CARE OF PATIENT ON VENTILATOR

1. Identify the indications for mechanical ventilation.

2. List the steps in preparing a patient for intubation.

3. Determine the FIO2, tidal volume, rate and mode of ventilation on a given

ventilator.

4. Describe the various modes of ventilation and their implications.

5. Describe at least two complications associated with patient’s response to

mechanical ventilation and their signs and symptoms.

6. Describe the causes and nursing measures taken when trouble-shooting

ventilator alarms.

7. Describe preventative measures aimed at preventing selected other

complications related to endotracheal intubation.

8. Give rationale for selected nursing interventions in the plan of care for the
ventilated patient.

9. Complete the care of the ventilated patient checklist.

10. Complete the suctioning checklist.

1. To review indications for and basic modes of mechanical

ventilation, possible complications that can occur, and nursing
observations and procedures to detect and/or prevent such
complications.
2. To provide a systematic nursing assessment procedure to ensure
early detection of complications associated with mechanical
ventilation.

Indication for Intubation

1. Acute respiratory failure evidenced by the lungs inability to maintain arterial

oxygenation or eliminate carbon dioxide leading to tissue hypoxia in spite of
low-flow or high-flow oxygen delivery devices. (Impaired gas exchange, airway
obstruction or ventilation-perfusion abnormalities).
2. In a patient with previously normal ABGs, the ABG results will be as
follows:

PaO2 > 50 mm Hg with pH < 7.25

PaO2 < 50 mm Hg on 60% FIO2 : restlessness, dyspnea, confusion, anxiety,

tachypnea, tachycardia, and diaphoresis

PaCO2 > 50 mm Hg : hypertension, irritability, somnolence (late), cyanosis

(late), and LOC (late)

3. Neuromuscular or neurogenic loss of respiratory regulation. (Impaired

ventilation)

4. Usual reasons for intubation: Airway maintenance, Secretion control,

Oxygenation and Ventilation.

Types of intubation: Orotracheal, Nasotracheal, Tracheostomy

Preparing for Intubation

1. Recognize the need for intubation.

2. Notify physician and respiratory therapist. Ensure consent obtained if not

emergency.

3. Gather all necessary equipment:

a. Suction canister with regulator and connecting tubing

b. Sterile 14 Fr. suction catheter or closed in-line suction catheter

c. Sterile gloves

d. Normal saline

e. Yankuer suction-tip catheter and nasogastric tube

f. Intubation equipment: Manual resuscitator bag (MRB), Laryngoscope and

blade, Wire guide, Water soluble lubricant, Cetacaine spray

g. Endotracheal attachment device (E-tad) or tape

h. Get order for initial ventilator settings

i. Sedation prn

j. Soft wrist restraints prn

k. Call for chest x-ray to confirm position of endotracheal tube

l. Provide emotional support as needed/ ensure family notified of change in

condition.

Intubation

Types of Ventilators

Ventilator Settings

Modes of Mechanical Ventilation

Complications of Mechanical Ventilation

1. Associated with patient’s response to mechanical ventilation:

A. Decreased Cardiac Output

1. 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.

2. Symptoms – increased heart rate, decreased blood pressure and perfusion to

vital organs, decreased CVP, and cool clammy skin.

3. 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).

B. Barotrauma

1. Cause – damage to pulmonary system due to alveolar rupture from excessive

airway pressures and/or overdistention of alveoli.

2. Symptoms – may result in pneumothorax, pneumomediastinum,

pneumoperitoneum, or subcutaneous emphysema.
3. Treatment - aimed at reducing TV, 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).

C. Nosocomial Pneumonia

1. 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.

2. 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

D. Positive Water Balance

1. Syndrome of Inappropriate Antidiuretic Hormone (SIADH) – due to vagal

stretch receptors in right atrium sensing a decrease in venous return and see it as
hypovolemia, leading to a release of ADH from the posterior pituitary gland and
retention of sodium and water. Treatment is aimed at decreasing fluid intake.

2. Decrease of normal insensible water loss due to closed ventilator circuit

preventing water loss from lungs. This fluid overload evidenced by decreased
urine specific gravity, dilutional hyponatremia, increased heart rate and BP.

