Mechanical Ventilation Flashcards
Desired Outcomes for patients on Mechanical Ventilators
- Client will reestablish/ maintain effective respiratory pattern via ventilator with absence of accessory muscle use
- Arterial blood gases are within normal range
- Breath sounds are CLEAR.
2 types of INVASIVE application of mechanical ventilation support
- Tracheostomy
- Endotracheal intubation
3 Modes of Ventilation
(how breaths are delivered)
- Controlled ventilatory support
- Assisted ventilatory support
- CPAP
Ventillator does ALL work of breathing
Controlled ventilatory support
Controlled Ventilatory Support:
Pt’s usually need to be ___.
sedated
Ventilator & patient SHARE work of breathing
Assisted Ventilatory Support
(ie. SIMV)
Which ventilator support is used to WEEN patients off.
Assisted Ventilatory Support
- Patient breathing on their own
- positive pressure maintained
CPAP
Rate setting is set to
(breaths per min)
10-12
What is Tidal Volume (Vt)
Amount of air delivered during inspiration
Normal range of Tidal Volume (Vt)
6-10 mL/kg
What is FiO2?
Percentage of O2 a person breathes in
- tells us how much oxygen is in the air someone is breathing. Normal room air has about 21% oxygen, but if someone needs extra oxygen, like with a mask, the FiO2 can be higher. It’s important in healthcare to know how much oxygen is being given to help a patient breathe better.
Room air FiO2
21%
FiO2 usual setting on Ventilators
50-65%
(ventilator is always more than room air)
Whats the highest % of FiO2 can be given?
- Up to 100% may be given- if needed!
With ventilated patient, what is the PaO2 goal?
PaO2 > 60
- Norm ABG: PaO2 80-100 mmHG
With ventilated patient, what is the SpO2 goal?
SpO2 > 92%
(pulse ox)
Why are Ventilator goals lower than ABGs?
- Prevent O2 toxicity
- Ventilator pts are at higher risk of O2 toxicity
What is PEEP (Positive End-Expiratory Pressure)
- A setting on the ventilator
- Used to keep alveoli open at the end of expiration to prevent atelectasis
Common setting of PEEP
5cm H2O
Setting of PEEP for patients with ARDS
(Acute Respiratory Distress Syndrome)
40cm H2O
Is Oxygen a drug?
YES
Overexposure of O2 leads to
O2 toxicity
High risk patients for O2 toxicity
- Mechanically ventilated patients receiving high levels of FIO2 for prolonged periods of time are at increased risk.
- Specifically those on 50% FIO2 for >24 hours
FiO2 levels:
Goal level for SpO2
SpO2 > 92%
FiO2 levels:
Goal level for PaO2
PaO2 between 60 and 90 mm Hg.
What is an important nursing action when managing patients on high levels of oxygen?
Regularly assess arterial blood gases (ABGs) for signs of excess O2.
S/S of O2 toxicity
- Substernal discomfort- pain behind sternum
- Restlessness
- Fatigue
- Malaise
- Progressive respiratory difficulty
- Refractory hypoxemia- low O2 despite receiving O2
6 Nursing Managements for Artificial Airway
- Maintain Correct Tube Placement
- Maintain Proper trach cuff Inflation
- Monitor O2 and Ventilation
- Maintain Tube Patency: clear secretions as needed
- Provide Oral Care and Skin Care
- Foster Comfort and Communication
Oral care should be performed every __.
2-4 hrs
15 Daily care steps to be performed
- Continuous Monitoring of Pulse Oximetry
- Check Settings against physician’s orders.
- Alarm Functionality- NEVER turn off alarms; they must be audible at the nurse’s station
- Assess endotracheal tube (ETT) Placement
- Auscultate Breath Sounds Q2 hrs & if distressed
- Ensure Secure Placement of ETT
- Maintain NG Tube if present
- Ensure Adequate Nutrition
- Suction as Needed ONLY!!!
- Assess for Pressure Ulcers on Lips and Tongue
- Rotate Tube Placement
- Provide Oral and Lip Care
- Sedate as needed
- Monitor Condensation in Tubing
- Monitor Intake and Output (I & O)
What is an important guideline regarding suctioning patients on ventilators?
- Do not routinely suction patients
- Assess the need first.
What signs will let you know patient needs suctioning?
List 7
- Visible Secretions in ET Tube
- Sudden onset of Respiratory Distress
- Suspected Aspiration of Secretions
- Increased Respiratory Rate: with or without sustained coughing.
- Sudden Decrease in SPO2
- Increased Peak Airway Pressure in Ventilator
- Adventitious Breath Sounds
When the ventilator alarm sounds what is the 1st thing you do?
Assess the patient
2nd thing to assess when ventilator alarm sounds and patient is okay.
Check connections. Usually the #1 issue
First connection you will check.
pulse oximetry (SpO2) reading.
What should you do if a patient’s SpO2 decreases significantly?
Connect to a bag-valve mask (BVM) and ventilate manually.
Ventilators alarms:
- If unable to resolve the situation…
call for immediate assistance.
