Caring patient on Mechanical Ventilator
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The document outlines the indications for mechanical ventilation, nursing interventions, and goals for patients on mechanical ventilation. It highlights the importance of continuous assessment of the patient and ventilator settings, monitoring complications, and preparing for the weaning process. Additionally, it discusses methods of weaning from the ventilator and the need for comprehensive patient care and support to ensure successful outcomes.
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 ↓in oxygenation (PaO2 ) • Increase in PaCO2 • Persistent acidosis ( Decreased pH) • Abdominal/ Thorasic Surgery • Drug overdose • Neuromuscular disease • Inhalation injury • COPD • Pt with apnea –not 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 – 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 .… • Monitor for barotrauma – 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 – to diminish pulm. effects of immobility • Monitor adequate Fluid balance – 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 – physiotherapy, position changes, - not as scheduled – but clinically related Observe for barotrauma/ pneumothorax • Humidification – • Bronchodilators, mucolytic agents – dilate bronchioles and liquefy secretions 10
- 11. Preventing trauma and infection • Maintain ET /tracheostomy tube – position ventilator --- no pulling on tube • Monitor cuff pressure Q8hrly – 25cm H2O • Tracheostomy/tube care Q6hrs • More care to immuno compromised patients • Replace Vent Circuits/ inline suction tubing – as peer policy • Oral hygiene • NGT and use of antacids—cause 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 – stimulate respiration and improve morale • Active /passive ROM exercise if bed bound – prevent muscle atrophy , contractures and venous stasis 12
- 13. Promote optimal Communication • Evaluate his abilities—Conscious?- can communicate ? he node or move hand ? • Can he write? – right – left hand • Understand patient 13
- 14. Promoting coping ability • Encourage family to communicate – and verbalize fears • Explain procedures every time to patient • Restore sense of control- encourage to participate in his care • Inform his progress – if long time on vent • Stress reduction techniques – rubbing back , relaxation techniques …………… 14
- 15. Nurse should assess /monitor the ventilator • Check type of ventilator—Volume 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 – (Fraction of inspired O2) – 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. Ventilator……. • 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 – usually 1.5 times the TV ..and range from 1-3 /hr… if applicable • Tubing. Water in the tubing – 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 edema……………. 17
- 18. Bucking the ventilator …contd Correct these problems before giving paralyzing agents …..otherwise the underlying problem will mask the condition and condition become worse • Muscle relaxants, tranquilizers, analgesics and paralyzing agents are administered – to increase Patient – machine synchrony • Obtain Baseline ABG – To monitor progress of therapy 18
- 19. ALARMS……Causes High pressure alarms • Increased secretions in airway • Decreased A Way size due to wheezing or bronchospasm • Displacement of ET tube • Obstructed ET tube – water/kink in tubing • Pt coughs gags, or bites the ET tube • Anxious pts – 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 – which increase intra thoracic pressure and inhibit blood return to heart • Air leak • Airway obstruction • Respiratory complications…. pneumothorax, subcutaneous emphysema due to +ve pressure (Barotrauma ), resp failure • G.I alterations – stress ulcers bleeding • Malnutrition – if not supported • Infections • Muscular deconditioning • Ventilator dependence or inability to wean 20
- 21. WEANING ……………. The process of going OFF from ventilator dependence to spontaneous breathing 3 stages………pt gradually weaned from ------------ • Ventilator • Tube • Oxygen • Decision is made on the physiologic view point by the physician considering his clinical status. • It’s a joined effort of Physician – Resp Therapist & Nurse 21
- 22. Criteria for weaning The ventilator capacities include— 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 → 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 questions… • 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 – success depends on – • 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 (Brigg’s Adaptor) --15 mm connection – 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 – 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 –piece trial……….ABG – 20mts after spont. breathing at a constant FiO2 ( Alveolar-Arterial equalization occur15-20mins) • If ABG↓—exhaustion--- hypoxia---→ hook back to vent • Wean on and off (Pt who had prolonged vent support need gradual weaning process – even weeks) • Primarily weaned during day time and placed back on Vent during night 27
- 28. SIMV – Method In pts who – 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 – to support insp. pressure ,and boost the spontaneous breaths. PS is reduced gradually as pts strength increases 28
- 29. Successful weaning is supplemented by intensive pulm care like--- • O2 therapy • ABG evaluation • Pulse oxymetry • Bronchodilator therapy • Chest physio • Adequate Nutrition, hydration, humidification, • Incentive spirometry 29
- 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 removed—a trail with nose/mouth breathing is done – Deflating cuff, using fenestrated tube etc 30
- 31. Weaning from O2 • Pt successfully weaned---- and has adequate respiratory function – 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 – especially if nutrition is inadequate, • High CHO diet increase CO2—thus increase the work of breathing – 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 45—50% @ 6-7 L/min 55 –60% @ 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 – 40% @ 5L/min 40 – 44% @ 6L/min FiO2 through Nasal Cannula Simple FACE MASK VENTI MASK : Delivers exact O2 Conc. between 20-40% --despite patient’s 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 – 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
- 38. Thank youAll 38