Week 9: Mechanical Ventilation - Start of Exam 3 Flashcards
Oxygen
A medication that needs an order to survive
Can have standing orders though or use in emergent situations
At what concentrations is O2 administered
ones higher than RA so greater than 21%
Goals of O2 Therapy
Decrease Workload of heart and lungs
Increase tissue perfusion
Adequate transport of O2
Nasal Cannula
low flow (1-5 L at 24-40%/ 6L at 44%) or high flow (10-15 L at 65-90%) device where nares need to be in the nose to work
Can be an issue with mouth breathers
air can be humidified or non-humidified
What is are important nursing interventions for nasal cannula?
Watching for COPD patients as their O2 goal is 88-92 %
Knowing that high flow nasal cannula are often better tolerated by children
Simple Mask
Has tubing like the nasal cannula but has vents that allow the exhaled CO2 to escape
A low flow device at 5-8 L/min at 40-60%
Nursing intervention/consideration for a simple mask
May need nasal cannula at meals
Those with calustrophobia hate the feeling
Partial Rebreather Mask
Has a reservoir bag for part of the patients exhaled air while also having vents like the simple mask allowing remained exhaled air to escape
Exhaled air trapped in bag mixes wiht 100% O2 for next inhalation so you rebreathe 1/3 of expired air allowing for O2 conservation
Also, the vents allow breathing in room air too if somehow O2 from the flowmeter is interrupted
BREATHING OUT SOME AIR BUT A MIX OF RA AND O2 COMES BACK
Does low flow 8-11 L at 50-75%
Nursing intervention for a partial rebreather mask
watching for kinks in bags and tubing
skin checks
Nonrebreather Mask
similar to partial rebreather but it has 2 one way valves not allowing any exhaled air rebreathing - only supplied O2 gets into the bag
need to plug the vent so bag fills with O2 and they do not suffocate
does Low flow 10-15 L at 80-95%
Which oxygen delivery system delivers the highest O2 concentration
Nonrebreather at 80-95% as no rebreathing of exhaled air occurs
Venturi Mask
Has a large tube with an O2 inline allowing pressure to drop and air to build up in side ports
Ports can be adjusted for very precise O2 concentration but need to be open (the liters and % on each venturi mask part)
What is the exception for COPD patients for O2 delivery systems
Venturi Mask
The most precise O2 delivery comes from what device
Venturi Mask
What are some other methods of O2 Therapy (beside delivery devices)
Nebulizer
IPPB
CPAP
Bi PAP
Ventilator
Nebulizer
Used to ain in bronchial hygiene by hydrating dried secretions, promoting expectoration of secretions, humidifying inspired O2 and delivering medication deep into lung fields
Can be with or without medication delivery
IPPB - Intermittent Positive Pressure Breathing
A machine that administers either RA or O2 at a pressure higher than atmospheric pressure
It also aids in delivery of inhaled medication like a nebulizer does
How does the Nebulizer and IPPB compare
Neither is better than the other, but IPPD can be used to treat atelectasis and promote airway clearance, especially in those not doing well with IS or chest physiotherapy
PAP - Positive Airway Pressure
a method of O2 therapy used to keep airways open by use of mild air pressure
can be used for sleep apnea including OSA, heart failure, and obesity hypoventilation syndrome
NIPPV
noninvasive positive pressure ventilation
includes PAP
2 types: BiPAP and CPAP
What patients is NIPPV good for
those who cannot undergo intubation or invasive ventilation with the goals of decreasing the work of the respiratory muscles and relieve dyspnea
CPAP - Continuous positive airway pressure
method to keep airways open by providing constant mild air pressure
it helps hold the airway open, mobilize secretions, treat atelectasis, and ease work of rbeathing
BIPAP - Bi Level Positive Airway Pressure
(Pressure Support Ventilation)
NOT a continuous set of pressure - there are 2 pressure settings
Amount og pressure provided changes whether patient is in inspiration or expiration and is indepenently adjusted for each
When does BIPAP deliver higher pressure and lower pressure?
