Nursing Care of ventilated patient

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Nursing Care of ventilated patient: 

Nursing Care of ventilated patient Dr G agan pal singh

Indication for Intubation: 

Indication for Intubation 1. Acute respiratory failure 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-perfusion abnormalities). 2. In a patient with previously normal ABGs, the ABG results will be as follows: PaCO2 > 50 mm Hg with pH < 7.25 PaO2 < 50 mm Hg on 60% FIO2 : restlessness, dyspnea , confusion, anxiety, tachypnea , tachycardia, and diaphoresis, 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: 

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: Suction canister with regulator and connecting tubing Sterile 14 Fr. suction catheter Sterile gloves Normal saline nasogastric tube Intubation equipment: Manual resuscitator bag (AMBU), Laryngoscope and blade, Endotracheal attachment device (E-tad) or tape Get order for initial ventilator settings Sedation Call for chest x-ray to confirm position of endotracheal tube Ensure family notified of change in condition.

Checklist of Equipments: : 

Checklist of Equipments : Oxygen flowmeter and O 2 tubing Suction apparatus and tubing Suction catheter Ambu bag and mask Laryngoscope with assorted blades 3 sizes of ET tubes Stylet , Bougie Stethoscope Tape Syringe Magill forceps Towels for positioning

Miller vs. MacIntosh Blades: 

Miller vs. MacIntosh Blades

Intubation Procedure: 

Intubation Procedure Position your patient into the sniffing position

Intubation Procedure: 

Intubation Procedure Preoxygenate with 100% oxygen to provide apneic or distressed patient with reserve while attempting to intubate . Do not allow more than 30 seconds to any intubation attempt. If intubation is unsuccessful, ventilate with 100% oxygen for 3-5 minutes before a reattempt.

Intubation Procedure: 

Intubation Procedure Insert Laryngoscope

Intubation Procedure: 

Intubation Procedure

Intubation Procedure: 

Intubation Procedure After displacing the epiglottis insert the ETT. The depth of the tube for a male patient on average is 21-23 cm at teeth. The depth of the tube on average for a female patient is 19-21 at teeth.

Intubation Procedure: 

Intubation Procedure Confirm tube position: By auscultation of the chest Bilateral chest rise Tube location at teeth CO 2 detector – (esophageal detection device)

Intubation Procedure: 

Intubation Procedure Stabilize the ETT

Mechanical Ventilators: 

Mechanical Ventilators

Ventilator Settings Terminology: 

Ventilator Settings Terminology A/C : Assist-Control IMV : Intermittent Mandatory Ventilation SIMV : Synchronized Intermittent Mandatory Ventilation Bi-level/Biphasic : Non-invasive Pressure Ventilation with Pressure Support (consists of 2 levels of pressure) PRVC : Pressure Regulated Volume Control PEEP : Positive End Expiratory Pressure CPAP : Continuous Positive Airway Pressure PSV : Pressure Support Ventilation NIPPV : Non-Invasive Positive Pressure Ventilation

VOLUME vs. PRESSURE VENTILATION: 

VOLUME vs. PRESSURE VENTILATION Volume ventilation : Volume is constant and pressure will vary with patient’s lung compliance. Pressure ventilation : Pressure is constant and volume will vary with patient’s lung compliance.

MODES of VENTILATION : 

MODES of VENTILATION

Control Mode: 

Control Mode Delivers pre-set volumes at a pre-set rate and a pre-set flow rate. The patient CANNOT generate spontaneous breaths, volumes, or flow rates in this mode.

Control Mode: 

Control Mode

Assist/Control Mode: 

Assist/Control Mode Delivers pre-set volumes at a pre-set rate and a pre-set flow rate. The patient CANNOT generate spontaneous volumes, or flow rates in this mode. Each patient generated respiratory effort over and above the set rate are delivered at the set volume and flow rate.

