overview of mechanical ventilation and nursing care
TRANSCRIPT
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Mechanical ventilation
Presented By
Miss Pallavi Rai
M.Sc. Nursing
KGMU Institute
of Nursing
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Objectives of the session
• Define mechanical ventilation.
• Identify clinical situations in which mechanical ventilation is used.
• Review and understand ventilator definitions and terminology
• Describe types and modes of ventilation
• State the major components of ventilation
• Understand ventilator parameters
• PEEP Therapy
• Recognize common causes of alarms
• State complications from mechanical ventilation
• Review the weaning process
• Explain the nursing responsibility
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Mechanical Ventilation & ventilator
• Mechanical Ventilation isventilation of the lungs by
artificial means.
• A mechanical ventilator control or assist patient breathing by delivering a predetermined percentage of oxygen to
the lungs.
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Goals for MECHANICAL VENTILATION
• Achieve and maintain adequate pulmonary gas exchange
• Minimize the risk of lung injury
• Reverse respiratory muscle fatigue
• Reduce patient work of breathing
• Optimize patient comfort
• To normalize blood gases and provide comfortable breathing
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INDICATIONSMechanical ventilation is indicated when the patient cannot maintain spontaneous ventilation to provide adequate oxygenation or carbon dioxide removal.
INDICATION EXAMPLES
1.Acute ventilatory failure
pH<7.3,PaCO2>50mmHg
2.Severe hypoxemia PaO2<40mmHg,SaO2<75%
3.Impending ventilatory failure
Progressive acidosis and hypoventilation to pH<7.3,PaCO2>50mmHg
4.Prophylactic ventilatory support
Post anaesthesia recovery
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INDICATIONS FOR PROPHYLACTIC
VENTILATORY SUPPORT
INDICATION EXAMPLES
Reduced risk of pulmonary complications Prolonged shockHead injurySmoke inhalation
Reduced hypoxia of major body organs Hypoxic brainHypoxia of heart muscles
Reduced cardiopulmonary stress Prolonged shockCoronary artery bypass surgeryOther thoracic or abdominal surgeries
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Contraindicationsof Mechanical Ventilation
• Contraindications
– Untreated pneumothorax
• Relative Contraindications
– Patient’s informed consent
– Medical futility
– Reduction or termination of patient pain and suffering
8
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Types of Mechanical ventilators
• Negative pressure ventilators
• Positive pressure ventilators
Mechanical ventilator
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Negative-Pressure Ventilators
• The patient’s body was encased in an iron cylinder and negative pressure was generated.
• The use of negative-pressure ventilators is restricted in clinical practice,, because they limit positioning and movement and they lack adaptability to large or small body torsos (chests) .
• This is not used nowadays .
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Mechanism of negative pressure ventilators
It is similar to the spontaneous breathing
& Expiration occurs passively
Allows the air to flows in the lungs
Decrease the intrathoracic pressure during inspiration
Exert negative pressure on the external chest as compared to atmospheric pressure
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Positive-pressure ventilators
• Positive-pressure ventilators deliver gas to the patient under positive-pressure, during the inspiratory phase.
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Mechanism Of Positive Ventilators
& Expiration occurs passively
Allows the air to flows in the lungs
Forcing the alveoli to expand during the inspiration
Inflate the lungs by exerting positive pressure on the airway as compared to atmospheric pressure
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Types Of MECHANICAL Ventilation
1.INVASIVE
2. NON INVASIVE
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Invasive ventilation
• Mechanical ventilation via artificial airways which can either be endotracheal intubation or tracheostmy tube.
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Non invasive ventilation • It refers to the delivery of
mechanical ventilation to the lungs using techniques that do not require an invasive artificial airway(ETT, TT)
• It provide breathing support through CPAP,BiPAP.
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Classification of positive-pressure ventilators
• Ventilators are classified according to how the inspiratory phase ends. The factor which terminates the inspiratory cycle reflects the machine type.
• They are classified as:
Volume cycled ventilators
Pressure cycled ventilators
Time cycled ventilators
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1- Volume-cycled ventilator
• The ventilator delivers a preset tidal volume (VT), and inspiration stops when the preset tidal volume is achieved.
