Introduction to Nursing Diagnosis: Dysfunctional Ventilatory Response to the Weaning of the Adult
The NANDA nursing diagnosis Dysfunctional Ventilatory Response to the Weaning of the Adult is one of the diagnoses that addresses the degree of difficulty experienced by a patient in relation to their ability to successfully wean from the assistance of mechanical ventilators. The diagnosis is most commonly used for those who are undergoing weaning from mechanical ventilator support, however it can equally be used when assessing those with other forms of chronic respiratory disturbances.
NANDA Nursing Diagnosis Definition
Dysfunctional Ventilatory Response to the Weaning of the Adult is defined as an inability of an adult patient to successfully wean from mechanical ventilation due to inadequate minute ventilation and/or oxygenation.
- Difficulty speaking
- Shortness of breath
- Alterations in respiratory rate or pattern
- Use of accessory muscles for respiration
- Decreased SpO2
- Age-related physiological changes
- Decreased mobility
- Reduced physical fitness level
- Weak neuromuscular coordination
- Impaired lung function
- Inadequate ventilation/perfusion ratio
- Elderly adults
- Adults with acute and/or chronic respiratory illness
- Individuals with neurological disorders
- Immunosuppressed individuals
- Individuals with underlying cardiovascular disease
- Respiratory failure/arrest
- Retained secretions
- Delayed psychomotor development
- Impaired quality of life
Suggestions for Use
- Monitoring vital signs, including oxygen saturation and respiratory rate
- Evaluating patient’s ability to tolerate weaning attempts
- Assessing patient’s emotional state
- Encouraging activity in appropriate settings using puffers and aerosols as necessary during exacerbations
- Teaching deep breathing techniques and pursed lip breathing
Suggested Alternates NANDA Nursing Diagnoses
- Ineffective Breathing Pattern
- Ineffective Airway Clearance
- Impaired Gas Exchange
- Ventilatory Weaning Readiness
- Be sure to consider both physiological and psychological components when assessing for dysfunctional ventilatory response.
- Be cautious of potential adverse effects from weaning that can result from patients being weaned too quickly.
- Ventilation: Gas Exchange – Measures taken to maximize the exchange of oxygen-carbon dioxide gases as evidenced by improved oxygen saturation and decreased levels of carbon dioxide in the blood.
- Breathing Pattern – Regularity in breathing assessed by noting effectiveness of breathing when at rest, activated by stress and other environmental factors, and measured by using pulmonary function tests and oxygen saturation.
- Respiratory Monitoring – Assess patient’s oxygenation by monitoring vital signs and other assessments as ordered.
- Ventilation Management – Monitor and adjust ventilator settings to ensure adequate oxygenation.
- Breathing Assistance – Assist patient with different breathing exercises to help promote optimal airway patency.
The NANDA nursing diagnosis Dysfunctional Ventilatory Response to the Weaning of the Adult is an important tool to help identify when a patient has difficulty achieving successful weaning from mechanical ventilation. Understanding both physiological and psychological components are necessary to provide effective care and assessment. Additionally, it is important to remain aware of potential adverse effects that can occur from weaning too quickly and adjust care accordingly.
- What does the NANDA nursing diagnosis Dysfunctional Ventilatory Response to the Weaning of the Adult mean? – The diagnosis means an inability of an adult patient to successfully wean from mechanical ventilation due to inadequate minute ventilation and/or oxygenation.
- What type of care is usually considered with this diagnosis? – Care that is provided may include monitoring vital signs, assessing and evaluating patient’s ability to tolerate weaning, teaching deep breathing and pursed lip breathing techniques, and assessing patient’s emotional state.