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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.
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. Conrms physicians orders


2. Washes hands
3. Selects, gathers and assembles
ventilator circuitry before bringing it to the
patients bedside
4. Fills humidier with sterile water (or
attaches HME to external circuit)
5. Introduces self, identies patient

6. Explains procedure and conrms 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.Conrms 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 (assistcontrol 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

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/CPAP & 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 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; 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 /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 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 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
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, compassionate care is
the corner stone of nursing management
of ventilator patient .

Thank you

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