Nursing Care Of Ventilated Patient 2nz3z

Nursing management of client on mechanical ventilator

MECHANICAL VENTILATOR Mechanical ventilation is a life saving intervention in the emergency department. It functions as a ive measure for patients during acute illness.

INDICATIONS •

Failure of ventilation

1. 2. 3. 4. 5.

Neuromuscular disease Central nervous system disease CNS depression Musculoskeletal disease Thoracic malformation/ trauma

•.

Disorders of pulmonary gas exchange

1. 2. 3. 4.

Acute respiratory failure Chronic respiratory failure Left ventricular failure Pulmonary disease resulting in difusion or perfusion abmornality

• An endotracheal (ET)/tracheostomy tube is needed for mechanical ventilation.

Articles for intubation

Intubation procedure • • • • • • • •

Head positioning The laryngoscope Endotracheal tube advancement Cuff inflation Conforming position Securing the tube NG tube insertion Connect to ventilator

Pre- ventilator preparations

1. Confirms physician’s orders 2. Washes hands 3. Selects, gathers and assembles ventilator circuitry before bringing it to the patientʼs bedside 4. Fills humidifier with sterile water (or attaches HME to external circuit) 5. Introduces self, identifies patient

6. Explains procedure and confirms patient understanding, if appropriate 7. Brings ventilator to bedside 8. Connects ventilator to test lung 9. Sets ventilator controls according to physician orders 10.Connects ventilator to test lung 11.Confirms proper ventilator function

12. Connects patient to ventilator during the expiratory phase 13. Fills ETT with air to minimal leak or to appropriate cuff pressure by gauge 14. Checks for chest expansion and bilateral breath sounds 15. Sets all alarm and monitoring functions

16. Uses respirometer to measure exhaled tidal volume 17. Analyzes FIO2 18. Assesses patient response 19. Charts pertinent data 20. Draws or has drawn an ABG in 15-30 minutes •

21. Readjusts ventilation parameters according to ABG results 22. Repeats steps 18-21 until patient stabilizes

Principles of nursing care • Ensure Patient safety – Patient assessment/Monitoring – Prevent and treat complications

• Ensure Patient comfort – – – – –

Position Hygiene Feeding Management of stressors Pain and sedation management

ASSESSING THE EQUIPMENT In monitoring the ventilator, the nurse should note the following: • Type of ventilator (such as volume-cycled, pressure-cycled, negative-pressure) • Controlling mode (such as controlled ventilation, assist– control ventilation, synchronized intermittent mandatory ventilation)

• Tidal volume and rate settings (tidal volume is usually 10 to 15 mL/kg; rate is usually 12 to 16/min) • FiO2 (fraction of inspired oxygen) setting • Inspiratory pressure reached and pressure limit (normal is 15 to 20 cm H2O; this increases if there is increased airway resistance or decreased compliance)

• Sensitivity (a 2-cm H2O inspiratory force should trigger the ventilator) • Inspiratory-to-expiratory ratio (usually 1:3 [1 second of inspiration to 3 seconds of expiration] or 1:2) • Minute volume (tidal volume × respiratory rate, usually 6 to 8 L/min) • Sigh settings (usually 1.5 times the tidal volume and ranging from 1 to 3 per hour), if applicable

• Water in the tubing, disconnection or kinking of the tubing • Humidification (humidifier filled with water) and temperature • Alarms (turned on and functioning properly) • PEEP and/or pressure level, if applicable. PEEP is usually 5 to 15 cm H2O

Initial Ventilator Settings 1. Set the machine to deliver the tidal volume required (10 to 15 mL/kg). 2. Adjust the machine to deliver the lowest concentration of oxygen to maintain normal PaO2 (80 to 100 mm Hg). This setting may be high initially but will gradually be reduced based on arterial blood gas results. 3. Record peak inspiratory pressure.

4. Set mode (assist–control or synchronized intermittent mandatory ventilation) and rate according to physician order Set PEEP and pressure if ordered. 5. Adjust sensitivity so that the patient can trigger the ventilator with a minimal effort (usually 2 mm Hg negative inspiratory force).