Higher Pressure =Inspiration
Lower Pressure = Exhalation
Ventilator
Machines used to assist or completely control ventilation for patients who have an Endotracheal or tracheostomy tube
Used in both acute and long term situations
How do IPPB and nebulizers differ in hwo they deliver O2/Medication
IPPB is its own machine while Nebulizers hook to the wall
What are some indications for supplemental O2
Hypoxemia
Hypoxia
Dyspnea
S/S of Resp. Distress: Dyspnea on exertion, changes in resp. pattern, abnormal ABG, fatigue, LOC changes
Hypoxemia
decrease in arterial O2 tension in the blood and is manifested by changes in mental status
decreased level of Blood O2
Hypoxia
Decrease in O2 supply to the cells and tissues
What leads to what: Hypoxemia and Hypoxia
Hypoxemia leads to Hypoxia usually
What are 2 problems cased by supplemental oxygen
Hypercapnia
Oxygen Toxicity
Hypercapnia
High amounts of CO2 in the blood
We need the drive to keep breathing though so like in COPD hyperoxygenation can cause loss of drive
__ - __% SaO2 for COPD patients
88-92%
One easy way to prevent O2 Toxicity
Give the least amount needed and titrate people off it when possible
Why is Hypercapnia a problem
High CO2 amounts in the blood –> Becomes normal mechanism for drive the breath
We usually rely on hypoxia for resp. drive but if PaO2 is too high we may go into resp. arrest and be unable to breath on our own
Similar to COPD
Oxygen Toxicity
occurs when adults are given long term percentages of O2 over 50-60% - this O2 in the end causes lung damage and damages lung surfactant
S/S Of Oxygen Toxicity
Fibrotic Changes
increase capillary congestion
Interstitial space thickening
Paresthesia
Dyspnea
Restlessness
Pulmonary Edema (Dyspnea, Restlessness, Fatigue, Resp. Distress)
What are the 2 treatments for O2 Toxicity
PEEP (Positive End Expiratory Pressure)
CPAP (Continuous Positive Airway Pressure)
These reverse or prevent micro-atelectasis which allows a lower % of O2 to be used
What is the best prevention method to prevent O2 toxicity
using lowest amount of O2 needed beforehand
What are some other treatments to increase Oxygenation
IS - Incentive Spirometry
PT - Chest Physiotherapy Methods
How does IS help oxygenation
helps promote the expansion of the alveoli and prevent or treat atelectasis
Feedback to the patient about ability to take deep breaths is given
Encourage deep inspiration with this
What are 3 methods of Chest PT
Postural Drainage
Chest Percussion
Vibration
Postural Drainage (CPT)
Position that uses force of gravity to drain secretions
Mobilizes secretions from bottom of the lungs
relieves or prevents accumulation of secretions that cause bronchial obstruction
Chest Percussion (CPT)
hand clapping to chest wall to loosen secretions
cupped hand
Vibration (CPT)
device is used to mobilize secretions
Rescue Breathing (EMS) Methods
Pocket Mask
Ambu Bag/Mask
Ambu Bag w/ ET Tube or Trach Tube attachment
What are some artificial airways to know of
Endotracheal Tube - ET Tube
Tracheostomy Tube
Endotracheal Tube
Provides patent airway when simpler methods cannot be used
For emergencies
Inserted via mouth or nose
Tube is cuffed or uncuffed
How long can an ET tube be used
NO LONGER THAN 3 WEEKS
What is easier to insert an ET tube through the mouth or nose
Orotracheal is easier to insert and it can use a larger tube size making ventilation easier
Tracheostomy Tube
Tube inserted into the trachea that is cuffed or uncuffed
It provides a patent airway
Used in more long term situations
It is an artifical opening in the trachea and the tube is inserted into the opening
temporary or permanent
A tracheostomy tube provides patent airway to…
bypass upper airway obstruction
permit long term mechanical ventilation
permit oral intake and speech
replace an endotracheal tube
remove tracheobronchial secretions
What situations determine if you use ET tubing or Tracheostomy tubing?
ET is for more emergency situations adn tracheostomy is if the ET tube is in place for more than 14-21 days but needs to be continued
What is the placement and process of placement like with endotracheal tubes
It is a flexible tube in many sizes bypassing the upper airway
It is placed via laryngoscope into the trachea and a cuff is inflated, taped, or secured with a collar for placement
Placement is then confirmed via lung sounds, end tidal CO2 levels and CXR
Requires special training to place (anesthesia provider, paramedic, resp therapist, ACLS training provider)
What is the placement and process of placement like with tracheostomy tubes?
