Nursing Care of Ventilated Patient

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1. Nursing Care of Ventilated Patient Prepared by: Mr. JABER A. ALNAMI ICU Staff Nurse:

2. Out lines: Objectives Definition of M.V Indications Modes of M.V Adjustment of M.V Complications of M.V Nursing Management

3. Objectives To define what is the mechanical ventilator. To know what are the indications for M.V . To determine modes of mechanical ventilation . To know how to adjust M.V . To know how to deal with complications of M.V . To determine what is the nursing management of ventilated patient .

4. Definition of Mechanical Ventilator

5. I s a machine that generates a controlled flow of gas into a patient’s airways. Oxygen and air are received from cylinders or wall outlets, the gas is pressure reduced and blended according to the prescribed inspired oxygen tension (FiO2), accumulated in a receptacle within the machine, and delivered to the patient using one of many available modes of ventilations.

6. Indications Need for sedation/ neuromuscular blockage. Need to decrease systemic or myocardial oxygen consumption. Use of hyperventilation to reduce intracranial pressure.

7. Indications Ventilation abnormalities Respiratory muscle dysfunction Respiratory muscle fatigue Chest wall abnormalities Neuromuscular diseases

8. Indications Oxygenation Abnormalities Refractory hypoxemia. Need for positive end expiratory pressure. Excessive work of breathing.

9. Modes of Ventilation :

10. Modes of Ventilation: Spontaneous : The machine is not giving pressure breath. The P t . breath spontaneously. The P t . needs only specific FIO2 to maintain its normal blood gases.

11. Controlled: The machine controls the patient ventilation according to set tidal volume and respiratory rate . spontaneous respiratory effort of Pt . is locked out , ( patient who receives sedation and paralyzing drugs he will on controlled Mode ).

12. SIMV : Machine allows the P t to breath spontaneously while providing preset FIO2 , and a number of ventilator breaths to ensure adequate ventilation without fatigue .

13. Assist / Control : The P t . triggers the machine with negative inspiratory effort. If the P t . fails to breath the machine will deliver a controlled breath at a minimum rate and volume already set .

14. Adjustment on the ventilator : The ventilator is adjusted so that the pt. is comfortable and "in sync " with the machine. Minimal alteration of the normal cardiovascular and pulmonary dynamics is desired. If the volume of ventilator is adjusted appropriately , the pt. arterial blood level will be satisfactory and there will be no or little cardiovascular compromise.

15. The Following Guidelines are Recommended : set the machine to deliver the required tidal volume ( 6 to 8 ml/kg ) adjust the machine to deliver the lowest concentration of the oxygen to maintain normal PaO2 (80 to 100mmhg).The setting may be set high and gradually reduced based on ABGs result.

16. Record peak inspiratory pressure. Set mode (assist/control or SIMV)and rate according to physician order. If Pt . is on assist/control mode , adjust sensitivity so that the P t . can trigger the ventilator with the minimum effort( usually 2mmHg negative inspiratory force)

17. Record minute volume and measure carbon dioxide partial pressure PaCO2, PH after 20 minutes of mechanical ventilation . Adjust FIO2 and rate according to results of ABG to provide normal values or those set by the physician.

18. In case of sudden onset of confusion , agitation or unexplained " bucking the ventilator " the P t . should be assessed for hypoxemia and manually ventilated on 100% oxygen with resuscitation bag ( AMBU bag) Bag – Valve – mask . Patient who are on controlled ventilation and have spontaneous respiration may " fight or buck " the ventilator, because they cannot synchronize their own respiration with the machine cycle.

19. Sedative and neuromuscular blocking agents may be given such as : Pancuornium bromide( Pavulon ) Midazolam Neuromuscular blocking agents block the transmission of nerve impulses and result in muscle paralysis.

20. Complications of M.V

21. 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).

22. B. 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 and subcutaneous emphysema. Treatment - aimed at reducing T.V , 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).

23. C. 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

24. 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

25. . 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.

26. Nursing Management of Ventilated Patient

27. Nursing Management:   Promote respiratory function. Monitor for complications Prevent infections. Provide adequate nutrition. Monitor GI bleeding.

28. PROMOTE RESPIRATORY FUNCTION Auscultate lungs frequently to assess for abnormal sounds.   Suction as needed. Turn and reposition every 2 hours. Secure ETT properly. Monitor ABG value and pulse oximetry .

29. Suction of an Artificial Airway To maintain a patent airway To improve gas exchange. To obtain tracheal aspirate specimen. To prevent effect of retained secretions. ( Its important to OXYGENATE before and after suctioning)

30. MONITOR FOR COMPLICATIONS   Assess for possible early complications Rapid electrolyte changes. Severe alkalosis. Hypotension secondary to change in Cardiac output.   Monitor for signs of respiratory distress: Restlessness Apprehension Irritability and increase HR.

31.   Assess for signs and symptoms of barotrauma(rupture of the lungs) Increasing dyspnea Agitation Decrease or absent breath sounds. Tracheal deviation away from affected side. Decreasing PaO2 level .   Assess for cardiovascular depression: Hypotension Tachy . and Bradycardia Dysrhythmias .

32.   PREVENT INFECTION Maintain sterile technique when suctioning. Monitor color, amount and consistency of sputum. PROVIDE ADEQUATE NUTRITION Begin tube feeding as soon as it is evident the patient will remain on the ventilator for a long time. Weigh daily. Monitor I&O .   MONITOR FOR GI BLEEDING Monitor bowel sounds. Monitor gastric PH and hematest gastric secretions every shift.

33. Questions!!!