B9 · Needs breathing machine support
Actual Breathing and circulation
Definition
The person cannot breathe well alone and relies on a ventilator or similar device.- Respiratory failure
- surgery
- brain injury
- severe weakness
- Connected to a ventilator
- unable to breathe alone
- sedated
- breathing tube in place
📋 Scenario
A sedated ICU patient after a head injury relies fully on a ventilator.
Subjective (S): (Sedated and unable to speak.) Family: "He couldn't breathe on his own after the accident."
Objective (O): On a ventilator with ordered settings; sedated; oxygen saturation 96%; secretions suctioned every 2 hours; head of bed raised 30 degrees.
Assessment tools for this scenario: CP-BREATH Breathing & Circulation Check
Validated scales to consider: NEWS2, SpO₂, ECG
**CarePath diagnosis:** Needs breathing machine support related to respiratory failure, as evidenced by connected to a ventilator and unable to breathe alone.
**Interventions and rationale**
| Intervention | Rationale |
|---|---|
| Check tube position and ventilator settings. | Correct tube position ensures air reaches both lungs, and checking settings confirms the machine delivers the ordered breaths and oxygen. |
| Suction as needed. | Suction removes secretions that a sedated patient cannot cough up, keeping the tube and airways open. |
| Give mouth care. | Mouth care reduces germs that could be breathed into the lungs and cause ventilator-related pneumonia. |
| Keep head raised. | A raised head lowers the chance that stomach contents or mouth secretions run into the lungs. |
| Prevent tube pulling. | Pulling out the breathing tube can cause sudden loss of the airway and injury, so securing it and preventing tugging is vital. |
| Keep talking to the patient. | Hearing is often kept during sedation, so talking reassures the patient, reduces distress and respects dignity. |
**Expected outcomes**
- Oxygen saturation stays at target.
- No accidental tube removal.
- No ventilator-related pneumonia.
- Weaning begins when the doctor orders.
- Mouth care done every 4 hours.
**Linking the data to the diagnosis**
The patient is sedated in intensive care after a head injury and relies fully on a ventilator. Family say he could not breathe on his own after the accident. The nurse records oxygen saturation 96%, secretions suctioned every 2 hours and the head of the bed raised 30 degrees. This is an actual problem because he cannot breathe alone now. Poor oxygen exchange in the lungs would describe lung failure in general, but this statement fits because the care centers on the machine and the breathing tube. The plan aims to keep oxygen at target, prevent tube removal and ventilator-related pneumonia, start weaning when ordered, and give mouth care every 4 hours.
CarePath diagnosis
Needs breathing machine support related to respiratory failure, as evidenced by connected to a ventilator and unable to breathe alone.
Interventions and rationale
Listed in priority order.
| Intervention | Rationale |
|---|---|
| 1. Check tube position and ventilator settings. | Correct tube position ensures air reaches both lungs, and checking settings confirms the machine delivers the ordered breaths and oxygen. |
| 2. Suction as needed. | Suction removes secretions that a sedated patient cannot cough up, keeping the tube and airways open. |
| 3. Give mouth care. | Mouth care reduces germs that could be breathed into the lungs and cause ventilator-related pneumonia. |
| 4. Keep head raised. | A raised head lowers the chance that stomach contents or mouth secretions run into the lungs. |
| 5. Prevent tube pulling. | Pulling out the breathing tube can cause sudden loss of the airway and injury, so securing it and preventing tugging is vital. |
| 6. Keep talking to the patient. | Hearing is often kept during sedation, so talking reassures the patient, reduces distress and respects dignity. |
Expected outcomes
- Oxygen saturation stays at target.
- No accidental tube removal.
- No ventilator-related pneumonia.
- Weaning begins when the doctor orders.
- Mouth care done every 4 hours.
Linking the data to the diagnosis
The patient is sedated in intensive care after a head injury and relies fully on a ventilator. Family say he could not breathe on his own after the accident. The nurse records oxygen saturation 96%, secretions suctioned every 2 hours and the head of the bed raised 30 degrees. This is an actual problem because he cannot breathe alone now. Poor oxygen exchange in the lungs would describe lung failure in general, but this statement fits because the care centers on the machine and the breathing tube. The plan aims to keep oxygen at target, prevent tube removal and ventilator-related pneumonia, start weaning when ordered, and give mouth care every 4 hours.