Caring for the Patient on a Ventilator
The nurse must be able to do the
following:
1. Identify the indications for mechanical ventilation.
2. List the steps in preparing a patient for intubation.
3. Determine the FIO2, tidal volume, rate and mode of
ventilation on a given
ventilator.
4. Describe the various modes of ventilation and their
implications.
5. Describe at least two complications associated with
patients response to mechanical ventilation and their
signs and symptoms.
6. Describe the causes and nursing measures taken when
trouble-shooting ventilator alarms.
7. Describe preventative measures aimed at preventing
selected other complications related to endotracheal
intubation.
8. Give rationale for selected nursing interventions in
the plan of care for the ventilated patient.
9. Complete the care of the ventilated patient checklist.
10. Complete the suctioning checklist.
- To review indications for and basic modes of
mechanical ventilation, possible complications that
can occur, and nursing observations and procedures to
detect and/or prevent such complications.
- To provide a systematic nursing assessment procedure
to ensure early detection of complications associated
with mechanical ventilation.
Indication for Intubation
1. Acute respiratory failure evidenced by the lungs
inability to maintain arterial oxygenation or eliminate
carbon dioxide leading to tissue hypoxia in spite of low-flow
or high-flow oxygen delivery devices. (Impaired gas exchange,
airway obstruction or ventilation-perfusion abnormalities).
2. In a patient with previously normal ABGs, the ABG
results will be as follows:
PaO2 > 50 mm Hg with pH < 7.25
PaO2 < 50 mm Hg on 60% FIO2 :
restlessness, dyspnea, confusion, anxiety, tachypnea,
tachycardia, and diaphoresis
PaCO2 > 50 mm Hg : hypertension,
irritability, somnolence (late), cyanosis (late), and LOC
(late)
3. Neuromuscular or neurogenic loss of respiratory
regulation. (Impaired ventilation)
4. Usual reasons for intubation: Airway maintenance,
Secretion control, Oxygenation and Ventilation.
Types of intubation: Orotracheal,
Nasotracheal, Tracheostomy
Preparing for Intubation
1. Recognize the need for intubation.
2. Notify physician and respiratory therapist. Ensure
consent obtained if not emergency.
3. Gather all necessary equipment:
a. Suction canister with regulator and connecting
tubing
b. Sterile 14 Fr. suction catheter or closed in-line
suction catheter
c. Sterile gloves
d. Normal saline
e. Yankuer suction-tip catheter and nasogastric
tube
f. Intubation equipment: Manual resuscitator bag (MRB),
Laryngoscope and blade, Wire guide, Water soluble
lubricant, Cetacaine spray
g. Endotracheal attachment device (E-tad) or tape
h. Get order for initial ventilator settings
i. Sedation prn
j. Soft wrist restraints prn
k. Call for chest x-ray to confirm position of
endotracheal tube
l. Provide emotional support as needed/ ensure
family notified of change in condition.
Intubation
Types of Ventilators
Ventilator Settings
Modes of Mechanical Ventilation
Complications of Mechanical Ventilation
1. Associated with patients response to mechanical
ventilation:
A. Decreased Cardiac Output
1. Cause - venous return to the right atrium impeded
by the dramatically increased intrathoracic pressures
during inspiration from positive pressure ventilation.
Also reduced sympatho-adrenal stimulation leading to a
decrease in peripheral vascular resistance and reduced
blood pressure.
2. Symptoms increased heart rate, decreased
blood pressure and perfusion to vital organs, decreased
CVP, and cool clammy skin.
3. Treatment aimed at increasing preload (e.g.
fluid administration) and decreasing the airway pressures
exerted during mechanical ventilation by decreasing
inspiratory flow rates and TV, or using other methods to
decrease airway pressures (e.g. different modes of
ventilation).
B. Barotrauma
1. Cause damage to pulmonary system due to
alveolar rupture from excessive airway pressures and/or
overdistention of alveoli.
2. Symptoms may result in pneumothorax,
pneumomediastinum, pneumoperitoneum, or subcutaneous
emphysema.
3. Treatment - aimed at reducing TV, cautious use of
PEEP, and avoidance of high airway pressures resulting in
development of auto-PEEP in high risk patients (patients
with obstructive lung diseases (asthma, bronchospasm),
unevenly distributed lung diseases (lobar pneumonia), or
hyperinflated lungs (emphysema).
C. Nosocomial Pneumonia
1. Cause invasive device in critically ill
patients becomes colonized with pathological bacteria
within 24 hours in almost all patients. 20-60% of these,
develop nosocomial pneumonia.
