Nurse's Pocket Guide

• Discuss impact of specific activities on respiratory status and
problem solve solutions to maximize weaning effort.
• Engage client in specialized exercise program to enhance respiratory
muscle strength and general endurance.
• Protect client from sources of infection (e.g., monitor health
of visitors, roommate, caregivers).
• Recommend involvement in support group; introduce to
individuals dealing with similar problems to provide role
models, assistance for problem solving.
• Encourage time-out for caregivers so that they may attend to
personal needs, wellness, and growth.
• Provide opportunities for client/SO(s) to discuss termination
of therapy/end-of-life decisions.
• Refer to individual(s) who are ventilator-dependent/have
managed home ventilation successfully to encourage hope
for the future.
• Refer to additional resources (e.g., spiritual advisor, counselor).
Documentation Focus
ASSESSMENT/REASSESSMENT
• Baseline findings, subsequent alterations in respiratory
function.
• Results of diagnostic testing.
• Individual risk factors/concerns.
PLANNING
• Plan of care and who is involved in planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Client’s/SO’s responses to interventions, teaching, and actions
performed.
• Skill level/assistance needs of SO(s)/family.
• Attainment, progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Discharge plan, including appropriate referrals, action taken,
and who is responsible for each action.
• Equipment needs and source.
• Resources for support persons/home care providers.
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
Diagnostic Studies Pediatric/Geriatric/Lifespan Medications 761
impaired spontaneous VENTILATION