Nursing care of ventilated patient

Nursing management of client on mechanical

ventilator

MECHANICAL

VENTILATOR

Mechanical ventilation is a life

saving intervention in the

emergency department. It

functions as a supportive

measure for patients during

acute illness.

INDICATIONS

• Failure of ventilation

1. Neuromuscular disease

2. Central nervous system disease

3. CNS depression

4. Musculoskeletal disease

5. Thoracic malformation/ trauma

• Disorders of pulmonary gas exchange

1. Acute respiratory failure

2. Chronic respiratory failure

3. Left ventricular failure

4. 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 support 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 support 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

CHECK

TUBING

AIRWAYS

PRESSURE

TOO HIGH

Airway is higher than set

PEEP plus 15 cm H2O for

more than 15 sec.

Disconnected pressure

transducer block pressure

transducer Water in

expiratory limb. Wet bacterial

filter clogged bacterial filter.

Kinked/blocked tubing.

Mucus or secretion plug in

ETT or airways client

coughing or fighting.

Check client, Check circuit

Check ventilator setting and

alarm limit.

Check ventilator internal

replace filter, remove water

from tubing Check heater

wire. Refer to service.

Check client, Check

ventilator setting and alarm

limit.

Display

message

Possible Cause Remedy

LIMITED

PRESSURE

EXPRIED

MINUTE

VOLUME TOO

HIGH

EXPRIED

MINUTE

VOLUME TOO

LOW

Kinked/blocked Mucus in

tubing coughing / fighting

patient.

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 ventilator

setting and alarm limit.

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

APNEA ALARM

PEEP/CPAP & OR

PLATEAV

PRESSURE FAILS

TO BE MAINTAIN

Flow transducer faulty

Circuit disconnected from

client

Time between two

consecutive insperatory

effort exceeds.

Adult : 20 sec.

Pead : 15 sec.

Neonate : 10 sec

Leakage in cuff and client

circuit Improper alarm limit

setting.

Replace flow transducer

connect Y piece to

client.

Check client and

ventilator setting

Check cuff pressure

Check client circuit

check pause time and

graphics to verify

consider more

ventilatory support .

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; L-

Laryngoscope; 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 /Passive

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 80-

120mm 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 joint

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

Cervical spine injury

in patients with

unstable cervical

spine,

Esophageal

intubation,

Right main bronchial

intubation,

Aspiration of gastric

contents

Perintubation :-

laryngeal trauma,

Pharyngeal trauma,

Tracheal or bronchial

rupture,

Epistaxis,

Tooth trauma,

Arrhythmias

Bronchospasm

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, compassionate care is

the corner stone of nursing management

of ventilator patient .

Thank you