 readings (measures of arterial blood oxygen saturation) will be below normal levels.

Related Factors

There are a number of factors that could be contributing to dysfunctional adult ventilatory weaning response. These include inadequate knowledge about what the patient should do while weaning, an underlying disease that affects respiration, ineffective oxygenation, airway obstruction, inadequate oxygen supply, inadequate control of secretions, poor lung compliance, malpositioning of endotracheal tube, excessive abdominal obesity, thoracic spine restriction, neuromusculoskeletal disorders, and recurrent aspiration.

At Risk Population

This condition is most often seen in critically ill adults who have been placed on mechanical ventilation as part of their treatment. This includes those with Traumatic Brain Injury (TBI), Stroke, and Chronic Obstructive Pulmonary Disease (COPD). Those with spinal cord injuries, neuromuscular diseases, and traumatic brain injuries are also at risk.

Associated Conditions

The following conditions may contribute to poor ventilator weaning and contribute to ultimately result in a diagnosis of Dysfunctional Adult Ventilatory Weaning Response: Pneumonia, Respiratory Failure, Bronchitis, Pulmonary Embolism, Acute Respiratory Distress Syndrome (ARDS), Asthma, Pulmonary Edema, Pleural Effusion, Pulmonary Fibrosis, Chronic Obstructive Pulmonary Disease (COPD), and Pulmonary Hypertension.

Suggestions for Use

When assessing a patient for this condition, it is important to identify the risk factors. This can help to ensure the patient receives the appropriate level of care and that the interventions are tailored to the individual's needs. The patient's clinical course should be monitored closely to detect any changes in the patient's symptoms or clinical status.

Suggested alternative NANDA Nursing Diagnosis

Other common NANDA diagnoses which might be considered in relation to Dysfunctional Adult Ventilatory Weaning Response include Impaired Gas Exchange, Activity Intolerance, Ineffective Breathing Pattern, Deficient Knowledge: Ventilation Practices, Risk for Ventilatory Insufficiency and Noncompliance.

Usage Tips

When using this diagnosis in the nursing process, it is important to note that there are several interventions that can be used. An individualized care plan should be developed used to meet the needs of the patient. This should include a combination of nursing and medical interventions, including the use of appropriate medications and assistive devices.

NOC Outcomes

A number of Nursing Outcomes Classification (NOC) outcomes may relate to the diagnosis of Dysfunctional Adult Ventilatory Weaning Response. These include Oxygenation Status, Ventilation Status, Self-Care Ability, Activity Tolerance, Self-Management Ability, and Perceived Health Status.

Oxygenation Status

This outcome measures the patient's ability to adequately oxygenate their tissues. It focuses on ensuring therapy is administered in a timely manner, preventing hypoxia and its complications.

Ventilation Status

This outcome looks at the patient's ability to effectively ventilate their lungs, measuring the amount of oxygen inhaled and exhaled during the ventilation period.

Self-Care Ability

This outcome evaluates the patient's ability to carry out self-care activities, such as grooming, hygiene, applying ointments, etc.

Activity Tolerance

This outcome assesses the patient's ability to engage in activities without becoming fatigued or short of breath.

Self-Management Ability

This outcome evaluates whether the patient is able to effectively manage their own health care, seeking appropriate help and following instructions.

Perceived Health Status

This outcome assesses the patient's overall perception of their current health and wellbeing.

Evaluation Objective and Criteria

The evaluation objectives and criteria for Dysfunctional Adult Ventilatory Weaning Response are very specific to the patient. Generally speaking, criteria should include adequacy of initial ventilation and oxygenation, patient's response to weaning strategies, and ability to maintain adequate ventilation and oxygenation on minimal support.

NIC Interventions

There are a number of Nursing Interventions Classification (NIC) interventions that are related to improving the patient's Ventilatory Weaning response. These include, but are not limited to: Teaching: Ventilation Practices, Administering Oxygen Therapy, Performing Endotracheal Suctioning, Monitoring Vital Signs and Oxygen/Ventilator Settings, Initiation of Positive Pressure Ventilation, Assisting with Positioning and Mobility, Assisting with Airway Maintenance, Assisting with Non-Invasive Ventilation and Assisting with Feeding.