2. Treatment aimed at prevention by the
following:
Avoid cross-contamination by frequent handwashing
Decrease risk of aspiration (cuff occlusion of
trachea, positioning, use of small-bore NG tubes)
Suction only when clinically indicated, using
sterile technique
Maintain closed system setup on ventilator
circuitry and avoid pooling of condensation in the
tubing
Ensure adequate nutrition
Avoid neutralization of gastric contents with
antacids and H2 blockers
D. Positive Water Balance
1. Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
due to vagal stretch receptors in right atrium
sensing a decrease in venous return and see it as
hypovolemia, leading to a release of ADH from the
posterior pituitary gland and retention of sodium and
water. Treatment is aimed at decreasing fluid intake.
2. Decrease of normal insensible water loss due to
closed ventilator circuit preventing water loss from
lungs. This fluid overload evidenced by decreased urine
specific gravity, dilutional hyponatremia, increased
heart rate and BP.
E. Decreased Renal Perfusion can be treated with
low dose dopamine therapy.
F. Increased Intracranial Pressure (ICP) reduce
PEEP
G. Hepatic congestion reduce PEEP
H. Worsening of intracardiac shunts reduce PEEP
2. Associated with ventilator malfunction:
A. Alarms turned off or nonfunctional may lead to
apnea and respiratory arrest
Troubleshooting Ventilator Alarms
Low exhaled volume: Cuff leak, Tubing disconnect,
Patient disconnected
Evaluate cuff; reinflate prn; if ruptured,
tube will need to be replaced. Evaluate
connections; tighten or replace as needed; check
ETT placement, Reconnect to ventilator
High pressure: Secretions in airway, Patient
biting tubing, Tube kinked, Cuff herniation,
Increased airway resistance/decreased lung compliance
(caused by bronchospasm, right mainstem bronchus
intubation, pneumothorax, pneumonia), Patient
coughing and/or fighting the ventilator; anxiety;
fear; pain.
Suction patient, Insert bite block, Reposition
patients head/neck; check all tubing
lengths, Deflate and reinflate cuff, Auscultate
breath sounds, Evaluate compliance and tube
position; stabilize tube, Explain all procedures
to patient in calm, reassuring manner, Sedate/medicate
as necessar
Low oxygen pressure: Oxygen malfunction
Disconnect patient from ventilator; manually
bag with ambu; call R.T
3. Other complications related to endotracheal intubation.
A. Sinusitis and nasal injury obstruction of
paranasal sinus drainage; pressure necrosis of nares
1. Prevention: avoid nasal intubations; cushion nares
from tube and tape/ties.
2. Treatment: remove all tubes from nasal passages;
administer antibiotics.
B. Tracheoesophageal fistula pressure necrosis of
posterior tracheal wall resulting from overinflated cuff and
rigid nasogastric tube
1. Prevention: inflate cuff with minimal amount of air
necessary; monitor cuff pressures q. 8 h.
2. Treatment: position cuff of tube distal to fistula;
place gastrostomy tube for enteral feedings; place
esophageal tube for secretion clearance proximal to
fistula.
C. Mucosal lesions pressure at tube and mucosal
interface
1. Prevention: Inflate cuff with minimal amount of air
necessary; monitor cuff pressure q. 8 h.; use appropriate
size tube.
2. Treatment: may resolve spontaneously; perform
surgical interventions.
D. Laryngeal or tracheal stenosis injury to area
from end of tube or cuff, resulting in scar tissue formation
and narrowing of airway
1. Prevention: inflate cuff with minimal amount of air
necessary; monitor cuff pressure q. 8.h.; suction area
above cuff frequently.
2. Treatment: perform tracheostomy; place laryngeal
stint; perform surgical repair.
E. Cricoid abcess mucosal injury with bacterial
invasion
1. Prevention: inflate cuff with minimal amount of air
necessary; monitor cuff pressure q. 8 h.; suction area
above cuff frequently.
2. Treatment: perform incision and drainage of area;
administer antibiotics.
4. Other common potential problems related to mechanical
ventilation:
Aspiration, GI bleeding, Inappropriate ventilation (respiratory
acidosis or alkalosis, Thick secretions, Patient discomfort due
to pulling or jarring of ETT or tracheostomy, High PaO2, Low PaO2,
Anxiety and fear, Dysrhythmias or vagal reactions during or after
suctioning, Incorrect PEEP setting, Inability to tolerate
ventilator mode.
PLAN OF CARE FOR THE VENTILATED PATIENT
Patient Goals:
- Patient will have effective breathing pattern.
- Patient will have adequate gas exchange.
- Patients nutritional status will be maintained to
meet body needs.
- Patient will not develop a pulmonary infection.
- Patient will not develop problems related to immobility.
- Patient and/or family will indicate understanding of the
purpose for mechanical ventilation.