• Most commonly used in adult.
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2- Pressure-cycled ventilator
• In which inspiration is terminated when a specific airway pressure has been reached.
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3- Time-cycled ventilator
• In which inspiration is terminated when a preset inspiratory time, has elapsed.
• Time cycled machines are not used in adult critical care settings. They are used in pediatric intensive care areas.
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Ventilator mode
The way the machine will ventilate the patient in relation to the patient’s own respiratory efforts.
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Various modes of mechanical ventilators
Controlled mandatory ventilation
(CMV)
Assist/control (AC)
Intermittent mandatory ventilation
(IMV)
Synchronized intermittent mandatory
ventilation (SIMV)
Positive end-expiratory pressure
(PEEP)
Continuous positive airway pressure
(CPAP)
Bilevel positive airway pressure
(BiPAP)
Pressure support ventilation (PSV)
Volume ventilation plus (VV1)
Pressure-controlled ventilation
(PCV)
Airway pressure release
ventilation (APRV)
Inverse ratio ventilation (IRV)
High-frequency oscillatory
Ventilation (HFOV)
Proportional assist ventilation
(PAV)
Pressure-regulated volume
control (PRVC)
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1.Controlled Mandatory Ventilation
• Delivers a set tidal volume and respiratory rate. The ventilator does ALL the work.
• Patient needs to be sedated or paralyzed.
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Pros Cons Nursing responsibility
• It is primary
ventilator
mode in
patients who
are apnic.
•Doesn't permit
normal
spontaneous
breathing, and can
cause respiratory
muscles to atrophy.
•Used in a
patient unable to
initiate a breath
•Spontaneously
breathing patient
must be sedated
and/or paralyzed.
•Frequent ABGs
monitoring .
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2. Synchronized intermittent mandatory ventilation (SIMV)
• Synchronized intermittent mandatory ventilation (SIMV) delivers a preset tidal volume and number of breaths per minute.
• Between ventilator-delivered breaths, the patient can breathe spontaneously with no assistance from the ventilator on those extra breaths.
• As the patient’s ability to breathe spontaneously increases, the preset number of ventilator breaths is decreased and the patient does more of the work of breathing.
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Pros Cons Clinical
applicability
•Patient can
exercise
respiratory
muscles. May
improve cardiac
output.
•that it may
increase the
work of
breathing and
respiratory
muscle fatigue
•Used as
weaning mode
•Patient who
require partial
ventilatory
support.
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3. Pressure Support Ventilation (PSV)
• Pressure support ventilation , is a spontaneous mode of ventilation. The patient initiates every breath and the ventilator delivers support with the preset pressure value. With support from the ventilator, the patient also regulates his own respiratory rate and tidal volume.
• PSV is used for patients with a stable respiratory status and is often used with SIMV to overcome the resistance of breathing through ventilator circuits and tubing.
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ADVANTAGES OF PS Ventilation• Supports the patient's spontaneous tidal volume
• Decrease in work of breathing
• Facilitates weaning
• May be applied in any mode that allows spontaneous breathing
• Improves patient comfort and reduces need for sedation
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Indications
• Spontaneously breathing patients
who require additional ventilatory
support to help overcome:
↑ WOB or respiratory muscle
weakness
• Weaning
Contraindications
• Requires consistent spontaneous breathing
• Fatigue and tachypnea if PS level is set too low
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PEEP(Positive end expiratory
pressure)
• It is A method of ventilation in which airway pressure
is maintained above atmospheric pressure at the end
of exhalation,which increases the functional
residual capacity (volume in lungs at the end of
exhalation)
•This is NOT a specific mode, but is rather an
adjunct to any of the vent modes.
• The application of positive pressure to the airways
during expiration may keep alveoli open and
prevent closure.
• Most patients are set on 5 of peep as a standard.
