Mechanical ventilators are used now in general wards , not only in ICU -to save patient's life. We need to care patient and ventilator while working with it ..
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Caring patient on Mechanical Ventilator
1. By: Ms. Shanta Peter
Caring patient on
Mechanical Ventilator
1
2. Indications for Mech. Vent
⢠PaO2 <50 mm Hg with FiO2 > 0.60
⢠PaO2<50mmHg with pH <7.25
⢠Vital Capacity <2 times TV
⢠Negative inspiratory force < 25 cm, H2O
⢠Respiratory >35/min
2
3. ⢠Pt has continuous âin oxygenation (PaO2 )
⢠Increase in PaCO2
⢠Persistent acidosis ( Decreased pH)
⢠Abdominal/ Thorasic Surgery
⢠Drug overdose
⢠Neuromuscular disease
⢠Inhalation injury
⢠COPD
⢠Pt with apnea ânot readily reversible
⢠Multiple trauma
⢠Multi system failure
⢠Coma
All these will lead to Resp Failure 3
4. Mechanical ventilator ⌠Nursing
Interventions
Unique technical and
interpersonal skill
Assess patient first
then ventilator
4
5. GOAL
⢠Patient will be supported on mechanical
ventilation without complication- then weaned ,
extubated . The complications will be detected,
treated timely
5
6. Two important Nsg interventions while caring
a patent on ventilator are :
Interpretation of ABG
&
Pulmonary Auscultation
6
7. General Nursing Interventions
⢠Assess for decreased cardiac output and
administer appropriate Nursing Care
⢠Monitor for positive water balance â Pressure
breathing may cause increase in ADH- Anti
Diuretic Hormone and retention of water
⢠Auscultate chest for altered breath sounds
-Take CVP /PCWP reading as ordered
-Observe /assess for peripheral edema
-Maintain accurate I & O
-Assess Daily weights
7
8. Nsg Intervention .âŚ
⢠Monitor for barotrauma â tension pneumothorax
⢠Assess ventilator checking every 4 hrs
⢠Auscultate breath sounds every 2 hrs
⢠Monitor ABGs
⢠Perform complete pulmonary-physical
assessment every shift
⢠Monitor for GI problems- stress ulcer
⢠Administer muscle relaxants . tranquilizers,
analgesics or paralyzing agents as ordered , to
increase client machine synchronized by relaxing
the client
8
9. Gas Exchange
⢠Judicious administration of analgesics
without suppressing the respiratory
drive
⢠Frequent re-positioning â to diminish
pulm. effects of immobility
⢠Monitor adequate Fluid balance â
observe peripheral edema, I& O chart,
weight
⢠Pot. side effects of medications
9
10. Promoting Effective Airway Clearance
Positive pressure increase secretion
⢠Auscultate lungs Q2-4 hrs
⢠Suctioning â physiotherapy, position changes,
- not as scheduled â but clinically related
Observe for barotrauma/ pneumothorax
⢠Humidification â
⢠Bronchodilators, mucolytic agents â dilate
bronchioles and liquefy secretions
10
11. Preventing trauma and infection
⢠Maintain ET /tracheostomy tube â position
ventilator --- no pulling on tube
⢠Monitor cuff pressure Q8hrly â 25cm H2O
⢠Tracheostomy/tube care Q6hrs
⢠More care to immuno compromised patients
⢠Replace Vent Circuits/ inline suction tubing â as
peer policy
⢠Oral hygiene
⢠NGT and use of antacidsâcause nosocomial
pneumonia from aspiration of tube feeding and
gastric contents
⢠Semi-fowlers position
11
12. Promote optimal level of mobility
⢠When stable -after weaning -- assist him to
sit up in chair
⢠Mobility of muscle activity â stimulate
respiration and improve morale
⢠Active /passive ROM exercise if bed bound â
prevent muscle atrophy , contractures and
venous stasis
12
13. Promote optimal Communication
⢠Evaluate his abilitiesâConscious?- can
communicate ? he node or move hand ?