4 Types of Ventilator Alarms
- High-Pressure Alarms
- Low-Pressure Alarms
- High Respiratory Rate
- High Respiratory Rate
What causes High-pressure Alarms to go off?
indicate increased resistance in the ventilator circuit or the patient’s airway.
- secretion buildup
- kinked tubing
- bronchospasm: *sudden tightening of the muscles around airway- causing narrowing *
- coughing
- decreased lung compliance
- biting on ET tube
- condensation
What causes Low-pressure Alarms to go off?
Ventilator is not encountering enough resistance, which could be due to a disconnection or a leak in the system.
- disconnection
- loose fittings
- a leaking airway
- loss of airway (partial/complete dislodgement from trachea
Causes of High RR alarms
- anxiety
- pain
- hypoxia
- fever
What does an apnea alarm indicate
alerts clinicians that the patient is not initiating breaths. Due to :
- oversedation
- airway loss (extubation)
What is this called?
Endotracheal intubation
What should be monitored during patient movements in those with endotracheal tubes (ETT)?
The exit mark on the ETT should remain consistent during any movements to ensure proper tube placement.
Endoctracheal Tubes:
What 2 assessmnts confirm proper ventilation of patients?
-
symmestric in movement during ventilation
(confirms that both lungs are receiving air evenly) - bilateral breath sounds
(indicate that air is reaching both lungs)
Endoctracheal Tubes:
How long should you wait AFTER making changes in ventilator settings BEFORE reassessing?
Wait 20-30 minutes
- gives the body time to adjust to new settings or interventions.
3 most important settings that need to be reassessed AFTER ventilator changes.
- Blood pressure!!!: mechanical ventilation increases intrathoracic pressure which affects BP and CO **
- Arterial Blood Gas Analysis (ABGs)
- SpO2 Measurement
- End-Tidal Carbon Dioxide Readings (proper CO2 eliminations)
What is the most common and serious complication of mechanical ventilation?
know
Ventilator-Associated Pneumonia (VAP)
- bacteria enter the lungs via the ventilator, leading to infection.
What 3 factors increase the risk of developing Ventilator-Associated Pneumonia (VAP)
- Prolonged time spent on a ventilator
- extended length of ICU stay
- extended stay in hospital AFTER ICU.
How long AFTER ET intubation does the risk or VAP occur?
48 hours or more
5 S/S of Ventilator-Associated Pneumonia (VAP)
know
- Fever
- Elevated WBC count
- Purulent/odorous sputum
- Crackles or rhonchi
- Pulmonary infiltrates on CXR
What is a key strategy for preventing Ventilator-Associated Pneumonia (VAP)?
Follow a Ventilator Care Bundle.
- evidence-based practices designed to reduce the risk of VAP
What are the steps of the ventilator care bundle?
6 steps
- Elevate head of the bed 30-45 degrees.
- Practice daily sedation vacations and assess readiness to wean from the ventilator.
- Perform regular oral care with chlorhexidine 0.12%
- Hand hygiene
- DVT propylaxis: enoxaparin (prevent the formation of blood clots), Q12 hrs, SCV’s
- Peptic ulcer prophylaxis:reduces GERD -> reduces acid -> reduces aspiration
know
What are the STRICT infection control measures to prevent VAP?
List 5
- Strict hand washing
- Use of sterile technique during endotracheal (ET) suctioning.
- Frequent oral hygiene.
- Change ALL oral and suction equipment tubing every 24 hours.
- After each use, rinse non-disposable oral suction tools with sterile normal saline and place them on a dry paper towel.
Do we encourage ventilated patients to move?
yes, patients should move early to help with breathing.
What feature do most endotracaheal tubes have to fascilitate suctioning in ventilated patients?
Subglottic drainage ports
* included in certain types of endotracheal tubing
If endotrach tube has no subglottic drainage port, we will manually suction what 2 sites?
- oral cavity
- pharynx
(suction only as needed)
When to change tubing on ventilated patients?
Don’t change ventilator tubing unless necessary to reduce infection risk.
- Changing ventilator tubing frequently can introduce bacteria and increase the risk of infections, such as Ventilator-Associated Pneumonia (VAP)
Drain water inventilation ___ from patient.
away
- prevent aspiration
What are the criteria for determining readiness for weaning from mechanical ventilation?
- Resolving the underlying condition.
- Stable hemodynamics (no myocardial ischemia or hypotension).
- Adequate oxygenation
- Patient ability to initiate breathing on their own (inspiratory effort)
Signs of intolerance to weaning:
know
- RR <8
- tachypnea: rapid breathing
- dyspnea: SOB
- agitation
- desaturation (SpO2 <90%)
- tachycardia (syst >20bpm)
- changes in mentation.
Extubation Process/Steps
- Hyperoxygenate 100%: before & after suctioning **
- Suction airway
- Have pt deep breath and at peak deflate cuff and remove ETT in one motion.
- Encourage coughing & deep breathing
- Provide supplemental oxygen
- Oral care
What are the respiratory considerations for geriatric patients on mechanical ventilation?
- Barotrauma: damage to the lung tissue due to excessive pressure
- Loss of alveolar elasticity: due to age
- Difficulty weaning from ventilation due to thoracic rigidity and chronic obstructive pulmonary disease (COPD).
