Mechanical ventilation

Presented By

Miss Pallavi Rai

M.Sc. Nursing

KGMU Institute

of Nursing

Objectives of the session

• Define mechanical ventilation.

• Identify clinical situations in which mechanical ventilation is used.

• Review and understand ventilator definitions and terminology

• Describe types and modes of ventilation

• State the major components of ventilation

• Understand ventilator parameters

• PEEP Therapy

• Recognize common causes of alarms

• State complications from mechanical ventilation

• Review the weaning process

• Explain the nursing responsibility

Mechanical Ventilation & ventilator

• Mechanical Ventilation isventilation of the lungs by

artificial means.

• A mechanical ventilator control or assist patient breathing by delivering a predetermined percentage of oxygen to

the lungs.

Goals for MECHANICAL VENTILATION

• Achieve and maintain adequate pulmonary gas exchange

• Minimize the risk of lung injury

• Reverse respiratory muscle fatigue

• Reduce patient work of breathing

• Optimize patient comfort

• To normalize blood gases and provide comfortable breathing

INDICATIONSMechanical ventilation is indicated when the patient cannot maintain spontaneous ventilation to provide adequate oxygenation or carbon dioxide removal.

INDICATION EXAMPLES

1.Acute ventilatory failure

pH<7.3,PaCO2>50mmHg

2.Severe hypoxemia PaO2<40mmHg,SaO2<75%

3.Impending ventilatory failure

Progressive acidosis and hypoventilation to pH<7.3,PaCO2>50mmHg

4.Prophylactic ventilatory support

Post anaesthesia recovery

INDICATIONS FOR PROPHYLACTIC

VENTILATORY SUPPORT

INDICATION EXAMPLES

Reduced risk of pulmonary complications Prolonged shockHead injurySmoke inhalation

Reduced hypoxia of major body organs Hypoxic brainHypoxia of heart muscles

Reduced cardiopulmonary stress Prolonged shockCoronary artery bypass surgeryOther thoracic or abdominal surgeries

Contraindicationsof Mechanical Ventilation

• Contraindications

– Untreated pneumothorax

• Relative Contraindications

– Patient’s informed consent

– Medical futility

– Reduction or termination of patient pain and suffering

8

Types of Mechanical ventilators

• Negative pressure ventilators

• Positive pressure ventilators

Mechanical ventilator

Negative-Pressure Ventilators

• The patient’s body was encased in an iron cylinder and negative pressure was generated.

• The use of negative-pressure ventilators is restricted in clinical practice,, because they limit positioning and movement and they lack adaptability to large or small body torsos (chests) .

• This is not used nowadays .

Mechanism of negative pressure ventilators

It is similar to the spontaneous breathing

& Expiration occurs passively

Allows the air to flows in the lungs

Decrease the intrathoracic pressure during inspiration

Exert negative pressure on the external chest as compared to atmospheric pressure

Positive-pressure ventilators

• Positive-pressure ventilators deliver gas to the patient under positive-pressure, during the inspiratory phase.

Mechanism Of Positive Ventilators

& Expiration occurs passively

Allows the air to flows in the lungs

Forcing the alveoli to expand during the inspiration

Inflate the lungs by exerting positive pressure on the airway as compared to atmospheric pressure

Types Of MECHANICAL Ventilation

1.INVASIVE

2. NON INVASIVE

Invasive ventilation

• Mechanical ventilation via artificial airways which can either be endotracheal intubation or tracheostmy tube.

Non invasive ventilation • It refers to the delivery of

mechanical ventilation to the lungs using techniques that do not require an invasive artificial airway(ETT, TT)

• It provide breathing support through CPAP,BiPAP.

Classification of positive-pressure ventilators

• Ventilators are classified according to how the inspiratory phase ends. The factor which terminates the inspiratory cycle reflects the machine type.

• They are classified as:

Volume cycled ventilators

Pressure cycled ventilators

Time cycled ventilators

1- Volume-cycled ventilator

• The ventilator delivers a preset tidal volume (VT), and inspiration stops when the preset tidal volume is achieved.

• Most commonly used in adult.

2- Pressure-cycled ventilator

• In which inspiration is terminated when a specific airway pressure has been reached.