Semi flexible, rigid or metal tube surgically inserted through an artifical opening made into the trachea at the second or third tracheal ring (trachostomy)
Tube has a plate to secure it with sutures or trach ties and comes in multiple sizes
An airway tube is positioned 2 cm above…
the carina
What are the parts of the tracheostomy tube
outer cannula or main shaft - remains in the trachea
inner cannula (disposable or non dispoable) - removed for cleaning or replaced periodically
obturator - inserted into tracheostomy during placement and removed once outer cannula is placed
What does it mean if a tracheostomy is single cuffed, double cuffed, or uncuffed?
Double cuffed is an alternative form that prevents tracheal damage
there are two inflatable cuffs you alternate using
What does trachostomy tubes that are fenestrated v not fenestrated mean
the pt can speak if the tube is fenestrated without a speaking valve
Advantages of ET Tubes
Keeps airway open
Can administer O2 directly to lungs
Ability to perform tracheal suctioning
Short term therapy - use is < 3 weeks
can be attached to a ventilator
Advantages of Tracheostomy Tube
Keeps airway open
can administer O2 directly to the lungs
can perform tracheal suctioning
can be used in long term use
can attach to ventilator, humidified O2 or Room Air
Can permit oral intake and speech (if not on a vent)
Disadvantages of ET Tube
discomfort
patient cannot speech
coughreflex depressed - closure of glottis inhibited
secretions thicker - requires suctioning
swallowing reflexes depressed
risk of aspiration and VAP (Ventilator associated pneumonia)
Unintention tube displacement leading to laryngeal swelling, hypoxemia, bradycardia, hypotension, and death
requires patient cooperation or restraint use
requires special training for nursing staff
oral assessment and care needed very frequently
Disadvantages of Tracheostomy Tubes
discomfort
patient is unable to speak if also on a vent
cough reflex depressed
secretions tend to be thicker
risk of aspiration and VAP
unintentional displacement of the tube
can be long term used
requires special training of nursing staff
oral assessment and care needed are frequent
What are some complications that can occur from ET tube use
- tube dislodgement
- Accidental removal - laryngeal swelling, hypoxemia, bradycardia, hypotension, death
- High cuff pressure leading to tracheal bleeding, ischemia, or necrosis
- Low cuff pressure leading to aspiration risk and hypoxia
- Trauma to tracheal lining
- VOCAL CORD PARALYSIS
What are some potential early complications of tracheostomy tube use
tube dislodgement
accidentaly decannulation
bleeding
pneumothorax
air embolism
subcutaneous emphysema
laryngeal nerve damage
posterior tracheal wall penetration
What are some later complications of tracheostomy tube use
airway obstruction from secretions
infection
rupture of innominate artery
dysphagia
tracheoesophageal fistula
tracheal dilation, ischemia, or necrosis
What are some important nursing care considerations for a patient with an ET or Trach Tube
Monitor O2 and oxygenation
Cuff management
maintain patent airway (tube)
oral care
skin care
safety and comfort
How should the nurse go about monitoring oxygenation in someone with an ET tube or trach tube
ASSESS FOR S/S OF HYPOEXMIA:
This includes changes in mentation, anxiety, dusky skin, dysrhythmias, checking ABGs, and doing continuous SaO2 monitoring
What is the Pneumonic for assessing hypoexmia and changes in oxygenation in a patient
“Gee Chap, I Can See Nasty Respirations Too”
Grunting Change in LOC Intercostal spaces evident Color (Cyanosis, pallor) Seesaw chest movement Nasal flaring Retration/dysRhythmias Tachypnea
ET/Trach Tube Cuffs need to be inflated if …
the patient requires mechanical ventilation
the patient is at high risk for aspiration
ET/Trach tube cuff pressure should be maintained at ___-___ mmHg and checked every ___-___ Hours
20-25; 6-8
Too High Cuff Pressure in the ET/Trach Tube can lead to…
tracheal bleeding
ischemia
pressure necrosis
Too low cuff pressure int he ET/Trach tube can lead to …
aspiration risk increasing
What are some methods of promoting effective airway clearance
chest physiotherapy
frequent position changes
increased mobility
suctioning when indicated
Unncessary suctioning can cause…
bronchospasm initiation and cause mechanical trauma to the tracheal mucosa
What are the indications to suction an ET/Trach Tube?