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Indications to PEEP Contraindications to PEEP
•ARDS
•COPD
•Asthma
•Pulmonary edema
Tension Pneumothorax - it will
get worse
Hypovolemic shock – cardiac
output will decrease
Bronchopleural fistula - it wont
heal
High intracranial pressure - it
will get higher
Right ventricular failure - the
failing right ventricle may fail more
with the addition of increased
afterload
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ADVANTAGES DISADVANTAGES
Increasing the functional
residual capacity
• Re-inflating atelectatic lung
areas and recruitment of
collapsed alveoli
• Optimizing the ventilation/
perfusion ratio
• Reducing the right-to-left
shunt
• Avoiding end-expiratory
Reducing the cardiac output
by reducing venous return
• Reducing renal, hepatic and
splanchnic circulation
• Over-distending alveoli and
alveolar rupture
• Increasing intracranial
pressure
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MODE FUNCTIONS CLINICAL
USE
Control Ventilation (CV)
Delivers preset volume or pressure regardless of patient’s own Inspiratory efforts
Usually used for patients who are apneic.
Assist-Control Ventilation (A/C)
Delivers breath in response to patient effort and if patient fails to do so within preset amount of time
Usually used for spontaneously breathing patients with weakened respiratory muscles
Synchronous Intermittent Mandatory Ventilation (SIMV)
Ventilator breaths are synchronized with patient’s respiratory effort
Usually used to wean patients from mechanical ventilation
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MODE FUNCTIONS CLINICAL
USE
Pressure
Support
Ventilation
(PSV)
Preset pressure that augments
the patient’s Inspiratory effort
and decreases the work of
breathing Often used with
SIMV during weaning
Often used with
SIMV during weaning
Constant
Positive
Airway
Pressure
(CPAP)
Used only with spontaneously
breathing patients Maintains
constant positive pressure in
airways so resistance is
decreased
Maintains constant
positive pressure in
airways so resistance
is decreased
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Parts of ventilator
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Ventilator monitor
Ventilator circuit
Ports
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Central oxygen and air supply to the ventilator
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Bacteria filter and HME Unit
Water trap
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Settings of Mechanical Ventilation
• Mechanical Ventilator Settings regulates the rate, depth and other characteristics of ventilation.
• Settings are based on the patient’s status (ABGs, Body weight, level of consciousness and muscle strength)
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Setting of ventilator
PARAMETERS
• Mode of ventilation
• Respiratory rate
• Tidal volume
• PEEP level
• Fraction of inspired O2 conc.(FiO2)
• I:E ratio
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Setting Functions Usual parameters
Mode how the machine will
ventilate the patient in
relation to the patient’s
own respiratory efforts
Depends upon the
clinical conditions of
the patients.
Respiratory rat e Number of breaths
delivered by the ventilator
per minute.
Usually 8-12 breaths
per minute
Fractional Inspired
Oxygen (FIO2)
Amount of oxygen
delivered by ventilator to
patient
21-100%
Tidal volume Volume of gas delivered
during each ventilator
breath
Usually 8 ml/kg.
PEEP amount of pressure left in
the alveoli at the end of
exhalation .
Usually 5 cm of
H2o(5-10cm of H20)
Inspiratory:Expirat Length of inspiration Usually 1:2 or 1:1.5
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Complications of Mechanical Ventilation:-
I- Airway Complications
II- Mechanical complications
III- Physiological Complications
IV- Artificial Airway Complications
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Airway Complication
1- Aspiration
2- Decreased clearance of secretions
3- Nosocomial or ventilator-acquired
pneumonia
Mechanical
complications1- Hypoventilation 2- Hyperventilation3- Barotrauma4- Alarm “turned off”5- Failure of alarms or
ventilator6- Inadequate nebulization
or humidification7- Overheated inspired air,
resulting in hyperthermia
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Physiological Complications
1- Fluid overload with humidified air andsodium chloride (NaCl) retention
2- Depressed cardiac function andhypotension
3- Stress ulcers4- Paralytic ileus5- Gastric distension6- Starvation
Artificial Airway Complications
• Complications related to Endotracheal Tube
• Complications related to Tracheostmy Tube
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NONINVASIVE
FORMS
OF
MECHANICAL
VENTILATION
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2.NONINVASIVE FORMS OF MECHANICAL VENTILATION
• Modality that supports breathing with out the need for invasive artificial airway.