3- Time-cycled ventilator

• In which inspiration is terminated when a preset inspiratory time, has elapsed.

• Time cycled machines are not used in adult critical care settings. They are used in pediatric intensive care areas.

Ventilator mode

The way the machine will ventilate the patient in relation to the patient’s own respiratory efforts.

Various modes of mechanical ventilators

Controlled mandatory ventilation

(CMV)

Assist/control (AC)

Intermittent mandatory ventilation

(IMV)

Synchronized intermittent mandatory

ventilation (SIMV)

Positive end-expiratory pressure

(PEEP)

Continuous positive airway pressure

(CPAP)

Bilevel positive airway pressure

(BiPAP)

Pressure support ventilation (PSV)

Volume ventilation plus (VV1)

Pressure-controlled ventilation

(PCV)

Airway pressure release

ventilation (APRV)

Inverse ratio ventilation (IRV)

High-frequency oscillatory

Ventilation (HFOV)

Proportional assist ventilation

(PAV)

Pressure-regulated volume

control (PRVC)

1.Controlled Mandatory Ventilation

• Delivers a set tidal volume and respiratory rate. The ventilator does ALL the work.

• Patient needs to be sedated or paralyzed.

Pros Cons Nursing responsibility

• It is primary

ventilator

mode in

patients who

are apnic.

•Doesn't permit

normal

spontaneous

breathing, and can

cause respiratory

muscles to atrophy.

•Used in a

patient unable to

initiate a breath

•Spontaneously

breathing patient

must be sedated

and/or paralyzed.

•Frequent ABGs

monitoring .

2. Synchronized intermittent mandatory ventilation (SIMV)

• Synchronized intermittent mandatory ventilation (SIMV) delivers a preset tidal volume and number of breaths per minute.

• Between ventilator-delivered breaths, the patient can breathe spontaneously with no assistance from the ventilator on those extra breaths.

• As the patient’s ability to breathe spontaneously increases, the preset number of ventilator breaths is decreased and the patient does more of the work of breathing.

Pros Cons Clinical

applicability

•Patient can

exercise

respiratory

muscles. May

improve cardiac

output.

•that it may

increase the

work of

breathing and

respiratory

muscle fatigue

•Used as

weaning mode

•Patient who

require partial

ventilatory

support.

3. Pressure Support Ventilation (PSV)

• Pressure support ventilation , is a spontaneous mode of ventilation. The patient initiates every breath and the ventilator delivers support with the preset pressure value. With support from the ventilator, the patient also regulates his own respiratory rate and tidal volume.

• PSV is used for patients with a stable respiratory status and is often used with SIMV to overcome the resistance of breathing through ventilator circuits and tubing.

ADVANTAGES OF PS Ventilation• Supports the patient's spontaneous tidal volume

• Decrease in work of breathing

• Facilitates weaning

• May be applied in any mode that allows spontaneous breathing

• Improves patient comfort and reduces need for sedation

Indications

• Spontaneously breathing patients

who require additional ventilatory

support to help overcome:

↑ WOB or respiratory muscle

weakness

• Weaning

Contraindications

• Requires consistent spontaneous breathing

• Fatigue and tachypnea if PS level is set too low

PEEP(Positive end expiratory

pressure)

• It is A method of ventilation in which airway pressure

is maintained above atmospheric pressure at the end

of exhalation,which increases the functional

residual capacity (volume in lungs at the end of

exhalation)

•This is NOT a specific mode, but is rather an

adjunct to any of the vent modes.

• The application of positive pressure to the airways

during expiration may keep alveoli open and

prevent closure.

• Most patients are set on 5 of peep as a standard.