Visible secretions in tube
Sudden Resp Distress
Suspected Aspiration of Secretions
Auculstation of adventitious breath sounds over bronchi or trachea
Increased resp. rate and sustained coughing
sudden or gradual decreases in SpO2
Changes in LOC, restlessness, or tachycardia
Cyanosis and Pallor
Increased pear airway pressure
Should suctioning be done every 1-2 hours?
No there is no rationale to do so
The need for suctioning should be assessed every 1-2 hours with assessment and auscultation prior to suctioning
Suctioning can clear secretions but can also damage mucosa in the airway and impair cilia action
Inline/Closed Suctioning
Allows suctioning WITHOUT disconnection from ventilator
Decreases hypoxemia
Sustains PEEP
Decreases patient anxiety
Protection of staff from infections
Open Suctioning
A sterile procedure needing sterile gloves
Staff must use PPE for splatter fo secretions
Higher risk for hypoxia exists here
What is Oral and Skin Care like with an ET Tube
- Brush teeth, gums, tongue, and surface of ET tube x2 daily
- Rinse pt mouth with an oral rinse 2x daily or as ordered
- Cleanse mouth every 2-4 hours between brushings wiht oral swab
- suction oropharyngeal secretions and apply oral moisturizer to lips and mucosa post burshing
- No mouthwash
- deep suction every 4 hours
* Move tube to other side to prevent pressure injury on the face and skin and rinse debris from oral suction*
What is oral and skin care like with a Trach Tube
similar to ET tube until #5
Differs in there needs to be an inner cannula cleanse every 8 hours or more if ordered, stoma and changes and assessment every 8 hours, and change ties or tube holder per order or policy
With tubes it is important to do oral care how many times a day at least
2 times a day
Ways to prevent complications with an ET/Trach Tube
Administer warm humidified air
Maintain appropriate cuff pressure
suction prn
maintain skin integrity
auscultate lung sounds often
monitor for s/s of infection
administer prescribed O2 and monitor SaO2
Monitor for cyanosis
maintain adequate hydration
sterile technique for suctioning and trach/Et tube care
Pain Control methods with breathing tubes
provide comfort measures
provide sedatives or opioid analgesia as ordered
Ways to promote communication when a patient has a breathing tube
explain procedures to patient
provide paper, erase board, picture boards
call bell in reach
hearing aid, glasses, etc
ET Tubes should be monitored for correct placement how often
every 2-4 hours
It is important to confirm what on the ET tube
exit mark
On a respiratory assessment of a pt with an ET tube the chest should be doing what
symmetrically expanding
With Breathing tubes what should always be available bedside
suction set up and an Ambu bag
*with trach tubes inner cannulas and spare tracheostomy of a smaller size should also be available
The HOB for ET and Trach tubes should be at what angle
30-45 degrees
What is an important consideration for long term tracheostomy placement?
involving patient or family in teaching
If an ET or Trach tube is displaced what may need to be done
manually ventilate and call for help
Mechanical Ventilation
a positive or negative pressure breathing device that is used to maintain a persons ventilation and O2 delivery for a prolonged period of time
comes in many types and brands
Ventilator care is a _____ process with …
collaborative; resp therapist and provider
What are some 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
ARDS
neuromuscular disorders
brain injury or damage
rest the respiratory muscles
coma
PaO2 <50 mmHg with FiO2 >.6 or PaO2 >50 mHg with pH <7.25
vital capacity <2 times tidal volume
negative inspiratory force <25 cm H2O
resp rate >35 b/min
What are the two types of mech. ventilation
- Negative Pressure (older/”Iron lungs”)
2. Positive Pressure (most common today)
Negative Pressure Ventilation
Exerts negative pressure on the external chest- EXTERNAL FORCE
Decreases intrathoracic pressure during inspiration adn allows air to flow into the lungs
simple to use, does not need intubation, adaptable for home use
Negative Pressure Ventilation is similar to ___ ___
spontaneous respiration
Negative Pressure Ventilation is commonly used in what situation still?