A/C cont….: 

A/C cont…. Negative deflection, triggering assisted breath

SYCHRONIZED INTERMITTENT MANDATORY VENTILATION (SIMV): 

SYCHRONIZED INTERMITTENT MANDATORY VENTILATION (SIMV) Delivers a pre-set number of breaths at a set volume and flow rate. Allows the patient to generate spontaneous breaths, volumes, and flow rates between the set breaths. Detects a patient’s spontaneous breath attempt and doesn’t initiate a ventilatory breath – prevents breath stacking

SIMV cont….: 

SIMV cont…. Machine Breaths Spontaneous Breaths

PRESSURE REGULATED VOLUME CONTROL (PRVC):: 

PRESSURE REGULATED VOLUME CONTROL (PRVC): This is a volume targeted, pressure limited mode. (available in SIMV or AC) Each breath is delivered at a set volume with a variable flow rate and an absolute pressure limit. The vent delivers this pre-set volume at the LOWEST required peak pressure and adjust with each breath.

PRVC: 

PRVC

POSITIVE END EXPIRATORY PRESSURE (PEEP):: 

This is NOT a specific mode, but is rather an adjunct to any of the vent modes. PEEP is the amount of pressure remaining in the lung at the END of the expiratory phase. Utilized to keep otherwise collapsing lung units open while hopefully also improving oxygenation. POSITIVE END EXPIRATORY PRESSURE (PEEP):

PEEP cont….: 

PEEP cont…. PEEP is the amount of pressure remaining in the lung at the END of the expiratory phase. Pressure above zero

Continuous Positive Airway Pressure (CPAP):: 

This IS a mode and simply means that a pre-set pressure is present in the circuit and lungs throughout both the inspiratory and expiratory phases of the breath. CPAP serves to keep alveoli from collapsing, resulting in better oxygenation and less WOB. The CPAP mode is very commonly used as a mode to evaluate the patients readiness for extubation . Continuous Positive Airway Pressure (CPAP):

Initial Settings: 

Initial Settings Select your mode of ventilation Set sensitivity at Flow trigger mode Set Tidal Volume Set Rate Set Inspiratory Flow (if necessary) Set PEEP Set Pressure Limit Humidification

Post Initial Settings: 

Post Initial Settings Obtain an ABG (arterial blood gas) about 30 minutes after you set your patient up on the ventilator. An ABG will give you information about any changes that may need to be made to keep the patient’s oxygenation and ventilation status within a physiological range.

ABG: 

ABG Goal: Keep patient’s acid/base balance within normal range: pH 7.35 – 7.45 PCO 2 35-45 mmHg PO2 80-100 mmHg

WHAT A NURSE SHOULD KNOW: 

WHAT A NURSE SHOULD KNOW Indications for mechanical ventilation. Steps in preparing a patient for intubation. Determine the FIO2, tidal volume, rate and mode of ventilation on a given ventilator. Various modes of ventilation and their implications. Complications associated with pt’s response to mechanical ventilation and their signs and symptoms. Causes and nursing measures taken when trouble-shooting ventilator alarms. Preventative measures aimed at preventing selected other complications related to endotracheal intubation. Complete the care of the ventilated patient checklist. Complete the suctioning checklist.

Complications of Mechanical Ventilation: 

Complications of Mechanical Ventilation Associated with patient’s response to mechanical ventilation: A. Decreased Cardiac Output Cause - venous return to the right atrium impeded by the dramatically increased intrathoracic pressures during inspiration from positive pressure ventilation. Also reduced sympatho -adrenal stimulation leading to a decrease in peripheral vascular resistance and reduced blood pressure. Symptoms – increased heart rate, decreased blood pressure and perfusion to vital organs, decreased CVP, and cool clammy skin. Treatment – aimed at increasing preload (e.g. fluid administration) and decreasing the airway pressures 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).