Indications to PEEP Contraindications to PEEP

•ARDS

•COPD

•Asthma

•Pulmonary edema

Tension Pneumothorax - it will

get worse

Hypovolemic shock – cardiac

output will decrease

Bronchopleural fistula - it wont

heal

High intracranial pressure - it

will get higher

Right ventricular failure - the

failing right ventricle may fail more

with the addition of increased

afterload

ADVANTAGES DISADVANTAGES

Increasing the functional

residual capacity

• Re-inflating atelectatic lung

areas and recruitment of

collapsed alveoli

• Optimizing the ventilation/

perfusion ratio

• Reducing the right-to-left

shunt

• Avoiding end-expiratory

Reducing the cardiac output

by reducing venous return

• Reducing renal, hepatic and

splanchnic circulation

• Over-distending alveoli and

alveolar rupture

• Increasing intracranial

pressure

MODE FUNCTIONS CLINICAL

USE

Control Ventilation (CV)

Delivers preset volume or pressure regardless of patient’s own Inspiratory efforts

Usually used for patients who are apneic.

Assist-Control Ventilation (A/C)

Delivers breath in response to patient effort and if patient fails to do so within preset amount of time

Usually used for spontaneously breathing patients with weakened respiratory muscles

Synchronous Intermittent Mandatory Ventilation (SIMV)

Ventilator breaths are synchronized with patient’s respiratory effort

Usually used to wean patients from mechanical ventilation

MODE FUNCTIONS CLINICAL

USE

Pressure

Support

Ventilation

(PSV)

Preset pressure that augments

the patient’s Inspiratory effort

and decreases the work of

breathing Often used with

SIMV during weaning

Often used with

SIMV during weaning

Constant

Positive

Airway

Pressure

(CPAP)

Used only with spontaneously

breathing patients Maintains

constant positive pressure in

airways so resistance is

decreased

Maintains constant

positive pressure in

airways so resistance

is decreased

Parts of ventilator

Ventilator monitor

Ventilator circuit

Ports

Central oxygen and air supply to the ventilator

Bacteria filter and HME Unit

Water trap

Settings of Mechanical Ventilation

• Mechanical Ventilator Settings regulates the rate, depth and other characteristics of ventilation.

• Settings are based on the patient’s status (ABGs, Body weight, level of consciousness and muscle strength)

Setting of ventilator

PARAMETERS

• Mode of ventilation

• Respiratory rate

• Tidal volume

• PEEP level

• Fraction of inspired O2 conc.(FiO2)

• I:E ratio

Setting Functions Usual parameters

Mode how the machine will

ventilate the patient in

relation to the patient’s

own respiratory efforts

Depends upon the

clinical conditions of

the patients.

Respiratory rat e Number of breaths

delivered by the ventilator

per minute.

Usually 8-12 breaths

per minute

Fractional Inspired

Oxygen (FIO2)

Amount of oxygen

delivered by ventilator to

patient

21-100%

Tidal volume Volume of gas delivered

during each ventilator

breath

Usually 8 ml/kg.

PEEP amount of pressure left in

the alveoli at the end of

exhalation .

Usually 5 cm of

H2o(5-10cm of H20)

Inspiratory:Expirat Length of inspiration Usually 1:2 or 1:1.5

Complications of Mechanical Ventilation:-

I- Airway Complications

II- Mechanical complications

III- Physiological Complications

IV- Artificial Airway Complications

Airway Complication

1- Aspiration

2- Decreased clearance of secretions

3- Nosocomial or ventilator-acquired

pneumonia

Mechanical

complications1- Hypoventilation 2- Hyperventilation3- Barotrauma4- Alarm “turned off”5- Failure of alarms or

ventilator6- Inadequate nebulization

or humidification7- Overheated inspired air,

resulting in hyperthermia

Physiological Complications

1- Fluid overload with humidified air andsodium chloride (NaCl) retention

2- Depressed cardiac function andhypotension

3- Stress ulcers4- Paralytic ileus5- Gastric distension6- Starvation

Artificial Airway Complications

• Complications related to Endotracheal Tube

• Complications related to Tracheostmy Tube

NONINVASIVE

FORMS

OF

MECHANICAL

VENTILATION

2.NONINVASIVE FORMS OF MECHANICAL VENTILATION

• Modality that supports breathing with out the need for invasive artificial airway.

• 2 types of NIPPV are commonly used

1. CPAP (continuous positive airway pressure )

2.BiPAP(Bilevel positive airway pressure )

Indications of nippv

• Obstructive sleep apnoea syndrome

• COPD with exacerbation

• Bilateral pneumonia

• Acute congestive heart failure with pulmonary oedema

• Neuromuscular disorder

• Acute lung injury

• Method of weaning

Contraindications• Patient’s inability to maintain his or her own

airway.

