Nursing Management of Patient with Artificial Ventilation Flashcards
What are the indications of administering supplemental oxygen therapy?
- Hypoxemia
- Hypoxia
- Dyspnea
- Other signs and symptoms of respiratory distress
- Dyspnea on exertion (DOE)
- Changes in respiratory pattern
- Abnormal Arterial Blood Gas (ABG)
- Fatigue
- Level of consciousness (LOC) changes
What are the two main complications of supplemental oxygen therapy that would indicate stopping oxygen therapy and how are they different?
Hypercapnia:
- high amounts of CO2 in the blood
- Patient Relies on hypoxia for respiratory drive
- When PaO2 becomes too elevated, it may cause respiratory Arrest
- Common COPD
Oxygen toxicity:
- Occurs when adults are given long term percentages of over 50 – 60% O2
- can cause lung damage
- Destroys lung surfactant
What signs and symptoms should the nurse monitor for the development of oxygen toxicity?
- Fibrotic changes (thickening of lungs)
- Increased capillary congestion
- Interstitial space thickening
- Respiratory distress including Dyspnea and pulmonary edema
- CNS effects like Paresthesia, seizures and Restlessness
What are the two main treatments for oxygen toxicity the nurse can expect to be ordered?
- Positive End Expiratory Pressure(PEEP)
- Continuous Positive Airway Pressure(CPAP)
What nursing Interventions can be utilized to increase oxygenation?
- Incentive Spirometer
- Encourage coughs and deep breathing
- Position patient to encourage drainage of secretions
- chest percussion
What is included in the nursing care of a patient with an endotracheal tube?
- Monitor O2
- Cuff Management
- Maintain patent airway (tube)
- Oral care
- Skin care
- Safety and Comfort
How does the RN monitor the oxygenation of a patient with an endotracheal/tracheostomy tube?
- Assess for signs and symptoms of hypoxemia
- Change in mentation, anxiety, dusky skin, dysrhythmias
- Continuous SpO2
- arterial blood gases for more accurate assessment
What signs would the nurse observe in a patient with an endotracheal or tracheostomy tube that would indicate hypoxemia?
- Grunting,
- Change in level of consciousness (LOC),
- Intercostal spaces evident,
- Color (Cyanosis, Circumoral Pallor),
- Seesaw chest movement,
- Nasal flaring,
- Retractions and Dysrhythmias,
- Tachypnea
How does the nurse manage the cuff of a patient with an endotracheal or tracheostomy tube?
- Inflate cuff when patient requires mechanical ventilation or is high risk for aspiration
- Cuff pressure should be maintained at 20-25 mmHg and checked every 6-8 hrs; record routinely
What are 5 reasons tracheostomy tubes are used?
- Bypass upper airway obstruction
- Permit long term mechanical vent
- Permit oral intake and speech
- Replace an endotracheal tube
- Remove tracheobronchial secretions
In an emergency situation where the patient is comatose the nurse would expect what to be utilized to maintain a patent airway in the patient?
Endotracheal Tube
In a patient requiring long term intubation greater than 3 weeks what tube will likely be utilized?
Tracheostomy tube
What methods can the nurse use to promote effective airway clearance?
- Chest physiotherapy,
- Frequent position changes,
- Increased mobility,
- Suctioning
When assessing a patient with an endotracheal or tracheostomy tube what would indicate to the nurse the patient requires suctioning?
- Visible secretions in the tube
- Sudden onset of respiratory distress
- Suspected aspiration of secretions
- Auscultation of adventitious breath sounds over bronchi or trachea
- Increased respiratory rate & sustained coughing
- Sudden or gradual decrease in SpO2
- Changes in LOC, restlessness, tachycardia
- Cyanosis or pallor
- Increased peak airway pressure
What is the priority assessment the nurse should perform when caring for a patient with a tracheostomy or endotracheal tube?
Respiratory status
What are early complications of tracheostomy tubes or endotracheal intubation the nurse must be aware of?