Complications of Mechanical Ventilation…..: 

Complications of Mechanical Ventilation….. Barotrauma Cause – damage to pulmonary system due to alveolar rupture from excessive airway pressures and/or overdistention of alveoli. Symptoms – may result in pneumothorax , pneumomediastinum , pneumoperitoneum , or subcutaneous emphysema. 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 obstructive lung diseases (asthma, bronchospasm ), unevenly distributed lung diseases (lobar pneumonia), or hyperinflated lungs (emphysema).

Complications of Mechanical Ventilation…..: 

Complications of Mechanical Ventilation….. Nosocomial Pneumonia 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. Treatment – aimed at prevention by the following: Avoid cross-contamination by frequent handwashing 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

Complications of Mechanical Ventilation…..: 

Complications of Mechanical Ventilation….. Positive Water Balance 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 of ADH from the posterior pituitary gland and retention of sodium and water. Treatment is aimed at decreasing fluid intake. Decrease of normal insensible water loss due to closed ventilator circuit preventing water loss from lungs. This fluid overload evidenced by decreased urine specific gravity, dilutional hyponatremia , increased heart rate and BP.

Complications of Mechanical Ventilation……: 

Complications of Mechanical Ventilation…… Decreased Renal Perfusion – can be treated with low dose dopamine therapy. Increased Intracranial Pressure (ICP) – reduce PEEP Hepatic congestion – reduce PEEP Worsening of intracardiac shunts –reduce PEEP

Complications of Mechanical Ventilation…..: 

Complications of Mechanical Ventilation….. Associated with ventilator malfunction: Alarms turned off or nonfunctional – may lead to apnea and respiratory arrest Troubleshooting Ventilator Alarms

Complications of Mechanical Ventilation…..: 

Complications of Mechanical Ventilation….. Other complications related to endotracheal intubation. 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. 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. Treatment: position cuff of tube distal to fistula; place gastrostomy tube for enteral feedings; place esophageal tube for secretion clearance proximal to fistula. 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.

Complications of Mechanical Ventilation…..: 

Complications of Mechanical Ventilation….. 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. Cricoid abcess – mucosal injury with bacterial invasion 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. Other common potential problems related to mechanical ventilation: Aspiration, GI bleeding, Inappropriate ventilation (respiratory acidosis or alkalosis, Thick secretions, 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, Incorrect PEEP setting, Inability to tolerate ventilator mode.

PLAN OF CARE FOR THE VENTILATED PATIENT: 

PLAN OF CARE FOR THE VENTILATED PATIENT Patient Goals: Patient will have effective breathing pattern. Patient will have adequate gas exchange. Patient’s nutritional status will be maintained to meet body needs. Patient will not develop a pulmonary infection. Patient will not develop problems related to immobility. Patient and/or family will indicate understanding of the purpose for mechanical ventilation.

ROLE OF A NURSE: 

ROLE OF A NURSE Observe changes in respiratory rate and depth; observe for SOB and use of accessory muscles. An increase in the work of breathing will add to fatigue; may indicate patient fighting ventilator. Observe for tube misplacement- note and post cm. Marking at lip/teeth/ nares after x-ray confirmation and q. 2 h. Indicates correct position to provide adequate ventilation. Prevent accidental extubation by taping tube securely, checking q.2h.; restraining/sedating as needed. Avoid trauma from accidental extubation , prevent inadequate ventilation and potential respiratory arrest. Inspect thorax for symmetry of movement. Determines adequacy of breathing pattern; asymmetry may indicate hemothorax or pneumothorax . Measure tidal volume and vital capacity. Indicates volume of air moving in and out of lungs.