• Unstable facial fractures ,or facial lacerations

• Laryngeal trauma

• Basal skull fracture

• Patient with recent GI surgery or at risk of GIT bleeds/ileus

• Vomiting/ and or high aspiration risk

• Uncooperative or unmotivated patients.

• Cardiac or respiratory arrest

• Severe encephalopathy

• Coma

Advantages of NPPV

• Avoids potential trauma secondary to

endotracheal intubation

• Avoids need for sedation

• Allows patient to maintain ability to

communicate, eat and drink.

• Avoids risk of ventilator associated

pneumonia.

• Increases functional residual capacity.

Disadvantages of NIPPV

• Patient must be alert.

• have spontaneous respirations

• tight mask fit (no facial hair)

• feeling of claustrophobia

• Increased Thoracic Pressure (ITP) can reduce Cardiac Output (CO)

Equipment

• BiPAP machine

• BiPAP disposable circuit with disposable proximal pressure line and exhalation port (flushes exhaled gas from the circuit)

• Low resistance bacterial filter

• BiPAP Total Face Mask, Full Face Mask or Nasal Mask plus head strap.

• Disposable Humidifier

• Distilled water

Interfaces

Parts of facemask

One way exhalation

port

Head gear straps

CPAP (Continuous Positive

Airway Pressure)

• CPAP is spontaneous breathing at a positive end-expiratory pressure.

• CPAP delivers a single, constant pressure during both inhalation and exhalation.

• Requires only a source of oxygen and a face mask with an expiratory valve that maintains a PEEP.

• Usually set at 5-10cm H2O.

• In neonates, nasal CPAP is the method of choice.

BiPAP (Bi-level Positive Airway Pressure)

• It delivers two pressures. It provides a combination of both IPAP and EPAP.

• High pressure level is inspiratory positive airway pressure (IPAP) and low pressure level is expiratory positive airway pressure (EPAP).

Nursing Responsibilities: NIPPV

• Check ventilator setting.

• Hrly observations, HR, RR, BP,SPO2 ,lungs sounds

• Maintain adequate face/mask seal .

•

• Observe patients level of consciousness, chest wall movement, co-ordination of patient respiratory effort with the ventilator, work of breathing.

• Pressure areas on the skin beneath the mask

• Change tubing and device check every 7 days

• Maintain patient comfort, oral, nasal and eye

hygiene.

• Reassure the patient that they may experience feelings of suffocation, their mouth will be dry and the mask does smell &they can feel very nauseous due to the high flow of oxygen.

ALARMS OF VENTILATOR

High Pressure Alarm Low pressure alarm

•Secretions in ETT/airway or

•Kinking in tubing

•Patient biting on ETT

•Patient coughing, gagging, or

trying to talk

•Increased airway pressure from

bronchospasm or pneumothorax

•Vent tubing not connected

•Displaced ETT or trach tube

High Respiratory Rate Low Exhaled Volume

•Patient anxiety or pain •Secretions in ETT/airway •Hypoxia •Hypercapnia

•Vent tubing not connected • Leak in cuff or inadequate cuff seal Occurrence of another alarm preventing full delivery of breath

Responding to alarm

• Check client

• check circuit

• check ventilator setting and alarms limits

• Replace filter

• Remove water from tubing and check humidifier setting (i.e., relative humidity )

• Check cuff pressure

• Consider more ventilatory support for client

Complications

• Infection

Because of placement of artificial airways and

invasive lines

• Ulcerations

may be because of pressure from tubing's and prolonged immobility

Complications of MV

• Ventilator Associated Pneumonia (VAP)

– Ventilator Associated Pneumonia is an infection of the lungs occurring more than 48 hours after intubation.

Complications

• Accidental Extubation/ Displacement

– can occur if the patient pulls the ET Tube out, or when it becomes dislodged during routine care.

• Tracheal and Laryngeal Damage

– can occur when the patient is unintentionally extubated while the cuff is still inflated.

– Other causes are laryngoedema from extubation, and cranial nerve damage.