- Tube dislodgment
- Accidental decannulation
- Bleeding
- Pneumothorax
- Air embolism
- Aspiration
- Subcutaneous emphysema
- Laryngeal nerve damage
- Posterior tracheal wall penetration
What are late complications of tracheostomy tubes or endotracheal intubation the nurse must be aware of?
- Airway obstruction from secretions
- Infection(Ventilator associated pneumonia)
- Rupture of innominate artery
- Dysphagia
- Tracheoesophageal fistula
- Tracheal dilation, ischemia, or necrosis
What complications of endotracheal intubations must the nurse be aware of?
- Tube dislodgment
- Accidental removal
- Laryngeal swelling, hypoxemia, bradycardia, hypotension, death
- High cuff pressure
- Tracheal bleeding, ischemia, or necrosis
- Low cuff pressure
- Risk of aspiration and hypoxia
- Trauma to tracheal lining
- Vocal cord paralysis
- Ventilator associated pneumonia
A nurse is caring for a patient with severe hypoxia, hypoxemia and pulmonary edema requiring continuous ventilation and PEEP. The nurse observes multiple indications for suctioning. Which type of suctioning should the nurse use?
Inline/Closes suctioning because it allows for continuous ventilation, sustains PEEP, and has a lower risk of exacerbating patient’s hypoxia than open suctioning.
How can the nurse assess for correct placement of endotracheal tubes?
- Auscultate lungs sounds,
- end-tidal carbon dioxide levels,
- chest x-ray ordered if suspicions of poor placement
What is included in oral care of patient with an endotracheal tube
- Brush patient’s teeth, gums, tongue, and surface of the ET tube twice a day
- Rinse patient’s mouth with 0.12% chlorhexidine gluconate oral rinse twice a day, or as ordered(NO MOUTHWASH)
- Cleanse mouth every 2-4 hours between brushings with an oral swab
- Post brushing teeth and oral care
- Suction oropharyngeal secretions whenever apparent
- Perform deep suctioning at least every 4 hours
- Apply oral moisturizer to the oral mucosa and lips
- Rotate tube to other side of mouth to prevent pressure injuries
What is included in oral care of patient with a tracheostomy tube
- Brush patient’s teeth, gums, and tongue twice a day
- Rinse patient’s mouth with 0.12% chlorhexidine gluconate oral rinse twice a day, or as ordered(NO MOUTHWASH)
- Cleanse mouth every 2-4 hours between brushings with an oral swab
- Post brushing teeth and oral care
- Suction oropharyngeal secretions
- Apply oral moisturizer to the oral mucosa and lips
- Change or cleanse inner cannula at least every 8 hours or more frequently if needed or as ordered
- Cleanse, assess, and dry stoma and change protective dressing at least every 8 hours or more frequent if needed or as ordered
- Change Tracheostomy ties or tube holder per frequency as ordered or per facility policy
What can the nurse do to best prevent and monitor for complications in patients with endotracheal or tracheostomy tubes?
- Administer warmed humidity – should see mist in tubing
- Maintain appropriate cuff pressure
- Suction as needed
- Maintain skin integrity
- Auscultate lung sounds
- Monitor for signs and symptoms of infection (temp, WBC)
- administer prescribed O2; monitor O2 sat
- Monitor for cyanosis
- Maintain adequate hydration
- Sterile technique for suctioning and care
How often should the nurse assess the placement of tracheostomy and endotracheal tubes and what should nurse focus on?
Assess every 2-4 hours, focus on airway remaining patent and respiratory status including assessing vitals, lung sounds, skin/mucosa color, equal bilateral chest rise and fall,
What degree should the head of bed be at for patients with tracheostomy and endotracheal tubes and what would the nurse want by the bedside?
- The HOB should be at 30-45 degrees
- Ambu bag and suction at bedside both tubes
- Extra Inner cannulas and spare tracheostomy tube
In a situation where a tube is dislodged what is the immediate action the nurse should take?
