Caring for the Patient on a Ventilator

8/3/2019 Caring for the Patient on a Ventilator

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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 mechanicalventilation 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 toendotracheal 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.

1. To review indications for and basic modes of mechanical ventilation, possiblecomplications that can occur, and nursing observations and procedures to detect

and/or prevent such complications.2. 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-perfusionabnormalities).

2. In a patient with previously normal ABGs, the ABG results will be as follows:

PaO2 > 50 mm Hg with pH < 7.25


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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.


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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 intrathoracicpressures 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 airwaypressures 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 pressuresand/or overdistention of alveoli.

2. Symptoms may result in pneumothorax, pneumomediastinum, pneumoperitoneum, orsubcutaneous 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 obstructivelung 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


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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 ofADH 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 lossfrom 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,T

ubing 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


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mainstem bronchus intubation, pneumothorax, pneumonia), Patient coughing and/or fighting theventilator; 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 asnecessar

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.T

reatment: 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


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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, Thicksecretions, 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, IncorrectPEEP setting, Inability to tolerate ventilator mode.

PLAN OF CARE FORTHE VENTILATED PATIENT

Patient Goals:

1. Patient will have effective breathing pattern.2. Patient will have adequate gas exchange.3. Patients nutritional status will be maintained to meet body needs.4. Patient will not develop a pulmonary infection.5. Patient will not develop problems related to immobility.6. 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 inrespiratory rate and

depth; observe for SOBand use of accessory

muscles.

An increase in the workof breathing will add to

fatigue; may indicatepatient fighting

ventilator.

Observe for tube

misplacement- note andpost cm. Marking at

lip/teeth/nares after x-ray confirmation and q.

2 h.

Indicates correctposition to provide

adequate ventilation.


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Prevent accidental

extubation by tapingtube securely, checking

q.2h.;restraining/sedating as

needed.

Avoid trauma from

accidental extubation,prevent inadequate

ventilation andpotential respiratory

arrest.

Inspect thorax for

symmetry ofmovement.

Determines adequacyof breathing pattern;

asymmetry mayindicate hemothorax or

pneumothorax.

Measure tidal volume

and vital capacity.

Indicates volume of air

moving in and out oflungs.

Asses for pain

Pain may prevent

patient from coughingand deep breathing.

Monitor chest x-raysShows extent andlocation of fluid or

infiltrates in lungs.

Maintain ventilator

settings as ordered.

Ventilator providesadequate ventilator

pattern for the patient.

Elevate head of bed 60-

90 degrees.

This position moves

the abdominal contentsaway from the

diaphragm, whichfacilitates its

contraction.

Impaired gas exchange r/t alveolar-

capillary membrane changesMonitor ABGs.

Determines acid-basebalance and need foroxygen.

Assess LOC,

listlessness, andirritability.

These signs mayindicate hypoxia.


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Observe skin color and

capillary refill.

Determine adequacy of

blood flow needed tocarry oxygen to tissues.

Monitor CBC.

Indicates the oxygen

carrying capacityavailable.

Administer oxygen asordered.

Decreases work ofbreathing and supplies

supplemental oxygen.

Observe for tubeobstruction; suction

prn; ensure adequatehumidification.

May result in

inadequate ventilationor mucous plug.

Reposition patient q. 1-

2 h.

Repositioning helps alllobes of the lung to be

adequately perfusedand ventilated.

Potential altered nutritional status:

less than body requirements r/tNPO status

Monitor lymphocytesand albumin.

Indicates adequatevisceral protein.

Provide nutrition as

ordered, e.g. TPN,lipids or enteralfeedings.

Calories, minerals,

vitamins, and proteinare needed for energyand tissue repair.

Obtain nutrition

consult.

Provides guidance and

continued surveillance.

Potential for pulmonary infectionr/t compromised tissue integrity.

Secure airway and

support ventialtortubing.

Prevent mucosaldamage.

Provide good oral careq. 4 h.; suction when

need indicated usingsterile technique;

handwashing withantimicrobial for 30

seconds before and

Measures aimed atprevention of

nosocomial infections.


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after patient contact; do

not empty condensationin tubing back into

cascade.

Use disposable saline

irrigation units to rinsein-line suction; ensure

ventilator tubingchanged q. 7 days, in-

line suction changed q.24 h.; ambu bags

changes betweenpatients and whenever

become soiled.

IAW Infection ControlPolicy and Respiratory

Therapy Standards ofCare for CCNS.

Potential for complications r/timmobility.

Assess for psychosocialalterations.

Dependency on

ventilator withincreased anxiety when

weaning; decreasedability to communicate;

socialisolation/alteration in

family dynamics.

Assess for GIproblems. Preventative

measures includerelieving anxiety,

antacids or H2 receptorantagonist therapy,

adequate sleep cycles,adequate

communication system.

Most serious is stress

ulcer. May developconstipation.

Observe skin integrity

for pressure ulcers;preventative measures

include turning patientat least q. 2 h.; keep

HOB < 30 degrees witha 30 degree side-lying

position; use pressure

Patient is at high riskfor developing pressure

ulcers due toimmobility and

decreased tissueperfusion.


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relief mattress or

turning bed ifindicated; follow

prevention of pressureulcers plan of care;

maintain nutritionalneeds.

Maintain musclestrength withactive/active-

assistive/passive ROMand prevent

contractures with useof span-aids or splints.

Patient is at risk fordevelopingcontractures due to

immobility, use ofparalytics and

ventilator relateddeficiencies.

Knowledge deficit r/t intubation

and mechanical ventilation

Explain

purpose/mode/and alltreatments; encourage

patient to relax andbreath with the

ventilator; explainalarms; teach

importance of deepbreathing; provide

alternate method of

communication; keepcall bell within reach;keep informed of

results ofstudies/progress;

demonstrateconfidence.

Reduce anxiety, gaincooperation and

participation in plan ofcare.

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Caring for the Patient on a Ventilator

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