Prevention is Key!

• Accidental Extubations/ Displacement

– Ensure you have enough slack in the circuit before

moving the patient

– Monitor sedation. If the patient is grabbing at the

ventilator you may need an order for more sedation or

light wrist restraints as a reminder to keep their hands

away from the vent.

– Placement at the lips

– No movement in the epigastric area

Prevention is Key!

• Tracheal and Laryngeal Trauma

– Prevent accidental extubations

– Ensure the cuff is fully deflated before extubation

• VAP

– Head of bed up to at least 30 degrees

– Mouth care including chlorhexidine, suctioning, and

brushing teeth

– Check and secure the tubes

– Change the circuit per protocol

Prevention is Key!

• Volutrauma and Barotrauma– Low Tidal Volumes with a higher rate

– Ideally PEEP should be kept at 5

– Monitor pressures (Inspiratory, Plateau, Expiratory)

• Ulcerations and infections– Mouth care

– switch side of mouth (angle change )

– Suctioning of secretions

Prevention is Key!

• Sedation levels must be closely observed during the weaning period.

• Patients may need to be occasionally stimulated during weaning but if excessive stimulation is needed to maintain adequate rate, the patient is not ready to wean.

Prevention is Key!

• The number one way to prevent complications

related to ventilators is to wean as early as

possible. Get your patient off the vent!

Weaning from

mechanical ventilator

Weaning is the word used to describe the

process of gradually removing the

patient from ventilator and restoring

spontaneous breathing after a period

of mechanical ventilator.

EVALUATING A PATIENT FOR

WEANING

A daily routine follow up should be done in every patient receiving mechanical ventilation and exploring the following condition

Resolution/improvement of the underlying disease

Stop sedation

Core temperature below 38 ºC

Stable haemodynamics

Adequate haemoglobin ( Hb > 8 g/dL)

Adequate mentation ( arousable, GCS > 13)

No major metabolic and/or electrolyte disturbances

Criteria for Weaning

• Careful assessment is required to determine whether the patient is ready to be removed from mechanical ventilation.

Respiratory criteria Other criteria

•Minute

ventilation<15/L

•Respiratory rate <38

breaths /mint

•Tidal volume > 325 ml

•Maximum inspiratory

pressure < -15cm of

H2O

•FiO2< 50%

•Improvement, correction, or

stabilization of the active disease

process

•Nutritional and fluid status sufficient

to maintain the increased metabolic

needs and demands of spontaneous

respiration

•Adequate physical strength and

mental alertness

•Afebrile status (any infections

controlled)

•Stable cardiovascular ,renal and

cerebral status

•Optimal levels of ABGs, electrolytes

Other criteria

• Chest x-ray reviewed for correctable factors; treated as indicated.

• Major electrolytes within normal range,• Hematocrit >25%,• Core temperature >36°C and <39°C,• Adequate management of

pain/anxiety/agitation,• Adequate analgesia/ sedation (record scores

on flow sheet),• No residual neuromuscular blockade.

WEANING PRECEDURE

• Rapid ventilator discontinuation

• Spontaneous breathing trials

• Pressure support ventilation (PSV)

• SIMV

• Other Modes used for weaning

RAPID VENTILATOR

DISCONTINUATION• Considered in patients with no underlying cardiovascular,

pulmonary, neurologic, or neuromuscular disorders and patients receiving ventilatory support for short periods e.g. post-op patients.

• SBTs are superior to both SIMV and PS in both duration of weaning and the likelihood of success after weaning.

Patient on ventilator for < 72 hrs

SBT for 30 to 120 min.EXTUBATE if no other

limiting factor

Good spont RR, MV, MIP, f/Vt

2. SPONTANEOUS BREATHING

TRIALSBT can be in the form of or

SIMV

PSV of 5-10 cm H2O

T – tube trial

CPAP 5-7 cmH2O.