Manually ventilate patient and call for necessary help
What are the indications for mechanical ventilation?
- Compromised airway
- Severe decrease in oxygenation
- Altered breathing pattern
- Drug overdose
- Inhalation injury
- Shock
- Multi-system Failure
- COPD
- Thoracic or abdominal surgery
- Trauma or lung injury
- Acute respiratory distress syndrome (ARDS)
- Neuromuscular disorders
- Brain injury or damage
- Rest the respiratory muscles
- Coma
- PaO2 <50 mmHg with FiO2 >0.60 or PaO2 >50 mmHg with pH <7.25
- Vital Capacity <2 times tidal volume
- Negative inspiratory force <25 cm H20
- Respiratory Rate >35/min
What type of ventilation will a patient with chronic respiratory failure or neuromuscular conditions like poliomyelitis, MD, ALS and Myasthenia Gravis be provided to use at home and why?
Negative pressure ventilation because..
- it does not require intubation,
- it is simple and adaptable for home use.
- It exerts negative pressure on external chest
- decreases the intrathoracic pressure during inspiration and allows air to flow into lung simulating spontaneous respiration
What is positive pressure ventilation and the 4 different types?
- Used in acute care, operating room, or at home
- Generally used with an ET tube or tracheostomy
- During inspiration, the ventilator pushes air into the lungs under positive pressure
- Intrathoracic pressure is RAISED during lung inflation (unlike normal inspiration)
- Patient exhales passively
- 4 types are volume cycled, pressure cycled, high frequency oscillatory support, non-invasive positive-pressure ventilation
What are nursing Interventions for patients with mechanical ventilation via Endotracheal or Tracheostomy tube?
- Assessment of settings
- Assessment and troubleshooting of alarms
- Maintenance of airway and patient safety
- Suctioning of patient (see other section)
- Restraints
- Excess water in system
- Timely change of disposable components
Volume cycled ventilation
- Delivers preset volume with each inspiration, Airway pressure varies based on patient’s need, Exhalation occurs passively
- Disadvantage: possibility of barotrauma
Pressure cycled ventilation
- Delivers preset pressure of air with each inspiration, Volume of air/oxygen varies based on patient’s resistance or compliance
- Disadvantage: inconsistent tidal volume
High Frequency Oscillatory Support Ventilation
- High respiratory rates (180-900 breaths/min)
- Low tidal volume,
- High airway pressure,
- Used to open alveoli
Non-Invasive Positive-Pressure Ventilation (NIPPV)
- Eliminates need to ET tube or tracheostomy, CPAP, BiPAP,
- Decreases risk of pneumonia,
- Pressure controlled ventilation with pressure support
- 3 types (PEEP, CPAP, and BiPAP)
Positive end-expiratory pressure (PEEP):
- Positive pressure during exhalation,
- Useful in pulmonary edema
- WATCH COPD or those with low cardiac output.
Continuous positive airway pressure (CPAP):
- Delivered continuously during spontaneous breathing
- Good for sleep apnea
Bilevel positive airway pressure (BiPAP):
- Noninvasive modality
- Okay in COPD and heart failure, sleep apnea
- Can help prevent re-intubation after extubation.
What are the 4 modes of mechanical ventilation and
CMV, AC ventilation, IMV, SIMV
How does controlled mechanical ventilation(CMV) work? What type of client would receive CMV and why is it the least used mode?
- Ventilator delivers a set tidal volume at a set rate
- Used for clients who cannot initiate any spontaneous respirations
- Least used because it does not allow any client-initiated breaths
What is the most common mode of mechanical ventilation and how does it work?
- Continuous Mandatory Ventilation aka Assist Control (A/C) Ventilation
- Ventilator delivers a set tidal volume OR pressure, and a set rate
What is the main difference between IMV and AC Ventilation?
- IMV allows the client to breath spontaneously at own rate and tidal volume between ventilator breaths
- Any spontaneous breaths are not machine assisted or machine sensed
- Patient could be exhaling as the machine is delivering a breath
What two modes of mechanical ventilation can be used as both a primary mode and a weaning mode and how do they differ from each other?