chronic respiratory failure - neuromuscular conditions like poliomyelitis, MD, ALS, myasthenia gravis
Positive Pressure Ventilation
4 types
Exerts positive pressure on the airway - it pushes air into the lungs which causes the alveoli to expand during inspiration
used in acute care, OR, or at home
What is inspiration/exhalation like during positive pressure ventilation
During inspiration, air is pushed into the lung under positive pressure
Intrathoracic pressure is RAISED during lung inflation (unlike normal inspiration)
Patient exhales passively
Positive Pressure ventilation is commonly used alongside what
an ET or Trach tube
4 types of Positive Pressure Ventilation
Volume Cycled Vents
Pressure Cycled Vents
High frequency oscillatory support ventilators
NIPPV - noninvasive positive pressure ventilation
Volume Cycled Ventilators
Pos pressure vent
delivers preset volume of O2 with each inspiration
airway pressure varies on patient need
exhalation is passive
Disadvantage of Volume Cycled Ventilators
possibility of barotrauma which can lead to damage of alveolar capillary membrane and cause air leaks into surrounding tissue
Pressure Cycled Ventilators
delivers present pressure of air on each inspiration
pos pressure vent
volume of air/o2 varies on pt resistance or compliance
Disadvantage of Pressure Cycled Ventilation
inconsistent tidal volume can occur which compromises ventilation
High Frequency Oscillatory Support Ventilators (HFOSV)
Pos Pressure Vent
Causes high resp rates (180-900 breaths/min) with low tidal volume and high airway pressure
When are high frequency oscillatory support vents usually used
To open alveoli and in small airway issues like atelectasis and ARDS
thought is also that it helps protect the lungs from injury
Noninvasive Positive Pressure Ventilation (NIPPV)
Pos Pressure Vent
Elimites the need for ET tube or trach tube
3 kinds
Pressure controlled ventilation with pressure support
What is thought to decrease with NIPPV use and why?
decreased risk of pneumonia since there are no tubes
What sort of patients may get NIPPV
Acute or chronic resp failure
COPD
CHF
acute pulmonary edema
sleep related breathing disorders
OSA
end of life care for those who do not want to be trached/tubed
What are the 3 types of NIPPV
PEEP - Positive end expiratory pressure
CPAP - continuous positive airway pressure
BiPAP - bilevel positive airway pressure
PEEP
positive end expiratory pressure - a type of NIPPV
Positive pressure occurs during exhalation
PEEP is useful in …
pulmonary edema
When should caution be used with PEEP
in those with COPD or decreased CO
CPAP
continuous positive airway pressure - a type of NIPPV
Air delivered continuously during spontaneous breathing
CPAP is good for…
sleep apnea
BiPAP
Bilevel positive airway pressure - a type of NIPPV
noninvasive method where pressure is based on the rate of inhalation and exhalation
BiPAP can help prevent…
reintubation needs after extubation
BiPAP is okay for patients in…
COPD, heart failure, and sleep apnea
Nursing Interventions for Mechanical Ventilation with an Airway Tube (ET/Trach)
Assess Setting
Assessment and Troubleshooting Alarms
Maintenance of airway and pt safety
What are some ways to maintain the airway and pt safety of a patient on a mechanical vent with a tube
suctioning of patient
restraints if needed and when needed
excess water in the system
timely change of disposable components
What are the 5 important ventilatory settings
Mode
Tidal Volume
FiO2
Rate
PEEP
How does Tidal Volume settings vary
based on pt size and age
tidal volume is the amount of air going in and out with each insp/exp
What is the standard ventilator rate
12-20 BPM
- can vary by pt age and condition
What is FiO2
the % of O2 given to a patient
When is the PEEP setting used on the ventilator
When O2 Sat is high and should be decreased
It usually is measured in 5-15 cm of pressure
What are the 6 ventilator modes going from most control over patient breathing (invasive) to minimal ventilator input (non-invasive)
CMV - Controlled Mechanical Ventilation most invasive
A/C Ventilation - Continuous Mandatory Ventalation aka Assist Control
IMV - Intermittent Mandatory Ventilation
SIMV - Synchronized Intermittent Mandatory Ventilation
PSV - Pressure Support Ventilation
APRV - Airway Pressure Release Ventilation *least invasive)
CMV Mode
Controlled Mechanical Ventilation Mode
Most INvasive
Used for clients who cannot initiate ANY spon. respirations
it is the lead used as it doesn no allow for any client initiated breaths
It will deliver a total set tidal volume at a set rate to the pt.