6. Record minute volume and measure carbon dioxide partial pressure (PCO2), pH, and PO2 after 20 minutes of continuous mechanical ventilation. 7. Adjust setting (FiO2 and rate) according to results of arterial blood gas analysis to provide normal values or those set by the physician.

8. If the patient suddenly becomes confused or agitated or begins bucking the ventilator for some unexplained reason, assess for hypoxia and manually ventilate on 100% oxygen with a resuscitation bag.

Trouble shoting alarams of ventilation Display message

Possible Cause

Remedy

HIGH CONTINOU S PRESSURE

Airway is higher than set PEEP plus 15 cm H2O for more than 15 sec.

Check client, Check circuit Check ventilator setting and alarm limit.

Disconnected pressure transducer block pressure transducer Water in expiratory limb. Wet bacterial filter clogged bacterial filter.

Check ventilator internal replace filter, remove water from tubing Check heater wire. Refer to service.

Kinked/blocked tubing. Mucus or secretion plug in ETT or airways client coughing or fighting.

Check client, Check ventilator setting and alarm limit.

CHECK TUBING

AIRWAYS PRESSURE TOO HIGH

Display message

Possible Cause

Remedy

LIMITED PRESSURE

Kinked/blocked Mucus in tubing coughing / fighting patient.

Check client, Check ventilator setting and alarm limit.

EXPRIED MINUTE VOLUME TOO HIGH EXPRIED MINUTE VOLUME TOO LOW

Increased client activity ventilator auto cycling. Improver alarm setting low flow transducer. Low spontaneous client breathing activity. Leakage in cuff. Improver alarm setting.

Check client Check trigger sencesitivity and alarm setting. Dry the flow transducer. Check client cuff pressure circuit pause time and graphics.

Display message

Possible Cause

Remedy

EXPRIED MINUTE VOLUME DISPLAY READS

Flow transducer faulty Circuit disconnected from client

Replace flow transducer connect Y piece to client.

APNEA ALARM

Time between two consecutive insperatory effort exceeds. Adult : 20 sec. Pead : 15 sec. Neonate : 10 sec

Check client and ventilator setting

PEEP/AP & OR PLATEAV PRESSURE FAILS TO BE MAINTAIN

Leakage in cuff and client circuit Improper alarm limit setting.

Check cuff pressure Check client circuit check pause time and graphics to consider more ventilatory .

Initial Patient assessment • • • • • • • •

Airway Stability/Patency of ETT Length of fixing CXR Breathing Chest expansion, breath sounds, synchrony Circulation Colour, warmth of extremities, pedal pulses

Systems assessment • CVS • CNS • Renal function • Gastro intestinal

• Metabolic

• Skin

• • • •

Color,pulse,HR,BP Sedation ,paralysis Urine output Abdominal distension, gastric aspirates,bowel sounds • Temperature,blood sugar levels • Integrity,pressure sores

Position

• Compared to supine position, semirecumbent positioning (head of bed elevation > 30degree) reduces the frequency and risk for nosocomial pneumonia

Prevent and treat complications •The use of thrombo prophylaxis is effective for preventing deep venous thrombosis (DVT). •The use of peptic ulcer disease (PUD) prophylaxis reduces the risk of upper gastro-intestinal bleeding. •Patients should have secretion checks at least 2 hourly and be suctioned if required. Each patient with tracheostomy should receive adequate humidification. • This should be checked and documented 2 hourly. Inner tube should be removed, checked for secretion build up, cleaned, and replaced 4 hourly.

Prevent and treat complications • Availability of safety equipment relating to tracheostomy should be checked at the beginning of each shift. • (S-Suction catheter/apparatus; A-Airway; LLaryngoscope; T-Tube-Endotracheal and tracheostomy tubes; Bougie; T tracheal dilator; Laryngeal mask airway (LMA). • Cuff pressure should be checked during each shift. • It is to be kept at 20 cm H2O pressure. Dressing and tape should be changed once a day.