WEANING WITH SIMV

• Mandatory breaths are synchronized with patient’s own efforts

ADVANTAGES•Gradual transition•Easy to use•Alarm system may be used•Should be used in comb.

with PSV/CPAP

DISADVANTAGES

•Prolongs weaning•May worsen fatigue

PROTOCOL OF SIMV

WEANING

Monitor patient’s appearance, respiratory rate, SpO2, BP, obtain ABG sample

Start with SIMV rate at 80% of full support

Decrease 2 – 4 breaths twice daily

If the patient tolerates an SIMV rate of 2-4 breaths

for> 2 hrs

Consider extubation

If deterioration→ ↑ SIMV rate

Allow pt’s respmsls to rest at night by ↑ingSIMV rate

WEANING WITH PSV• Pressure support is given with each spontaneous

breath to ensure an adequate TV.

ADVANTAGES•Gradual transition•Prevents fatigue•Increased pt comfort•Weans faster than SIMV alone•Pt can control cycle length, rate

and inspiratory flow.•Overcomes resistive WOB d/t

ET tube and circuit.

DISADVANTAGES

•TV not guaranteed

Continuous Positive Airway Pressure ( CPAP) Weaning

• When placed on CPAP, the patient does all the work of breathing without the assistance form ventilator

• No mandatory (ventilator-initiated) breaths are delivered in this mode i.e. all ventilation is spontaneously initiated by the patient.

• Weaning by gradual decrease in pressure value.

3. Weaning trials using a T-piece

• Weaning trials using a T-piece or tracheostomymask are normally conducted with the patient disconnected from the ventilator, receiving humidified oxygen only, and performing all work of breathing.

• The goal is to progressively increase the time spent off the ventilator.

T-Tube trial: allows spontaneous breathing interspersed with periods of full ventilatory support

• ADVANTAGES• Tests pt’s spontaneous• breathing ability• Allows periods of work and • rest• Weans faster than SIMV

• DISADVANTAGES• Abrupt transition difficult for some pts• No alarms, unless attached to ventilator• Requires careful observation.

WEANING PROTOCOL FOR SBT WITH A T-

TUBEPrepare for T-Tube trial

3 min. screening trial

Measure TV,RR

Measure MIP thrice

selecting the best

. Formal SBT for 30 – 120 min

MIP < -20 cm H20

TV spon. > 5 ml/kg

RR spon. < 35/min.

no signs of intolerance

If signs of intolerance are present

Put the patient

back on previous

ventilator

settings

Repeat next trial after 24 hrs

extubate

Optimize the patient’s medical condition suction, adequate humidification, bronchodilator therapy, good nutrition, optimal position, psychological counseling, adequate staff, equipment, no sedatives

NURSING ASSESSMENTS

• While on the T-piece, the patient should be observed for signs and symptoms of hypoxia, increasing respiratory muscle fatigue, or systemic fatigue.

• Observe respiratory rate, work of breathing etc.

• use of accessory muscles, tachycardia and paradoxical chest movement (asynchronous breathing, chest contraction during inspiration and expansion during expiration).

Role of nurse before weaning

1- Ensure that indications for the implementation of Mechanical ventilation have improved

2- Ensure that all factors that may interfere with successful weaning are corrected:-

- Acid-base abnormality

- Fluid imbalance

- Electrolyte abnormalities

- Infection

- Fever

- Anemia

- Hyperglycemia

- Protein

- Sleep deprivation

Role of nurse before weaning3- Assess readiness for weaning 4- Ensure that the weaning criteria / parameters are met.5- Explain the process of weaning to the patient and

offer reassurance to the patient.

6- Initiate weaning in the morning when the patient is rested.

7- Elevate the head of the bed & Place the patient upright

8- Ensure a patent airway and suction if necessary before a weaning trial,

9- Provide for rest period on ventilator for 15 – 20 minutes after suctioning

10- Ensure patient’s comfort & administer

pharmacological agents for comfort, such as

bronchodilators or sedatives as indicated.

11- Help the patient through some of the

discomfort and apprehension.

12- Support and reassurance help the patient

through the discomfort and apprehension

as remains with the patient after initiation

of the weaning process.

13- Evaluate and document the patient’s

response to weaning.

Role of nurse during weaning

1- Wean only during the day.

2- Remain with the patient during

initiation of weaning.

3- Instruct the patient to relax and breathe

normally.