Teaching: Ventilation Practices

This intervention involves teaching the patient techniques to reduce work of breathing, such as pursed lip breathing, diaphragmatic breathing, and positioning the patient in a way that facilitates the most efficient use of oxygen.

Administering Oxygen Therapy

This intervention involves providing supplemental oxygen, via a mask or cannula, to maintain sufficient oxygenation during weaning.

Performing Endotracheal Suctioning

This intervention involves suctioning the patient's airway and removing secretions to ensure an open airway and facilitate ventilation.

Monitoring Vital Signs and Oxygen/Ventilator Settings

This intervention involves monitoring the patient's vital signs, such as pulse and breathing rate, and ensuring that the ventilator settings are appropriate.

Initiation of Positive Pressure Ventilation

This intervention involves providing positive pressure ventilation to assist the patient in maintaining adequate oxygenation and ventilation and to reduce work of breathing.

Assisting with Positioning and Mobility

This intervention involves positioning the patient in a way that facilitates the most efficient use of oxygen and facilitates patient mobility while on the ventilator.

Assisting with Airway Maintenance

This intervention involves assisting the patient with maintenance of their airway, such as ensuring proper alignment of the tracheal tube and providing proper suctioning when needed.

Assisting with Non-Invasive Ventilation

This intervention involves helping the patient use non-invasive ventilation devices, such as CPAP or BiPAP, which can provide effective ventilation and reduce the risk of complications.

Assisting with Feeding

This intervention involves providing nutritional support to the patient while they are on mechanical ventilation to ensure proper nutrition and prevent additional complications.

Nursing Activities

Nursing activities associated with Dysfunctional Adult Ventilatory Weaning Response include assessing the patient's response to weaning strategies, educating the patient on techniques to reduce work of breathing, monitoring vital signs and oxygen/ventilator settings, initiating appropriate interventions to maintain adequate ventilation and oxygenation, ensuring proper positioning and alignment of the endotracheal tube, administering oxygen therapy, performing endotracheal suctioning and assisting with feeding.

Conclusion

Properly diagnosing Dysfunctional Adult Ventilatory Weaning Response is essential in providing care to patients. Accurate diagnosis allows nurses to create an individualized plan of care and develop interventions tailored to the specific needs of the patient, reducing the risk of complications and helping the patient recover more quickly.

FAQs

Q: What is Dysfunctional Adult Ventilatory Weaning Response?
A: Dysfunctional Adult Ventilatory Weaning Response is a condition that can occur when a patient's progress towards weaning from has been adversely affected due to inadequate physiological and respiratory responses.

Q: What factors may contribute to Dysfunctional Adult Ventilatory Weaning Response?
A: A number of factors may contribute to dysfunctional adult ventilatory weaning response, including inadequate knowledge about weaning practices, underlying disease that affects respiration, ineffective oxygenation, airway obstruction, and inadequate oxygen supply.

Q: Who is at risk for Dysfunctional Adult Ventilatory Weaning Response?
A: This condition is most often seen in critically ill adults who have been placed on mechanical ventilation as part of their treatment. This includes those with Traumatic Brain Injury (TBI), Stroke, and Chronic Obstructive Pulmonary Disease (COPD). Those with spinal cord injuries, neuromuscular diseases, and traumatic brain injuries are also at risk.

Q: What associated conditions may increase risk of Dysfunctional Adult Ventilatory Weaning Response?
A: Associated conditions thatmay increase the risk of Dysfunctional Adult Ventilatory Weaning Response include Pneumonia, Respiratory Failure, Bronchitis, Pulmonary Embolism, Acute Respiratory Distress Syndrome (ARDS), Asthma, Pulmonary Edema, Pleural Effusion, Pulmonary Fibrosis, Chronic Obstructive Pulmonary Disease (COPD), and Pulmonary Hypertension.

Q: What interventions may be used to manage Dysfunctional Adult Ventilatory Weaning Response?
A: Potential interventions include Teaching: Ventilation Practices, Administering Oxygen Therapy, Performing Endotracheal Suctioning, Monitoring Vital Signs and Oxygen/Ventilator Settings, Initiation of Positive Pressure Ventilation, Assisting with Positioning and Mobility, Assisting with Airway Maintenance, Assisting with Non-Invasive Ventilation and Assisting with Feeding.