• 2 types of NIPPV are commonly used
1. CPAP (continuous positive airway pressure )
2.BiPAP(Bilevel positive airway pressure )
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Indications of nippv
• Obstructive sleep apnoea syndrome
• COPD with exacerbation
• Bilateral pneumonia
• Acute congestive heart failure with pulmonary oedema
• Neuromuscular disorder
• Acute lung injury
• Method of weaning
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Contraindications• Patient’s inability to maintain his or her own
airway.
• Unstable facial fractures ,or facial lacerations
• Laryngeal trauma
• Basal skull fracture
• Patient with recent GI surgery or at risk of GIT bleeds/ileus
• Vomiting/ and or high aspiration risk
• Uncooperative or unmotivated patients.
• Cardiac or respiratory arrest
• Severe encephalopathy
• Coma
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Advantages of NPPV
• Avoids potential trauma secondary to
endotracheal intubation
• Avoids need for sedation
• Allows patient to maintain ability to
communicate, eat and drink.
• Avoids risk of ventilator associated
pneumonia.
• Increases functional residual capacity.
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Disadvantages of NIPPV
• Patient must be alert.
• have spontaneous respirations
• tight mask fit (no facial hair)
• feeling of claustrophobia
• Increased Thoracic Pressure (ITP) can reduce Cardiac Output (CO)
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Equipment
• BiPAP machine
• BiPAP disposable circuit with disposable proximal pressure line and exhalation port (flushes exhaled gas from the circuit)
• Low resistance bacterial filter
• BiPAP Total Face Mask, Full Face Mask or Nasal Mask plus head strap.
• Disposable Humidifier
• Distilled water
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Interfaces
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Parts of facemask
One way exhalation
port
Head gear straps
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CPAP (Continuous Positive
Airway Pressure)
• CPAP is spontaneous breathing at a positive end-expiratory pressure.
• CPAP delivers a single, constant pressure during both inhalation and exhalation.
• Requires only a source of oxygen and a face mask with an expiratory valve that maintains a PEEP.
• Usually set at 5-10cm H2O.
• In neonates, nasal CPAP is the method of choice.
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BiPAP (Bi-level Positive Airway Pressure)
• It delivers two pressures. It provides a combination of both IPAP and EPAP.
• High pressure level is inspiratory positive airway pressure (IPAP) and low pressure level is expiratory positive airway pressure (EPAP).
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Nursing Responsibilities: NIPPV
• Check ventilator setting.
• Hrly observations, HR, RR, BP,SPO2 ,lungs sounds
• Maintain adequate face/mask seal .
•
• Observe patients level of consciousness, chest wall movement, co-ordination of patient respiratory effort with the ventilator, work of breathing.
• Pressure areas on the skin beneath the mask
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• Change tubing and device check every 7 days
• Maintain patient comfort, oral, nasal and eye
hygiene.
• Reassure the patient that they may experience feelings of suffocation, their mouth will be dry and the mask does smell &they can feel very nauseous due to the high flow of oxygen.
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ALARMS OF VENTILATOR
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High Pressure Alarm Low pressure alarm
•Secretions in ETT/airway or
•Kinking in tubing
•Patient biting on ETT
•Patient coughing, gagging, or
trying to talk
•Increased airway pressure from
bronchospasm or pneumothorax
•Vent tubing not connected
•Displaced ETT or trach tube
High Respiratory Rate Low Exhaled Volume
•Patient anxiety or pain •Secretions in ETT/airway •Hypoxia •Hypercapnia
•Vent tubing not connected • Leak in cuff or inadequate cuff seal Occurrence of another alarm preventing full delivery of breath
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Responding to alarm
• Check client
• check circuit
• check ventilator setting and alarms limits
• Replace filter
• Remove water from tubing and check humidifier setting (i.e., relative humidity )
• Check cuff pressure
• Consider more ventilatory support for client
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Complications
• Infection
Because of placement of artificial airways and
invasive lines
• Ulcerations
may be because of pressure from tubing's and prolonged immobility
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Complications of MV
• Ventilator Associated Pneumonia (VAP)
– Ventilator Associated Pneumonia is an infection of the lungs occurring more than 48 hours after intubation.
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Complications
• Accidental Extubation/ Displacement
– can occur if the patient pulls the ET Tube out, or when it becomes dislodged during routine care.