⢠Can he write? â right â left hand
⢠Understand patient
13
14. Promoting coping ability
⢠Encourage family to communicate â and
verbalize fears
⢠Explain procedures every time to patient
⢠Restore sense of control- encourage to
participate in his care
⢠Inform his progress â if long time on vent
⢠Stress reduction techniques â rubbing back ,
relaxation techniques âŚâŚâŚâŚâŚ
14
15. Nurse should assess /monitor
the ventilator
⢠Check type of ventilatorâVolume cycled, Pres
Cycled, -ve pres
⢠Controlling mode- ( Controlled vent, A/C , SIMV)
⢠TV and rate settings- ( TV is usually 10-15 ml/Kg ,
rate 12-16;lmt
⢠FiO2 â (Fraction of inspired O2) â setting
⢠Inspiratory pressure reached and pressure limit
( normal 15- 20 cm of H2O (This increase in
conditions where there is increased Airway
resistance or decreased compliance)
⢠Sensitivity:( 2cm H2O Inspiratory force should
trigger the ventilator
15
16. VentilatorâŚâŚ.
⢠Insp to Exp Ratio(IE) usually 1:3 ( 1 second of
insp to 3 sec of expiration) or 1:2
⢠Minute Volume ( TV X RR ) usually 6-8 L/min
⢠SIGH setting â usually 1.5 times the TV ..and
range from 1-3 /hr⌠if applicable
⢠Tubing. Water in the tubing â disconnection or
kinking of the tubing
⢠Humidification( Humidifier filled with water)
and temperature
⢠Alarms ( Functioning properly)
⢠PEEP and/or Pressure support level, if applicable
PEEP is usually 5-15 cm of H2O
Observe for Complications
16
17. BUCKING the Ventilator
Patient struggles out of phase of ventilator
⢠Patient try to breathe out during the
ventilators inspiratory phase , or when there
is a jerky and abd. muscle effort
Causes:
⢠Anxiety, hypoxia, increased secretions
hypercarbia, inadequate minute volume ,
pulm edemaâŚâŚâŚâŚâŚ.
17
18. Bucking the ventilator âŚcontd
Correct these problems before giving
paralyzing agents âŚ..otherwise the underlying
problem will mask the condition and condition
become worse
⢠Muscle relaxants, tranquilizers, analgesics
and paralyzing agents are administered â to
increase Patient â machine synchrony
⢠Obtain Baseline ABG â To monitor progress of
therapy
18
19. ALARMSâŚâŚCauses
High pressure alarms
⢠Increased secretions in airway
⢠Decreased A Way size due to wheezing or
bronchospasm
⢠Displacement of ET tube
⢠Obstructed ET tube â water/kink in tubing
⢠Pt coughs gags, or bites the ET tube
⢠Anxious pts â fights(Bucking) on Vent
LOW Pressure alarm
⢠Disconnection /leak in the ventilator or airway cuff
⢠Pt stops spontaneous breathing
19
20. COMPLICATIONS
⢠Hypotension caused by +ve pressure â which increase
intra thoracic pressure and inhibit blood return to
heart
⢠Air leak
⢠Airway obstruction
⢠Respiratory complicationsâŚ. pneumothorax,
subcutaneous emphysema due to +ve pressure
(Barotrauma ), resp failure
⢠G.I alterations â stress ulcers bleeding
⢠Malnutrition â if not supported
⢠Infections
⢠Muscular deconditioning
⢠Ventilator dependence or inability to wean
20
21. WEANING âŚâŚâŚâŚâŚ.
The process of going OFF from ventilator dependence
to spontaneous breathing
3 stagesâŚâŚâŚpt gradually weaned from ------------
⢠Ventilator
⢠Tube
⢠Oxygen
⢠Decision is made on the physiologic view point by
the physician considering his clinical status.
⢠Itâs a joined effort of Physician â Resp Therapist
& Nurse
21
22. Criteria for weaning
The ventilator capacities includeâ
Ability to generate Vital Capacity of 10-15 ml/kg
(The minimum required volume is usually range of 1000ml in
adult)
⢠A spontaneous resp. force at least 20 cmH20
⢠PaO2 > 60mmHg with an FiO2 of < 40%
⢠Stable vital signs ..When the
⢠above ventilator capacity is adequate
CHECK â
22
Baseline Measurements
⢠Vital Capacity
⢠Insp . Force
⢠Resp Rate
⢠Resting TV
⢠Minute Ventilation
⢠ABG levels
⢠FiO2
23. Patient Preparation
must consider patient as a whole
Consider factors that--
⢠impair the deliver the O2
⢠impair elimination of CO2
⢠increase O2 demand ( sepsis, seizures, thyroid imbalance)
⢠Decrease in pts over all strength ( Nutrition, Neuro-
muscular disease)
Adequate psychological preparations
⢠Pt need to know what is expected of them during
procedure Explain properly..