4- Monitor the respiratory rate, vital signs,

ABGs, diaphoresis and use of accessory

muscles frequently.

If signs of fatigue or respiratory distress develop.

• Discontinue weaning trials and put the patient on ventilatory support.

Role of nurse after weaning

1- Ensure that extubation criteria are

met .

2- Decanulate or extubat

2- Documentation

Nursing care in Mechanical ventilation

• Assessment• Check ventilator settings

and modes• Prevent respiratory

function.• Monitor for complications• Prevent infections.• Provide adequate

nutrition.• Monitor GI bleeding.

Nursing Assessment

• All ventilator settings should be recorded at least every hour.

• parameters including HR, BP, Sp02 and respiration should be recorded every 30 minutes. Temperature should be checked every 4 hours..

• Assess for the airway patency & securing of tubes• Listen to air movement ,chest rise and fall.• Observe for breathing rate rhythm,TV,Fio2 etc.• Check for circulation and level of consciousness • Check for GCS,ability to communicate and sedation level.• Monitor ABG analysis and pulse oximetry • Check for adequacy of humidification .

Nursing assessment

• Check temp,BP,Heart rate and other hemodynamic parameters .

• Observe for presence of pressure ulcers

• Monitor urine output ,serum electrolytes, blood glucose level .

• Check frequency of bowel movements

• Physical strength and body weight

• Observe for signs of DVT

respiratory care • Measure tidal volume and vital capacity

• Auscultate lungs frequently to assess for abnormal sounds.

• Arterial blood gas analysis and Spo2 monitoring

• Heat and moisture exchangers (HMEs) must be changed every 24 hours.

• Suction as needed..

• Turn and reposition every 2 hours.

• Secure ETT properly. Observe for tube

misplacement

• Prevent accidental extubation by taping tube

securely, checking q.2h.; restraining/sedating

as needed.

• Monitor ABG value and sPO2.

2. PREVENT INFECTION• Maintain sterile technique when suctioning.

• Monitor color, amount and consistency of sputum.

• ensure ventilator tubing changed q. 7 days, in-line suction changed q. 24 h.; ambu bags changes between patients and whenever become soiled

• Regular oral care with an antibacterial solution and to suction the pharynx.

• Lines, drains and tubes – IV catheters, central catheters, arterial catheters, urinary catheters and any other form of tube/drain should be checked at least twice daily for signs of complications.

• Central lines should be managed aseptically. Feeding tube should be cleaned daily.

• Intravenous catheters should be rewrapped daily and veins evaluated for signs of phlebitis or infection.

• Eye care and Ophthalmic ointment should be

applied at least every 2 hours to protect against

corneal drying and ulceration.

• Body position should be changed every 4 hours

and passive range of motion exercises

performed.

provide adequate nutrition

• Begin tube feeding as soon as POSSIBLE.

• Provide nutrition as ordered, e.g. TPN, lipids or

parental feedings.

• Weigh daily.

• Monitor I&O .

• Assess for GI problems. Preventative

measures include relieving anxiety, antacids

or H2 receptor antagonist therapy, adequate

sleep cycles.

• Regular palpation of the colon is advised, and

enemas should be administered as needed.

• Auscultate bowel sounds.

• Explain purpose/mode/and all treatments

• encourage patient to relax and breath with the ventilator

• explain alarms; teach importance of deep breathing

• provide alternate method of communication; keep informed of results of studies/progress;

Responding To Alarms

• If an alarm sounds, respond immediately because the problem could be serious.

• Assess the patient first, while you silence the alarm.

• Alarms must never be ignored or disarmed.

• Alarms setting should be checked every 2-4 hours

Patient Comfort

Carefully explain all procedures to the

patient, prior to their

commencement;

At all times, the nurse should attempt to:

Orientate the patient to theirenvironment and events;

Provide a suitable

means of

communication for the patient.Involve the patient and their

family in the planning andimplementation of nursing care;

Facilitate a proper day /night

rhythm for the patient;

DOCUMENT ALL NURSING ACTIONS

Suctioning

MM J

Oral care and eye care

Respiratory auscultation

Securing of tubing

What we should not forget

words of comfort

,skillfully

administered ,are

the oldest therapy

known to man