AC Vent Mode
Continuous Mandatory Ventilation AKA Assist Control Ventilation Mode
2nd most invasive
Machine can respond to clients own breath - but those breaths are assisted
Ventilator delivers a set tidal volume OR pressure and a set rate
What is the msot common ventilatory mode
AC Mode
SIMV mode
Synchronized intermittent mandatory ventilation mode
4th most invasive
can be a primary mode or weaning mode
Like AC, but lets the client breath spon. at their own rate and at a tidal volume between ventilator breaths
Also similar to IMV but it senses spontaneous breaths and will not deliver a breath during an exhale
delivers a set tidal volume and has a set rate (for machine assisted breaths taken)
What is the benefit of SIMV over IMV Mode
it will not try to deliver a breath during exhalation / fight the ventilator
it allows spontaneous breaths when detected and will administer as needed
IMV Mode
Intemrittent Mandatory Ventilation - can be used as a primary mode or weaning mode
3rd most invasive mode
Similar to AC but allows client to breath spontaneously at their own rate and tidal volume between vent breaths
vent delivers a set tidal volume at a set rate for machine assisted breaths
What is the issue with IMV mode
spontaneous breaths ar enot machine assisted or sensed which can lead to fighting/bucking the ventilator
a patient could be trying to exhale while the machien delivers a breath
What is the benefit of IMV over AC
allows the pt to use their own muscles for ventilation
When assessing “Sync” on IMV or SIMV mode what does this mean?
Does the pt seem synchronous with the vent, breathing easy? or are they fighting it?
What is “bucking”
attemting to breathe on your own with IMV, and now allowing ventilator to deliver breaths - fighting the vent
Things to monitor on IMV and SIMV vents
resp rate
minute volume
spon machine generated TV
FiO2
ABGs
PSV Mode
pressure support ventilation
least invasive
completely relies on spon breaths - provides a constant pressure to the patients own breaths and the tidal volume and rate is based on the patient’s own
When assessing a patient on PSV mode what may need to be checked and changed
Rate and Tidal Volume should be assessed and pressure may need to be changed to avoid tachypnea and large tidal volumes
APRV Mode
Airway pressure release ventilation
is pressure limited and a time triggered mode - gives cont. positive airway rpessure either high or low and two levels of inspiratory time as high or low
there are then time triggered mandatory breaths delivered by the machine but pt can take spon breaths
the tidal volume is pt driven
When is APRV good for
APneic Episodes as it delivers a breath for the patient when needed
Also for improving oxygenation and treating refractory hypoxemia in acute lung injuries, ARDS, and severe atelectasis
What to do when a ventilatory alarm goes off
ALWAYS ASSES PATIENT FIRST, then the alarm!
Do not ignore it do not turn it off - and when in doubt call the resp. therapist for consultation
However, some alarms need to be addressed yourself
When an alarm goes off and when in doubt…
bag the patient and call respiratory STAT
What are some reasons ALARMs on vents may go off
High pressure
Low Pressure
Temperature
Apnea
What is a high pressure alarm caused by
increased airway secretions, bronchospasm, displaced or obstructed tube, water in tubes, stiff airway (ARDS) and kinked tubing
What is a low pressure alarm caused by
usually a disconnection or leak in the system
What does an apnea alarm mean
the patient is off the ventilator or tubing disconnected from the pateint
What does a temperature alarm mean
usually needs more water for humidification
What is important aspects of nursing documentaiton to include for ventilated patients
Mode Used
Tidal Volume (usually 6-10 L/kg)
Rate (12-16)
FiO2 (Percent O2)
Amount of PEEP (if ussed)
Pressure Support (If Used)
Sputum - amount, frequency, color
Patient tolerance to vent and suctioning
Risks associated with mechanical ventilation
Infection - Ventilator Acquired Pneumonia
Pneumothorax
Lung Damage
SE of sedation and paralytic medications - may need sedation vacation
Maintenance of life when not wanted
Hypotension
sodium and water imbalance
Gi system issues
What about ventilators causes hypotension
increased positive pressure increasing the itnrathoracic pressure which inhibits blood return to the heart
What sort of GI system issues occur with ventilators
Usually due to the fact they are bedbound:
Stress Ulcers + GI Bleeding (Need peptic ulcer prophylaxis)
Decreased peristalsis
Sodium and Water Imbalance from Mechanical Ventilation
progressive fluid retention after 48-72 hours of positive pressure ventilation can occur leading to decreased UO and increased Na+
Nutritional Issues while on a Ventilator
Hypermetabolism from critical illness
Elimination of normal route for eating
Inadequate nutrition puts eprson at risk for Poor oxygen transport secondary to anemia and poor exercise (bedbound)
Decreased total protein and albumin
delays O2 weaning
decreased response to infection
increased risk for stress ulcer
OVERALL BODY DECONDITIONING IS OCCURRING
What is a possible intervention for nutritional issues on ventilators?