Nursing
Diagnosis
|
Nursing
Interventions
|
Rationale
|
Ineffective
breathing pattern r/t
____________________________. |
Observe
changes in respiratory rate and depth; observe
for SOB and use of accessory muscles. |
An
increase in the work of breathing will add to
fatigue; may indicate patient fighting ventilator. |
| Observe
for tube misplacement- note and post cm. Marking
at lip/teeth/nares after x-ray confirmation and q.
2 h. |
Indicates
correct position to provide adequate ventilation. |
| Prevent
accidental extubation by taping tube securely,
checking q.2h.; restraining/sedating as needed. |
Avoid
trauma from accidental extubation, prevent
inadequate ventilation and potential respiratory
arrest. |
| Inspect
thorax for symmetry of movement. |
Determines
adequacy of breathing pattern; asymmetry may
indicate hemothorax or pneumothorax. |
| Measure
tidal volume and vital capacity. |
Indicates
volume of air moving in and out of lungs. |
| Asses
for pain |
Pain
may prevent patient from coughing and deep
breathing. |
| Monitor
chest x-rays |
Shows
extent and location of fluid or infiltrates in
lungs. |
| Maintain
ventilator settings as ordered. |
Ventilator
provides adequate ventilator pattern for the
patient. |
| Elevate
head of bed 60-90 degrees. |
This
position moves the abdominal contents away from
the diaphragm, which facilitates its contraction.
|
Impaired
gas exchange r/t alveolar-capillary membrane
changes |
Monitor
ABGs. |
Determines
acid-base balance and need for oxygen. |
| Assess
LOC, listlessness, and irritability. |
These
signs may indicate hypoxia. |
| Observe
skin color and capillary refill. |
Determine
adequacy of blood flow needed to carry oxygen to
tissues. |
| Monitor
CBC. |
Indicates
the oxygen carrying capacity available. |
| Administer
oxygen as ordered. |
Decreases
work of breathing and supplies supplemental
oxygen. |
| Observe
for tube obstruction; suction prn; ensure
adequate humidification. |
May
result in inadequate ventilation or mucous plug. |
| Reposition
patient q. 1-2 h. |
Repositioning
helps all lobes of the lung to be adequately
perfused and ventilated. |
Potential
altered nutritional status: less than body
requirements r/t NPO status |
Monitor
lymphocytes and albumin. |
Indicates
adequate visceral protein. |
| Provide
nutrition as ordered, e.g. TPN, lipids or enteral
feedings. |
Calories,
minerals, vitamins, and protein are needed for
energy and tissue repair. |
| Obtain
nutrition consult. |
Provides
guidance and continued surveillance. |
Potential
for pulmonary infection r/t compromised tissue
integrity. |
Secure
airway and support ventialtor tubing. |
Prevent
mucosal damage. |
| Provide
good oral care q. 4 h.; suction when need
indicated using sterile technique; handwashing
with antimicrobial for 30 seconds before and
after patient contact; do not empty condensation
in tubing back into cascade. |
Measures
aimed at prevention of nosocomial infections. |
| Use
disposable saline irrigation units to rinse in-line
suction; ensure ventilator tubing changed q. 7
days, in-line suction changed q. 24 h.; ambu bags
changes between patients and whenever become
soiled. |
IAW
Infection Control Policy and Respiratory Therapy
Standards of Care for CCNS. |
Potential
for complications r/t immobility. |
Assess
for psychosocial alterations. |
Dependency
on ventilator with increased anxiety when
weaning; decreased ability to communicate; social
isolation/alteration in family dynamics. |
| Assess
for GI problems. Preventative measures include
relieving anxiety, antacids or H2 receptor
antagonist therapy, adequate sleep cycles,
adequate communication system. |
Most
serious is stress ulcer. May develop constipation. |
| Observe
skin integrity for pressure ulcers; preventative
measures include turning patient at least q. 2 h.;
keep HOB < 30 degrees with a 30 degree side-lying
position; use pressure relief mattress or turning
bed if indicated; follow prevention of pressure
ulcers plan of care; maintain nutritional needs. |
Patient
is at high risk for developing pressure ulcers
due to immobility and decreased tissue perfusion. |
| Maintain
muscle strength with active/active-assistive/passive
ROM and prevent contractures with use of span-aids
or splints. |
Patient
is at risk for developing contractures due to
immobility, use of paralytics and ventilator
related deficiencies. |
Knowledge
deficit r/t intubation and mechanical ventilation |
Explain
purpose/mode/and all treatments; encourage
patient to relax and breath with the ventilator;
explain alarms; teach importance of deep
breathing; provide alternate method of
communication; keep call bell within reach; keep
informed of results of studies/progress;
demonstrate confidence. |
Reduce
anxiety, gain cooperation and participation in
plan of care. |
This page last updated 07/25/10
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