-Intermittent Mandatory Ventilation(IMV) and Synchronized Intermittent Mandatory Ventilation(SIMV)
- SIMV works the same as IMV but the SIMV machine senses spontaneous breaths and will not deliver a breath during exhale
- Ventilator delivers a set tidal volume and has a set rate (only for machine assisted breaths)
What is included in the nurse’s assessment of a client on IMV or SIMV?
-“Sync”: does the patient seem synchronous with vent, breathing easily?
-“Bucking”: attempting to breathe on own, not allowing ventilator to deliver breaths
Monitor:
-Respiratory rate,
-Minute volume,
- Spontaneous or machine Tidal Volume ,
-FiO2,
-ABGs
What is Pressure Support Ventilation (PSV) and how does the nurse assess a client on it?
- PSV provides constant pressure to patient own
- Completely relies on patient’s spontaneous breaths
-Nurse should assess the rate and tidal volume of breaths and pressure
What can occur in a patient on PSV if the nurse does not assess the pressure and change it accordingly?
-Can cause tachypnea and large tidal volumes
What is Airway Pressure Release Ventilation (APRV)?
- Pressure limited and time triggered mode
- Two levels of continuous positive airway pressure: high level and low level
- Two levels of inspiratory time: high and low
- Time triggered mandatory breaths are delivered by the machine, but patient can take spontaneous breaths
- Tidal volume is patient driven
What are the types of alarms associated with mechanical ventilation and main causes of each?
- High Pressure Alarm: Caused by increased airway secretions, bronchospasm, displaced or obstructed tube, water in tubes, stiff airway (ARDS), kinked tubing
- Low Pressure Alarm: Usually a disconnection or leak in the system
- Apnea Alarm: patient off ventilator, tubing disconnected from patient
- Temperature Alarm: usually needs more water for humidification
What is the first action of a nurse responding to an alarm
Immediately ASSESS PATIENT
Nursing Documentation for Ventilated Patients
- Mode
- Tidal Volume
- Rate
- FiO² (Percent oxygen)
- Amount of PEEP (if used)
- Pressure Support (if used)
- Sputum – amount, frequency, color
- Patient tolerance to vent and to suctioning
Risks Associated with Mechanical Ventilation
- Infection: especially Ventilator Acquired Pneumonia(VAP),
- Pneumothorax, Lung damage
- Side effects of sedation/paralytic meds
- Hypotension: increased positive pressure increases intrathoracic pressure, which inhibits blood return to the heart
- Maintenance of life when not wanted
- Sodium and water imbalance: progressive fluid retention after 48-72 hours of positive pressure ventilation (PPV), decreased UO, increased Na+
- GI system problems like stress ulcers and GI bleeding, peptic ulcer prophylaxis and Decreased peristalsis
- Nutritional Issues
What are the potential nutritional issues associated with mechanical ventilation?
- Hyper-metabolism associated with critical illness
- Elimination of normal route for eating causing inadequate nutrition
What further complications can nutritional issues associated with mechanical ventilation and what nursing interventions can be used to prevent them?
- Inadequate nutrition puts person at risk for -poor oxygen transport secondary to anemia -poor exercise
- Decreased total protein, albumin
- Can also contribute to water and sodium imbalance
- Delayed weaning
- Decreased response to infections
-Nurse can use enteral feeding tube and an IV to provide adequate nutrients, fluid sodium/ Saline and electrolytes.
What complication should the nurse be aware of and monitor for after using an enteral tube to address malnutrition in a patient on mechanical ventilation?
-Be aware of Stress ulcer: assess for
-upper abdominal pain
-pain that varies based on food intake.
-feeling unusually full or bloated.
symptoms of anemia(pale skin and dyspnea)
-nausea or vomiting.
- Also can cause GI distress like constipation and Diarrhea can also exacerbate fluid, sodium electrolyte and nutrient imbalances
What are the 3 steps of the weaning process?
