accelerated ventilator weaning guideline a path to excellence! click here a path to excellence!...
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Accelerated Ventilator Accelerated Ventilator Weaning GuidelineWeaning Guideline
A path to excellence!A path to excellence!
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A path to excellence!A path to excellence!
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Directions
• Read the follow questions and simulations. Answer by clicking on the number of the best choice available.
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ObjectivesObjectives
• The health care provider will become more competent in safely managing patients on the accelerated ventilator weaning guidelines.
• The health care provider will become more understanding of their roles and responsibilities while weaning patients on the guidelines.
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Which of the following statements about JCAHO is true?
Due to the increased number of nurses and therapists not responding to audible ventilator alarms, JCAHO recommends that accredited organizations like UHC provide competencies based on remedial training.
JCAHO recommends that accredited organizations like UHC assures that alarms are activated with appropriate settings and are sufficiently audible with respect to distances and competing noise within the unit.
Due to the increased number of false audible alarms JCAHO recommends that nurses be trained to distinguish between important and non-important alarms.
In January 2002, the Joint Commission reviewed 23 reports of deaths or injuries related to long term ventilation. The top two contributing factors related to the deaths or injuries were related to?
Restraint Failure and No alarm testing
Insufficient staffing levels and communication with patient/family.
An inadequate orientation/training process of staff and communication among staff members
Review the following before proceeding.
• Evaluation of HypoxemiaConditions: On room air and patient is less than 60yrs.Hypoxemia PaO2
Mild <80 mmHgModerate <60 mmHgSevere <40 mmHg
Continue ABG Review• Normal Laboratory Ranges for PaCO2 and pH
Mean NormalPaCO2 40 35 - 45pH 7.40 7.35 - 7.45
• An acute change in the patient’s ventilation will cause the following when starting from a PaCO2 of 40 mmHg.
– If the PaCO2 increases by 20mmHg, the pH will decrease by .10.
– If the PaCO2 decreases by 10mmHg, the pH will increase by .10.
Now interpret the following blood gases.pH - 7.32 PCO2 - 50, PaO2- 75
Metabolic acidosis partially compensated with severe hypoxemia.
Combined Metabolic and Respiratory Alkalosis uncompensated with moderate hypoxemia.
Respiratory acidosis uncompensated with mild hypoxemia.
You are covering CICU when a patient arrives intubated from the OR. The patient is immediately placed on the CV pathway. Your first action should be
Decide what you believe the settings should be, set them, and then place the
patient on the vent. Adjust the vents tidal volume to maintain a safe peak inspiratory pressure.
Set the ventilator settings within the pathway limits and adjust according to
changes in the patient.
Set the ventilator settings according to the physician’s orders adjust according
to the accelerated weaning guidelines.
A CICU patient returns post-op CABG and is placed on MV with the following parameters: VT - 12ml/Kg, Rate - 8, PEEP - 5cmH2O, FIO2 - 40%Patient presents with the following blood gasses. pH - 7.25; PCO2 - 59; PO2 - 88 Select the best action below.
Decrease the rate by 2 breaths and increasethe FIO2 by 10%.
Increase the rate by 2 breaths and decrease the FIO2 by 10%.
Increase the rate by 4 breaths and increase the FIO2 by 10% and notify the MD for further orders.
Patients heart rate increases to 160bpm. SATs drop from 88 to 85. Patient BP drops from 135/80 to 110/70. Your next action would be to.
Increase the FIO2 to maintain Saturation > 92%, Increase the respiratory rate to 12, continue monitoring patient re-page the MD on call.
Maintain the current settings and call your supervisor.
Increase the FIO2 by 20%, Increase rate to 12, and continue monitoring patient.
Congratulations, Good Choice!
Good Results: MD paged but has not responded. Patients heart rate remains stable at 100bpm in a sinus rhythm. SATs increase from 88 to 92. Your next action would be to.
Evaluate q2 and PRN, continue weaning per accelerated ventilator weaning guidelines.
Stop the weaning guidelines
and request ABG and continue evaluating patient q2h and PRN.
Request ABG and continue evaluating patient q2h and PRN.Continue wean if patient meets criteria.
Increase the set Vt to 900ml
Stop the weaning guidelines increase sedation and place back on the initial vent settings
Increase the pressure support to maintain 5-10ml/Kg and monitor accessory muscle use.
A patient on the following settings (SIMV,rate of 4bpm,Vt - 800ml, FIO2 40%) has a spontaneous Vt that ranges from 175 to 325ml. The patient is using accessory muscles to breathe. Arterial Blood Gas results are within the normal range. Which of the following might be appropriate?
A patient is admitted to the CICU with the following ventilator orders; Vt-1100, rate - 18bpm, PEEP - 5, FIO2- 100%. You should first
Contact the physician, notify him that the orders are outside the guidelines and ask for further orders.
Continue with the guidelines as long as the Inclusion Criteria has been met.
Decrease the Vt to 900 and the rate to 12 only after discussing the change between the nurse and therapist responsible for the patient.
Place the patient on the ordered settings, discuss any problems between the nurse and therapist, obtain a ABG and send to lab, and notify the Nurse Manager and Respiratory Supervisor.
During weaning of a patient on the Weaning Guidelines a discrepancy occurs between the Respiratory Therapist and Nurse on a ventilator change. Which of the following is the best answer.