• Tracheal and Laryngeal Damage
– can occur when the patient is unintentionally extubated while the cuff is still inflated.
– Other causes are laryngoedema from extubation, and cranial nerve damage.
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Prevention is Key!
• Accidental Extubations/ Displacement
– Ensure you have enough slack in the circuit before
moving the patient
– Monitor sedation. If the patient is grabbing at the
ventilator you may need an order for more sedation or
light wrist restraints as a reminder to keep their hands
away from the vent.
– Placement at the lips
– No movement in the epigastric area
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Prevention is Key!
• Tracheal and Laryngeal Trauma
– Prevent accidental extubations
– Ensure the cuff is fully deflated before extubation
• VAP
– Head of bed up to at least 30 degrees
– Mouth care including chlorhexidine, suctioning, and
brushing teeth
– Check and secure the tubes
– Change the circuit per protocol
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Prevention is Key!
• Volutrauma and Barotrauma– Low Tidal Volumes with a higher rate
– Ideally PEEP should be kept at 5
– Monitor pressures (Inspiratory, Plateau, Expiratory)
• Ulcerations and infections– Mouth care
– switch side of mouth (angle change )
– Suctioning of secretions
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Prevention is Key!
• Sedation levels must be closely observed during the weaning period.
• Patients may need to be occasionally stimulated during weaning but if excessive stimulation is needed to maintain adequate rate, the patient is not ready to wean.
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Prevention is Key!
• The number one way to prevent complications
related to ventilators is to wean as early as
possible. Get your patient off the vent!
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Weaning from
mechanical ventilator
Weaning is the word used to describe the
process of gradually removing the
patient from ventilator and restoring
spontaneous breathing after a period
of mechanical ventilator.
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EVALUATING A PATIENT FOR
WEANING
A daily routine follow up should be done in every patient receiving mechanical ventilation and exploring the following condition
Resolution/improvement of the underlying disease
Stop sedation
Core temperature below 38 ºC
Stable haemodynamics
Adequate haemoglobin ( Hb > 8 g/dL)
Adequate mentation ( arousable, GCS > 13)
No major metabolic and/or electrolyte disturbances
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Criteria for Weaning
• Careful assessment is required to determine whether the patient is ready to be removed from mechanical ventilation.
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Respiratory criteria Other criteria
•Minute
ventilation<15/L
•Respiratory rate <38
breaths /mint
•Tidal volume > 325 ml
•Maximum inspiratory
pressure < -15cm of
H2O
•FiO2< 50%
•Improvement, correction, or
stabilization of the active disease
process
•Nutritional and fluid status sufficient
to maintain the increased metabolic
needs and demands of spontaneous
respiration
•Adequate physical strength and
mental alertness
•Afebrile status (any infections
controlled)
•Stable cardiovascular ,renal and
cerebral status
•Optimal levels of ABGs, electrolytes
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Other criteria
• Chest x-ray reviewed for correctable factors; treated as indicated.
• Major electrolytes within normal range,• Hematocrit >25%,• Core temperature >36°C and <39°C,• Adequate management of
pain/anxiety/agitation,• Adequate analgesia/ sedation (record scores
on flow sheet),• No residual neuromuscular blockade.
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WEANING PRECEDURE
• Rapid ventilator discontinuation
• Spontaneous breathing trials
• Pressure support ventilation (PSV)
• SIMV
• Other Modes used for weaning
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RAPID VENTILATOR
DISCONTINUATION• Considered in patients with no underlying cardiovascular,
pulmonary, neurologic, or neuromuscular disorders and patients receiving ventilatory support for short periods e.g. post-op patients.
• SBTs are superior to both SIMV and PS in both duration of weaning and the likelihood of success after weaning.
Patient on ventilator for < 72 hrs
SBT for 30 to 120 min.EXTUBATE if no other
limiting factor
Good spont RR, MV, MIP, f/Vt
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2. SPONTANEOUS BREATHING
TRIALSBT can be in the form of or
SIMV
PSV of 5-10 cm H2O
T – tube trial
CPAP 5-7 cmH2O.