- Gradual removal from the ventilator
- Removal of ET or tracheostomy tube
- Removal from oxygen
When should the weaning process be initiated and what must be true about the patient before this happens?
-Weaning should be initiated at the earliest time possible when safe for patient
Patient must be
- hemodynamically and physiologically stable
- Spontaneously breathing
- Recovered from acute stage medical or surgical issues
- Cause of respiratory failure is reversed
Why should mechanical ventilation not be abruptly stopped and what are the actions of the nurse in a situation where it is?
- can decrease respiratory rate
- cause anxiety due to patient psychological dependence on ventilator
- Respiratory Distress or cardiac compromise
Nursing action
- Nurse can give short times off vent or with 0 rate
- Nurse may place patient on T-piece or Briggs as means of temporarily maintaining oxygenation
- Nurse must assess for respiratory distress or cardiac compromise
- Should not be done at night
What should be included in the Nurses education on the weaning process of a patient on long term mechanical ventilation?
- Prepare the patient psychologically
- Educate patient and family
- Explain that they may feel SOB
- explain that oxygen status, pulse ox, EKG, and respiratory pattern will be monitored
- explain that successful weaning is supplemented with intensive pulmonary care
- Let patient know the weaning process is a little different with each person.
What is the main goal of the weaning process of a patient on long term mechanical ventilation and how is this accomplished?(give specific ventilators)
- The main goal is to gradually decrease ventilators control over patient’s breathing
- CMV with PEEP->
- CMV without PEEP->
- AC with PEEP->
- AC without PEEP->
- IMV with PEEP->
- IMV without PEEP->
- SIMV->
- Briggs Adaptor, T piece, Trach collar/mask
What is extubation and when can it occur?
- Extubation is the removal of Endotracheal tube after intubation
- can occur within 2-3 hours post weaning if patient was intubated for a short period of time
- May take days to week depending on how long intubated with ET tube
What must the patient be able to do before the tracheostomy tube can be removed?
- Breathe spontaneously
- Cough up own secretions
- Swallow
- Move the jaw
What are the steps in the process of removing a tracheostomy tube and when can they be done?
Once pt has adequate secretion clearance
- move to a trial period of mouth and nose breathing
- Decrease tracheostomy size (completed by provider)
- Change to a fenestrated tube
- Switch to a smaller tracheostomy (stoma) button
Once pt demonstrates ability to maintain airway
-5. tube is removed and occlusive dressing is placed over stoma
Ventilator Associated Pneumonia(VAP)
- One of the most common nosocomial infections
- Leading cause of death from nosocomial infections
- Occurs 48 hours or more after mechanical ventilation with intubation
- Can occur with mechanically vented patients with a tracheostomy as well (occurrence may be different)
What risk factors of VAP should the nurse be aware of?
- Poor oral hygiene
- Contaminated respiratory equipment
- Poor hand washing
- Decreased ability of patient to cough and clear secretions
- Immobilization
- Patient’s age and co-morbidities
- Re-intubation
- Depressed consciousness
- Paralysis
What was the VAP Bundle that hospitals adopted and what guidelines did it include?
VAP bundle developed to include group of
interventions to provide a standardized method of care based on evidence/best practice and outcomes (prevent VAP)
-Elevate HOB 30 – 45 degrees
-Daily “sedation vacations” with assessment of readiness to extubate
-Peptic ulcer disease prevention
-Deep vein thrombosis prevention
-Oral care daily with chlorhexidine gluconate 0.12% oral rinse
What actions can the nurse caring for a patient on mechanical ventilation take to prevent VAP in addition to what is included in the VAP Bundle?
- Effective and frequent hand washing before and after suctioning, whenever ventilator equipment is touched or contact made with respiratory secretions
- Wear gloves when in contact with the patient
- Maintain ET tube cuff pressure
- Prevent condensation and sub-glottic drainage that collects in the ventilator tubing by draining it frequently
- Gastric volume monitoring