Stop the weaning and call the Rt Supervisor and Nurse Manager
Notify the physician on-call, explain the situation, and continue per MD order.
The Therapist must comply with the nurse because the nurse is the primary care provider for the patient.
After receiving a patient from surgery with the following orders. What action should you take?
• If intubated, initiate Accelerated Ventilator Weaning Guideline as follows:
• a. Wean the ventilator using the Accelerated Respiratory Weaning Management Care Plan.
– .Begin weaning with the following ventilatory settings in Phase I:
– Ventilator Mode: SIMV + PS Vt:_800_____ RR: (*4-12)___10___ BPM
– PS :__5___cmH2O FIO2 (*< 100):__100____%
– PEEP (*2.5-5.0):__5____ cm H2O• c. Maintain PaCO2 < 45 mm Hg.• d. Obtain and evaluate pulmonary mechanics PRN and prior to
extubation.• e. ABG PRN as required by guideline.
– .Wean FIO2 maintaining SaO2 > 92 % and PaO2 > 90 mm Hg .
– . Spontaneous Breathing Trial (SBT) to be conducted via (choose one of the following):
PSV 5 cm H2O X _____________ minutes** CPAP (* < 8) _______cm H2O X _______________
minutes** T-Tube X _____________ minutes**
•
Place the patient on the settings that were
ordered and notify the MD that the doctors orders are incomplete and weaning cannot start until they are complete.
Place the patient on the settings that were
ordered only if the patient meets the inclusion criteria then start weaning and notify the MD of the incomplete doctors orders. Continue with the SBT if the patients meets the guidelines.
Place the patient on the settings that were
ordered then start weaning only if the patient meets the inclusion criteria, and notify the MD of the incomplete doctors orders. Do not begin the SBT until the orders are complete.
Identify any problems associated to the orders?
If intubated, initiate Accelerated Ventilator Weaning Guideline as follows:
a. Wean the ventilator using the Accelerated Respiratory Weaning Management Care Plan.
.Begin weaning with the following ventilatory settings in Phase I:
Ventilator Mode: SIMV + PS Vt:_800_____ RR: (*4-12)___10___ BPM
PS :__5___cmH2O
FIO2 (*<100):__100____%
PEEP (*2.5-5.0):__15____ cm H2O
c. Maintain PaCO2 < 45 mm Hg.
d. Obtain and evaluate pulmonary mechanics PRN and prior to extubation.
e. ABG PRN as required by guideline.
.Wean FIO2 maintaining SaO2 > 92 % and PaO2 > 90 mm Hg .
. Spontaneous Breathing Trial (SBT) to be conducted via (choose one of the following):
PSV 5 cm H2O X ___15______ minutes** CPAP (* < 8) _______cm H2O X _______________
minutes** T-Tube X _____________ minutes**
No problems with current orders
PEEP set outside guidelines, notify MD for further orders.
PEEP set outside guidelines, SBT time limit set to low, notify MD for Further orders. Recommend setting SBT to a minimum 30 minute.
MD gives a phone order to decrease the PEEP to 8cmH2O and that the SBT is to be performed for a minimum of 15 minutes with a PEEP of 8cmH2O. Your next action would be
Explain to the MD that this order conflicts with the guidelines and the order can not be followed.
Write the order down. Confirm the order by reading back the phone order to the MD. Write order: Decrease PEEP to 8 and continue with guidelines. Write order: SBT to be conducted for a minimum of 15 minutes.
Stop the weaning guidelines and notify both the Nursing Supervisor and Respiratory Supervisor.
If intubated, initiate Accelerated Ventilator Weaning Guideline as follows:
a. Wean the ventilator using the Accelerated Respiratory Weaning Management Care Plan.
.Begin weaning with the following ventilatory settings in Phase I:
Ventilator Mode: SIMV + PS Vt:_800_____ RR: (*4-12)___10___ BPM
PS :__5___cmH2O
FIO2 (*<100):__100____%
PEEP (*2.5-5.0):__5____ cm H2O
c. Maintain PaCO2 < 45 mm Hg.
d. Obtain and evaluate pulmonary mechanics PRN and prior to extubation.
e. ABG PRN as required by guideline.
.Wean FIO2 maintaining SaO2 > 93 % and PaO2 > 70 mm Hg .
. Spontaneous Breathing Trial (SBT) to be conducted via (choose one of the following):
PSV 5 cm H2O X _________ minutes** CPAP (* < 8) __5_____cm H2O X ____120__________
minutes** T-Tube X _____________ minutes**
You receive a patient from surgery with the following orders. Identify any problems associated to the orders?
No problems with current orders
SBT outside of guidelines (120 minutes to long for trial), notify MD for further orders.
FIO2 set outside guidelines, Call MD for further orders.
A patient is being weaned via the accelerated weaning guidelines. The MD writes the following order: Increase the respiratory rate from 6 to 10 bpm. Is the patient still on the weaning guidelines? Choose the best answer.
Yes. The physician must write to stop the weaning guidelines. If he doesn’t the patient can be weaned only if the patient meets the criteria for weaning.
No. The physician must write an order to re-start the guidelines
No. Any time a physician makes a change after the weaning guidelines are initiated weaning must stop and you must notify the physician for clarification on the order.
The EndThe EndThanks for your participation.
For questions or comments please see your supervisor or call
John Brinson at 5-8809.