ROLE OF A NURSE…..: 

ROLE OF A NURSE….. Asses for pain Pain may prevent patient from coughing and deep breathing. Monitor chest x-rays Shows extent and location of fluid or infiltrates in lungs. Maintain ventilator settings as ordered. Ventilator provides adequate ventilator pattern for the patient. Elevate head of bed 60-90 degrees. This position moves the abdominal contents away from the diaphragm, which facilitates its contraction. Impaired gas exchange r/t alveolar-capillary membrane changes Monitor ABG’s. Determines acid-base balance and need for oxygen. Assess LOC, listlessness, and irritability. These signs may indicate hypoxia. Observe skin color and capillary refill. Determine adequacy of blood flow needed to carry oxygen to tissues.

ROLE OF A NURSE…..: 

ROLE OF A NURSE….. Monitor CBC. Indicates the oxygen carrying capacity available. Administer oxygen as ordered. Decreases work of breathing and supplies supplemental oxygen. Observe for tube obstruction; suction prn ; ensure adequate humidification. May result in inadequate ventilation or mucous plug. Reposition patient q. 1-2 h. Repositioning helps all lobes of the lung to be adequately perfused and ventilated. Provide nutrition as ordered, e.g. TPN, lipids or enteral feedings. Calories, minerals, vitamins, and protein are needed for energy and tissue repair. Obtain nutrition consult. Provides guidance and continued surveillance. Potential for pulmonary infection r/t compromised tissue integrity. Secure airway and support ventialtor tubing. Prevent mucosal damage.

ROLE OF A NURSE…..: 

ROLE OF A NURSE….. Provide good oral care q. 4 h.; suction when need indicated using sterile technique; handwashing with antimicrobial for 30 seconds before and after patient contact. Measures aimed at prevention of nosocomial infections. Ensure ventilator tubing changed q. 7 days, in-line suction changed q. 24 h.; ambu bags changes between patients and whenever become soiled. Assess for GI problems. Preventative measures include relieving anxiety, antacids or H2 receptor antagonist therapy, adequate sleep cycles, adequate communication system. Most serious is stress ulcer. May develop constipation. Observe skin integrity for pressure ulcers; preventative measures include turning patient at least q. 2 h.; use pressure relief mattress or turning bed if indicated; follow prevention of pressure ulcers plan of care;

ROLE OF A NURSE…..: 

ROLE OF A NURSE….. Patient is at high risk for developing pressure ulcers due to immobility and decreased tissue perfusion. Maintain muscle strength with active/active-assistive/passive ROM and prevent contractures with use of span-aids or splints. Patient is at risk for developing contractures due to immobility, use of paralytics and ventilator related deficiencies. Encourage patient to relax and breath with the ventilator; explain alarms; teach importance of deep breathing; provide alternate method of communication; keep call bell within reach; Reduce anxiety, gain cooperation and participation in plan of care.

TROUBLESHOOTING: 

TROUBLESHOOTING Anxious Patient Can be due to a malfunction of the ventilator Patient may need to be suctioned Frequently the patient needs medication for anxiety or sedation to help them relax Attempt to fix the problem Call your DOCTOR

Low Pressure Alarm: 

Low Pressure Alarm Usually due to a leak in the circuit. Attempt to quickly find the problem Bag the patient and call your DOCTOR.

High Pressure Alarm: 

High Pressure Alarm Usually caused by: A blockage in the circuit (water condensation) Patient biting his ETT Mucus plug in the ETT You can attempt to quickly fix the problem Bag the patient and call for your DOCTOR.

Low Minute Volume Alarm: 

Low Minute Volume Alarm Usually caused by: Apnea of your patient (CPAP) Disconnection of the patient from the ventilator You can attempt to quickly fix the problem Bag the patient and call for your DOCTOR.

Accidental Extubation: 

Accidental Extubation Role of the Nurse : Ensure the Ambu bag is attached to the oxygen flowmeter and it is on! Attach the face mask to the Ambu bag and after ensuring a good seal on the patient’s face; supply the patient with ventilation. Bag the patient and call for your DOCTOR.

OTHER: 

OTHER Anytime you have concerns, alarms, ventilator changes or any other problem with your ventilated patient. Call for your DOCTOR NEVER hit the silence button!

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