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WEANING WITH SIMV
• Mandatory breaths are synchronized with patient’s own efforts
ADVANTAGES•Gradual transition•Easy to use•Alarm system may be used•Should be used in comb.
with PSV/CPAP
DISADVANTAGES
•Prolongs weaning•May worsen fatigue
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PROTOCOL OF SIMV
WEANING
Monitor patient’s appearance, respiratory rate, SpO2, BP, obtain ABG sample
Start with SIMV rate at 80% of full support
Decrease 2 – 4 breaths twice daily
If the patient tolerates an SIMV rate of 2-4 breaths
for> 2 hrs
Consider extubation
If deterioration→ ↑ SIMV rate
Allow pt’s respmsls to rest at night by ↑ingSIMV rate
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WEANING WITH PSV• Pressure support is given with each spontaneous
breath to ensure an adequate TV.
ADVANTAGES•Gradual transition•Prevents fatigue•Increased pt comfort•Weans faster than SIMV alone•Pt can control cycle length, rate
and inspiratory flow.•Overcomes resistive WOB d/t
ET tube and circuit.
DISADVANTAGES
•TV not guaranteed
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Continuous Positive Airway Pressure ( CPAP) Weaning
• When placed on CPAP, the patient does all the work of breathing without the assistance form ventilator
• No mandatory (ventilator-initiated) breaths are delivered in this mode i.e. all ventilation is spontaneously initiated by the patient.
• Weaning by gradual decrease in pressure value.
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3. Weaning trials using a T-piece
• Weaning trials using a T-piece or tracheostomymask are normally conducted with the patient disconnected from the ventilator, receiving humidified oxygen only, and performing all work of breathing.
• The goal is to progressively increase the time spent off the ventilator.
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T-Tube trial: allows spontaneous breathing interspersed with periods of full ventilatory support
• ADVANTAGES• Tests pt’s spontaneous• breathing ability• Allows periods of work and • rest• Weans faster than SIMV
• DISADVANTAGES• Abrupt transition difficult for some pts• No alarms, unless attached to ventilator• Requires careful observation.
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WEANING PROTOCOL FOR SBT WITH A T-
TUBEPrepare for T-Tube trial
3 min. screening trial
Measure TV,RR
Measure MIP thrice
selecting the best
. Formal SBT for 30 – 120 min
MIP < -20 cm H20
TV spon. > 5 ml/kg
RR spon. < 35/min.
no signs of intolerance
If signs of intolerance are present
Put the patient
back on previous
ventilator
settings
Repeat next trial after 24 hrs
extubate
Optimize the patient’s medical condition suction, adequate humidification, bronchodilator therapy, good nutrition, optimal position, psychological counseling, adequate staff, equipment, no sedatives
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NURSING ASSESSMENTS
• While on the T-piece, the patient should be observed for signs and symptoms of hypoxia, increasing respiratory muscle fatigue, or systemic fatigue.
• Observe respiratory rate, work of breathing etc.
• use of accessory muscles, tachycardia and paradoxical chest movement (asynchronous breathing, chest contraction during inspiration and expansion during expiration).
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Role of nurse before weaning
1- Ensure that indications for the implementation of Mechanical ventilation have improved
2- Ensure that all factors that may interfere with successful weaning are corrected:-
- Acid-base abnormality
- Fluid imbalance
- Electrolyte abnormalities
- Infection
- Fever
- Anemia
- Hyperglycemia
- Protein
- Sleep deprivation
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Role of nurse before weaning3- Assess readiness for weaning 4- Ensure that the weaning criteria / parameters are met.5- Explain the process of weaning to the patient and
offer reassurance to the patient.
6- Initiate weaning in the morning when the patient is rested.
7- Elevate the head of the bed & Place the patient upright
8- Ensure a patent airway and suction if necessary before a weaning trial,
9- Provide for rest period on ventilator for 15 – 20 minutes after suctioning
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10- Ensure patient’s comfort & administer
pharmacological agents for comfort, such as
bronchodilators or sedatives as indicated.
11- Help the patient through some of the
discomfort and apprehension.
12- Support and reassurance help the patient
through the discomfort and apprehension
as remains with the patient after initiation
of the weaning process.
13- Evaluate and document the patient’s
response to weaning.
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Role of nurse during weaning
1- Wean only during the day.