Humidification

• Inspired gas temperature 35-37 0 C • Maintain waterlevel • Circuit condensate/empty water trap

Patient comfort • HOB elevation 30-450 • Repositioning /ive limb exercises • Pain control and sedation • Prevent pressure sores • Wound care • Hygiene-Eye care/Mouth care, Body care

Feeding • Enteral feeding always!! • Check position of NGT • Continuous /Bolus feeds • Assessing feed intolerance? • Interruption of feeds • Feeding in prolonged ventilation

Endotracheal suctioning • Two nurses/ Physician in sick patients • Top up sedation • Hand hygiene/Sterile gloves

Care during suctioning • Preoxygenation, sedation, and reassurance are necessary before suction to avoid suction-induced hypoxemia. • Diameter of suction catheter should not exceed half of the inner diameter of the airway. Larger catheters can cause mucosal trauma. A smaller catheter may be ineffective at removing secretions

• It is necessary to pre-measure the suction catheter insertion distance for 0.5-1 cm past the distal end of the endotracheal or tracheostomy tube (same sized new endotracheal/tracheostomy tube may be used for this purpose). • Suction gauge should be adjusted to 80120mm Hg. Hypoxia, trauma, and atelectasis, can result from suctioning with negative pressure > 150mm Hg.

• Hyperoxygenating the patient before and after suctioning will decrease the chance of hypoxia related dangers (cardiac arrhythmias, bradycardia, seizures, cardiac arrest). • Squeezing the manual ventilating bag 4-6 times with 100% O2 before suctioning will help open the alveoli and lessen desaturation.

Nursing diagnosis • Impaired gas exchange related to underlying illness, or ventilator setting adjustment during stabilization or weaning. • Ineffective airway clearance related to increased mucus production associated with continuous positive-pressure mechanical ventilation

• Risk for trauma and infection related to endotracheal intubation or tracheostomy • Impaired physical mobility related to ventilator dependency • Impaired verbal communication related to endotracheal tube and attachment to ventilator • Defensive coping and powerlessness related to ventilator dependency

COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS

• Alterations in cardiac function • Barotrauma (trauma to the alveoli) and pneumothorax • Pulmonary infection • Sepsis

VAP prevention bundle • Daily sedation vacation • All patients will be assessed for weaning and extubation each day • Avoid supine position aiming to have the patient at least 30 head up • Prevent aspiration of gastric contents • Use chlorhexidine as part of daily mouth care

• Frequent suctioning of subglottic secretions in patients on ventilators • Stress ulcer prophylaxis / Reduce colonization of aero digestive tract

Altered skin integrity • Reposition second hourly to prevent pressure sores and t stiffness and deformities • Provide range of motion exercises. • Skin should be kept dry • Use alpha bed • ET tube should be repositioned at alternate sides of the mouth to prevent pressure ulcers. • NG tube should be fixed in such a way as to minimize pressure on the nares and plaster should be changed daily

WEANING

• • • • • • •

Physician orders Reverse paralysis Decrease sedation Stop feeds/4 hrs/start MF Decrease in RR/spontaneous modes Preventing airway edema Is the patient comfortable?

Weaning parameters Awake& alert PEEP 5cmH2O PaO2>60 mmHg on Fio2 50% Pao2 acceptable with PH of 7.35-7.45 Spontaneous inspiratory force of at least 20 cm of H2O • Stable vital signs • Adequate nutrition • • • • •

Factors to correct before weaning starts

• • • • • • •

Acid base abnormality Altered level consciousness Anaemia Arrhythmia Decreased cardiac out put Electrolyte abnormality Fluid imbalance

• • • • • •

Hyperglycemias Infection Renal failure Protein loss Shock Sleep deprivation

COMPLICATIONS  Perintubation : laryngeal trauma,  Pharyngeal trauma,  Tracheal or bronchial rupture,  Epistaxis,  Tooth trauma,  Arrhythmias  Bronchospasm

 Cervical spine injury in patients with unstable cervical spine,  Esophageal intubation,  Right main bronchial intubation,  Aspiration of gastric contents

During mechanical ventilation  Endotracheal tube obstruction,  Airway drying leading to inspissations of airway secretions,  Endotracheal tube migration,  Self extubation,  Cuff leak,

 Ventilator induced lung injury----- barotraumas  volutrauma  biotrauma

Evidence based practice

CONCLUSION • Patients on ventilator need constant observation and skilled care to protect, restore and maintain their health. Nursing care challenging, comionate care is the corner stone of nursing management of ventilator patient .

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