Domain 4. Activity-rest
Class 4. Cardiovascular-pulmonary responses
Diagnostic Code: 00034
Nanda label: Dysfunctional ventilatory weaning response
Diagnostic focus: Ventilatory weaning response
The purpose of this article is to provide healthcare professionals with a basic reference for understanding the nursing diagnosis of dysfunctional ventilatory weaning response. By understanding this nursing diagnosis, nurses can better identify at-risk populations, and employ most effective interventions and therapies.
NANDA Nursing Diagnosis Definition
According to the North American Nursing Diagnosis Association (NANDA), the definition of Dysfunctional Ventilatory Weaning Response (DVWR) is a “pattern of an impaired physiological response toward a gradual change in ventilator support.” This nursing diagnosis focuses specifically on ventilator-enabled breathing processes, such as those in mechanically ventilated patients who depend on an external device or machine for ventilation.
The defining characteristics of DVWR include both subjective and objective factors. Subjective factors such as patient/family reports of difficulty transitioning from assisted ventilation, increased day-to-day variability of clinical parameters, and increased requirement of sedation may be clues of DVWR.
Objective factors include decreased activities of daily living, decreasing tidal volume, low minute ventilation, and/or decreased peak expiratory flow as compared to baseline levels. An increase or decrease in pH or oxygen saturation levels, a decrease in pulse rate, or inspiratory-expiratory ratio greater than 1:4 can also suggest the presence of DVWR.
The related factors of DVWR may include physical factors such as ineffective airway clearance, decreased compliance of the respiratory system, impaired pulmonary circulation, and neuromuscular impairment. Psychological and mental health issues can also contribute to DVWR, such as unrealistic expectations, depression and anxiety, decreased cognitive ability, and poor coping abilities. Sociocultural aspects such as language barriers, cultural influences, and economic concerns can also impact a person’s ability to successfully transition off ventilator support.
At Risk Populations
At risk populations for DVWR may include those individuals who are critically ill and require long-term mechanical ventilation. Elderly patients, adults with long-standing chronic obstructive pulmonary disorder, infants, and children with trachea-bronchomalacia can also be at risk for ventilatory weaning.
Some associated conditions that may impact optimal ventilator weaning outcomes are obesity, pneumonectomy, pulmonary hypertension, heart failure, and pulmonary fibrosis. Other possible medical conditions associated with DVWR include asthma, bronchiectasis, restrictive thoracic disorders,and endobronchial lesions.
Suggestions for Use
When assessing a patient for Dysfunctional Ventilatory Weaning Response, healthcare providers should consider the entire person with regard to their physical, psychological, and sociocultural needs. Appropriate interventions should be tailored to an individual patient to maximize the chances of weaning ventilator support successfully.
Suggested Alternatives NANDA Nursing Diagnosis
Other NANDA nursing diagnosis that may be of value along with the diagnosis of DVWR include Breathing Pattern–Ineffective, Impaired Gas Exchange, Ineffective Airway Clearance, Anxiety, and Ineffective Coping.
When assessing a patient who is weaning from ventilator support, gather as much information as possible regarding the patient’s medical history, current condition, environmental influences, and emotional/psychological state. As much as feasible, identify and address any perceived social and emotional reservations, as well as physiological ones.
The following list outlines NOC outcomes for patients with Dysfunctional Ventilatory Weaning Response:
- Respiratory Status: Ventilation
- Ventilation: Mechanical
- Mobility Level
- Tolerance of Physical Activity
- Comfort Level
- Respiratory Strength
These NOC outcomes are important for gauging a patient’s progress and success with weaning off of ventilator support.
Evaluation Objectives and Criteria
When evaluating the effectiveness of interventions administered to a patient with DVWR, healthcare providers should consider the following evaluation criteria:
- Consistently meeting or exceeding NOC outcome goals.
- Demonstration of improved comfort and lessened anxiety/fears related to discontinuation of ventilator support.
- Progression towards indicators of safe, successful breathing without the need for mechanical ventilation.
The following list outlines NIC interventions for DVWR:
- Airway Management
- Breathing Exercise Therapy
- Exercise/Hemodynamic Monitoring
- Gastrointestinal Management
- Noninvasive Ventilation
- Psychosocial Support
- Ventilatory Weaning Strategies
When considering which interventions to administer, healthcare providers should take into consideration the patient’s acuity level, age, environment, personal preferences, financial resources, and culture.
When caring for a patient experiencing DVWR, some of the nursing activities that would be most beneficial include:
- Assess for physiologic signs of DVWR, utilizing knowledge of baseline parameters and individual patient data.
- Encourage patient participation in respiratory exercises and active breathing maneuvers.
- Assist patient with engaging in regular daily activities and helping them maintain independence as safely as possible.
- Encourage a normal sleep wake cycle, adequate hydration, and proper nutrition.
- Administer prescribed medications in a timely manner.
- Provide psychological and emotional support.
In conclusion, healthcare professionals should have an understanding of Dysfunctional Ventilatory Weaning Response in order to recognize and intervene effectively when an individual is at risk. Nurse activites such as assessment, encouragement, and providing psychosocial support are critical stages of successful weaning from ventilator support. Appropriate interventions should be tailored to each individual’s unique biology, psychology, and social needs in order to best increase chances of successful weaning.
- What is Dysfunctional Ventilatory Weaning Response? DVWR is a pattern of an impaired physiological response toward a gradual change in ventilator support.
- Who is most likely to experience Dysfunctional Ventilatory Weaning Response? Individuals who are critically ill, elderly, and those with long-standing COPD, infants, and children with trachea-bronchomalacia are most likely to experience DVWR.
- What types of interventions can be used to help wean a patient off of ventilator support? Some recommended interventions include airway management, breathing exercise therapy, noninvasive ventilation, and psychosocial support.
- What type of evaluation criteria should be used to evaluate a patient’s progress with ventilator weaning? Evaluation criteria should include consistently meeting or exceeding NOC outcome goals, demonstration of improved comfort levels, and progression towards indicators of safe and successful breathing without the need for mechanical ventilation.
- What nursing activities are beneficial for patients undergoing Dysfunctional Ventilatory Weaning Response? Nurses should assess for physiological signs of DVWR, encourage patient participation in respiratory exercises, assist with engaging in daily activities, encourage good sleep and proper nutrition, administer prescribed medications, and provide psychological and emotional support.