2- Remain with the patient during
initiation of weaning.
3- Instruct the patient to relax and breathe
normally.
4- Monitor the respiratory rate, vital signs,
ABGs, diaphoresis and use of accessory
muscles frequently.
If signs of fatigue or respiratory distress develop.
• Discontinue weaning trials and put the patient on ventilatory support.
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Role of nurse after weaning
1- Ensure that extubation criteria are
met .
2- Decanulate or extubat
2- Documentation
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Nursing care in Mechanical ventilation
• Assessment• Check ventilator settings
and modes• Prevent respiratory
function.• Monitor for complications• Prevent infections.• Provide adequate
nutrition.• Monitor GI bleeding.
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Nursing Assessment
• All ventilator settings should be recorded at least every hour.
• parameters including HR, BP, Sp02 and respiration should be recorded every 30 minutes. Temperature should be checked every 4 hours..
• Assess for the airway patency & securing of tubes• Listen to air movement ,chest rise and fall.• Observe for breathing rate rhythm,TV,Fio2 etc.• Check for circulation and level of consciousness • Check for GCS,ability to communicate and sedation level.• Monitor ABG analysis and pulse oximetry • Check for adequacy of humidification .
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Nursing assessment
• Check temp,BP,Heart rate and other hemodynamic parameters .
• Observe for presence of pressure ulcers
• Monitor urine output ,serum electrolytes, blood glucose level .
• Check frequency of bowel movements
• Physical strength and body weight
• Observe for signs of DVT
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respiratory care • Measure tidal volume and vital capacity
• Auscultate lungs frequently to assess for abnormal sounds.
• Arterial blood gas analysis and Spo2 monitoring
• Heat and moisture exchangers (HMEs) must be changed every 24 hours.
• Suction as needed..
• Turn and reposition every 2 hours.
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• Secure ETT properly. Observe for tube
misplacement
• Prevent accidental extubation by taping tube
securely, checking q.2h.; restraining/sedating
as needed.
• Monitor ABG value and sPO2.
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2. PREVENT INFECTION• Maintain sterile technique when suctioning.
• Monitor color, amount and consistency of sputum.
• ensure ventilator tubing changed q. 7 days, in-line suction changed q. 24 h.; ambu bags changes between patients and whenever become soiled
• Regular oral care with an antibacterial solution and to suction the pharynx.
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• Lines, drains and tubes – IV catheters, central catheters, arterial catheters, urinary catheters and any other form of tube/drain should be checked at least twice daily for signs of complications.
• Central lines should be managed aseptically. Feeding tube should be cleaned daily.
• Intravenous catheters should be rewrapped daily and veins evaluated for signs of phlebitis or infection.
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• Eye care and Ophthalmic ointment should be
applied at least every 2 hours to protect against
corneal drying and ulceration.
• Body position should be changed every 4 hours
and passive range of motion exercises
performed.
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provide adequate nutrition
• Begin tube feeding as soon as POSSIBLE.
• Provide nutrition as ordered, e.g. TPN, lipids or
parental feedings.
• Weigh daily.
• Monitor I&O .
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• Assess for GI problems. Preventative
measures include relieving anxiety, antacids
or H2 receptor antagonist therapy, adequate
sleep cycles.
• Regular palpation of the colon is advised, and
enemas should be administered as needed.
• Auscultate bowel sounds.
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• 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 informed of results of studies/progress;
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Responding To Alarms
• If an alarm sounds, respond immediately because the problem could be serious.
• Assess the patient first, while you silence the alarm.
• Alarms must never be ignored or disarmed.
• Alarms setting should be checked every 2-4 hours
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Patient Comfort
Carefully explain all procedures to the
patient, prior to their
commencement;
At all times, the nurse should attempt to:
Orientate the patient to theirenvironment and events;
Provide a suitable
means of
communication for the patient.Involve the patient and their
family in the planning andimplementation of nursing care;
Facilitate a proper day /night
rhythm for the patient;
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DOCUMENT ALL NURSING ACTIONS
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Suctioning
MM J
Oral care and eye care
Respiratory auscultation
Securing of tubing
What we should not forget
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words of comfort
,skillfully
administered ,are
the oldest therapy
known to man