Orogastric/Nasogastric/PEG Tube - however there are then issues associated with enteral feeding tubes
Overall, What are the most important nursing interventions for clients on ventilators/breathing assistance
Maintaining a Patent Airway
Monitoring and documenting vent settings hourly - rate, FiO2, tidal volume, mode of ventilation, alarm settings
Maintaining proper cuff pressure
Administering meds as needed (analgesics to relieve pain and boost gas exchange, sedatives, ulcer preventing agents, neuromuscular blocking agents)
Good Communication
Good Nutrition
Monitoring the Weaning Process
What ar ethe 3 stages of mechanical vent weaning process
- Gradual removal from the vent
- removal of ET or trach tube
- removal of O2
What stance is the decisiont to begin the weaning process made from
a physiological standpoint not a mechanical stand point
When does the weaning process begin
the earliest time possible when it is safe for the patient
What things needs to be looked at to start the weaning process
Hemodynamically and physiologically stable - Stable, ABGs stable
Spontaneous breathing occurring
Recovered from acute stage medical or surgical issues
cause of resp failure is reveresed
The weaning process required what among the primary nurse, primary provider, and resp therapist
collaboration
Never do what during the weaning process
- Never abruptly remove the patient from the ventilator
2. Never do weaning at night
Ways to facilitate weaning process
decrease resp rate setting
give short times off vent or with 0 rate
may place T piece or briggs on
assess for resp distress or cardiac compromise
educate pt and family
prep patient physiologically
explain potential SOB normal to an extent
Monitor O2 status, pulse ox, EKG, and resp pattern
It is important to acknolwedge what potential psychological issue regrading vent weaning
the patient may have developed a psychological dependence on the ventilator and have anxiety regarding weaning
The weaning process will look…
different a little with each patient
Successful weaning is supplemented with…
intensive pulmonary care
What may gradual decrease of ventilators control over patient breathing look like wiht the settings
CMV w/ PEEP –> CMV without PEEP –> AC with PEEP –> AC without PEEP –> IMV with PEEP –> IMV without PEEP –> SIMV –> Briggs adaptor/T piece or trach collar/mask
How long does it take before extubation fo ET tubes can occur post mech. vent
can take days to weeks depending on long intubation
if short intubation only takes 2-3 hours before they can be removed
Removal of the ET tube can occur when the patient can…
breath spon
cough up own secretions
swallow
move jaw
decrease tracheostomy size (completed by provider)
Removal of a tracheostomy can occur when the patient can
breath spon
cough up own secretions
swallow
move the jaw
What is the removal of tracheostomy process like
Pt has adequate secretion clearance –> Move to trial period of mouth and nose breathing
Change to fenestrated tube, decrease stoma size, and switch to smaller button (provider does this)
finally, once pt can maintain airway tube is removed and occlusive dressing is placed over the stoma for closure
What is one of the msot common nosocomial infections
VAP -Ventilator Acquired Pneumonia
What is the leading cause of death from nosocomial infectiosn
VAP
When does VAP usually occur
48 hours or more after mechanical ventilation with intubation (can also occur if they have a treacheostomy)
VAP is associated with what results?
longer hospital stays and increased mortality rates
Risk Factors for VAP
poor oral hygeine - we need to help
contaminated resp equipment - use new clean stuff and sterile while suctioning
poor hand hygiene
decreased ability of patient to cough and clear secretions
immobility
patient age and comorbidities
reintubation
depressed consciousness
paralysis
What is the VAP Bundle
A group of interventions to provide a standardized method of care based on EBP for VAP:
- HOB 30-45 degrees
- Daily sedation vacations to see if tube can get out ASAP
- Peptic Ulcer disease prevention
- Deep vein thrombosis prevention
- Oral care daily with chlorhexidine gluconate .12% oral rinse
What are some ways to prevent VAP
VAP Bundle (5 things)
Effective handwashing before and after suctioning, when vent equipment is touched and when in contact with resp secretions
wear gloves when in contact wiht the patient
maintain ET tube cuff pressure
prevent condensationa nd subglottic drainage that collects in vent tubing -drain it
gastric volume monitoring - prevent aspiration