⢠Assure the availability of Nurses near him at all time to
answer his questionsâŚ
⢠Often frightened --- reassure that they are improving and
well enough to handle his own spontaneous breathing
Proper preparation will reduce the weaning time
23
24. Methods of WEANING
⢠There is NO BEST method â
success depends on â
⢠Adequate patient preparation ,
⢠Available equipment, and
⢠Interdisciplinary approach to solve problems
24
25. Traditional method:
⢠T-Piece trials( one or more)
Used with short vent assistance ( <2 days) and pt is awake,
alert and breathing without difficulty , good gag reflex,
and hemo-dynamically stable
⢠Pt breathes spontaneously with humidified O2
⢠During the process pt is maintained on same or higher
O2 Conc than when on vent
T- Tube (Briggâs Adaptor) --15 mm connection â Connects
O2 source to an artificial airway. ET, tracheostomy.
⢠Recommended rate is 10L/min
⢠Inspired O2 Conc 24-100%
Caution: Clear secretions occlude T-Tube lead to suffocate
25
26. When on T-piece â observe
for signs & Symptoms of
Hypoxia, increasing fatigue, manifested as:
⢠Tachy cardia- PVCs, Ischemic ECC changes
⢠Restlessness
⢠RR > 35/mt
⢠Use of accessory muscles for breathing
⢠Paradoxical chest movement
26
27. If tolerating T âpiece trialâŚâŚâŚ.ABG â 20mts
after spont. breathing at a constant FiO2
( Alveolar-Arterial equalization occur15-20mins)
⢠If ABGââexhaustion--- hypoxia---â hook
back to vent
⢠Wean on and off
(Pt who had prolonged vent support need
gradual weaning process â even weeks)
⢠Primarily weaned during day time and placed
back on Vent during night
27
28. SIMV â Method
In pts who â satisfies all criteria for weaning but cannot
have spontaneous breathing for long time
SIMV for weaning--- observe the following
⢠Respiratory Rate
⢠Minute Volume
⢠Spont /Machine Breaths & TV
⢠FiO2
⢠ABG levels
No deterioration on parameters--- adequate TV , vent
resp gradually decreased-- then weaning is complete
Pressure support is used as an adjunct to SIMV
weaning â to support insp. pressure ,and boost the
spontaneous breaths. PS is reduced gradually as pts
strength increases 28
30. Weaning from Tube
ET/TT removed only if following criterion met
⢠Spontaneous ventilation is adequate
⢠Pharyngeal and laryngeal reflexes are active
⢠Pt maintain adequate airway and can
swallow, move the jaw clench teeth ,
voluntary cough is effective to bring out
secretion
Before the tube is removedâa trail with
nose/mouth breathing is done â Deflating cuff,
using fenestrated tube etc
30
31. Weaning from O2
⢠Pt successfully weaned---- and has adequate
respiratory function â weaned from O2
FIO2 is gradually reduced until PO2 is in range
of 80-100 mmHg while breathing in Room air
⢠If R air PO2 less than 70 supplementary O2
recommended
31
32. ⢠Long tern ventilated pt need aggressive-
judicious NUTRITIONAL support as
Resp. musculature( Diaphragm & intercostal
muscles) quickly become weak or atrophied
after a few days of Mech. Ventilation â
especially if nutrition is inadequate,
⢠High CHO diet increase CO2âthus
increase the work of breathing â
32
33. What you know about
OXYGEN supplies
& accessories ?
33
34. 34
Through bulk liquid O2 system which store O2 @-
34C (-29F) and deliver it as gas through wall
outlets
Gas Cylinders
Compressed O2 : Non-liquefied gas @
1800-2400 lbs /Sq inch @ 21C (70 F)
35. 35
40% -- @5-6 L/min
45â50% @ 6-7 L/min
55 â60% @ 7-10L/min
Flow rate must be set
at least
5L/min to flush
the mask.
21--24 % @ 1L/min
24--28 % @ 2L/min
28--32 % @ 3L/ min
32-- 36% @ 4L/min
36 â 40% @ 5L/min
40 â 44% @ 6L/min
FiO2 through Nasal
Cannula
Simple FACE MASK
VENTI MASK : Delivers exact O2 Conc. between
20-40% --despite patientâs respiratory pattern
36. Partial Re-Breather Mask
70-90% FiO2 is delivered at 6-15L/min
⢠A flow rate high enough to maintain the bag
2/3rd full during inspiration is needed.
⢠Make sure the reservoir bag do not twist or
kink â which result in a deflated bag
36
37. GOAL:
⢠Patient will be supported on mechanical
ventilation without complication- then
weaned , extubated .
⢠The complications will be detected , treated
timely
37