E. Decreased Renal Perfusion – can be treated with low dose dopamine therapy.

F. Increased Intracranial Pressure (ICP) – reduce PEEP

G. Hepatic congestion – reduce PEEP

H. Worsening of intracardiac shunts –reduce PEEP

2. Associated with ventilator malfunction:

A. Alarms turned off or non-functional – may lead to apnea and respiratory

arrest

Troubleshooting Ventilator Alarms

Low exhaled volume: Cuff leak, Tubing disconnect, Patient disconnected

Evaluate cuff; reinflate prn; if ruptured, tube will need to be replaced. Evaluate
connections; tighten or replace as needed; check ETT placement, Reconnect to
ventilator

High pressure: Secretions in airway, Patient biting tubing, Tube kinked, Cuff
herniation, Increased airway resistance/decreased lung compliance (caused by
bronchospasm, right mainstem bronchus intubation, pneumothorax,
pneumonia), Patient coughing and/or fighting the ventilator; anxiety; fear; pain.

Suction patient, Insert bite block, Reposition patient’s head/neck; check all
tubing lengths, Deflate and reinflate cuff, Auscultate breath sounds, Evaluate
compliance and tube position; stabilize tube, Explain all procedures to patient in
calm, reassuring manner, Sedate/medicate as necessar

Low oxygen pressure: Oxygen malfunction

Disconnect patient from ventilator; manually bag with ambu; call R.T

3. Other complications related to endotracheal intubation.

A. Sinusitis and nasal injury – obstruction of paranasal sinus drainage; pressure

necrosis of nares

1. Prevention: avoid nasal intubations; cushion nares from tube and tape/ties.

2. Treatment: remove all tubes from nasal passages; administer antibiotics.

B. Tracheoesophageal fistula – pressure necrosis of posterior tracheal wall

resulting from overinflated cuff and rigid nasogastric tube
1. Prevention: inflate cuff with minimal amount of air necessary; monitor cuff
pressures q. 8 h.

2. Treatment: position cuff of tube distal to fistula; place gastrostomy tube for
enteral feedings; place esophageal tube for secretion clearance proximal to
fistula.

C. Mucosal lesions – pressure at tube and mucosal interface

1. Prevention: Inflate cuff with minimal amount of air necessary; monitor cuff
pressure q. 8 h.; use appropriate size tube.

2. Treatment: may resolve spontaneously; perform surgical interventions.

D. Laryngeal or tracheal stenosis – injury to area from end of tube or cuff,

resulting in scar tissue formation and narrowing of airway

1. Prevention: inflate cuff with minimal amount of air necessary; monitor cuff
pressure q. 8.h.; suction area above cuff frequently.

2. Treatment: perform tracheostomy; place laryngeal stint; perform surgical

repair.

E. Cricoid abcess – mucosal injury with bacterial invasion

1. Prevention: inflate cuff with minimal amount of air necessary; monitor cuff
pressure q. 8 h.; suction area above cuff frequently.

2. Treatment: perform incision and drainage of area; administer antibiotics.

4. 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.

PLAN OF CARE FOR THE VENTILATED PATIENT

Patient Goals:

1. Patient will have effective breathing pattern.

 2. Patient will have adequate gas exchange.
3. Patient’s nutritional status will be maintained to meet body needs.
4. Patient will not develop a pulmonary infection.
5. Patient will not develop problems related to immobility.
6. Patient and/or family will indicate understanding of the purpose for
mechanical ventilation

Nursing Diagnosis Nursing Interventions Rationale

Observe changes in An increase in the work
respiratory rate and of breathing will add to
Ineffective breathing pattern r/t
depth; observe for SOB fatigue; may indicate
____________________________.
and use of accessory patient fighting
muscles. ventilator.
Observe for tube
misplacement- note and
Indicates correct position
post cm. Marking at
to provide adequate
lip/teeth/nares after x-
ventilation.
ray confirmation and q.
2 h.
Prevent accidental
Avoid trauma from
extubation by taping
accidental extubation,
tube securely, checking
prevent inadequate
q.2h.;
ventilation and potential
restraining/sedating as
respiratory arrest.
needed.
Determines adequacy of
breathing pattern;
Inspect thorax for
asymmetry may indicate
symmetry of movement.
hemothorax or
pneumothorax.
Indicates volume of air
Measure tidal volume
moving in and out of
and vital capacity.
lungs.
Pain may prevent patient
Asses for pain from coughing and deep
breathing.
Shows extent and
Monitor chest x-rays location of fluid or
infiltrates in lungs.
Maintain ventilator Ventilator provides
settings as ordered. adequate ventilator
 pattern for the patient.
This position moves the
abdominal contents away
from the diaphragm,
Elevate head of bed 60-
which facilitates its
90 degrees.
contraction.

 
Determines acid-base
Impaired gas exchange r/t alveolar-
Monitor ABG’s. balance and need for
capillary membrane changes
oxygen.
Assess LOC,
These signs may indicate
listlessness, and
hypoxia.
irritability.
Determine adequacy of
Observe skin color and
blood flow needed to
capillary refill.
carry oxygen to tissues.
Indicates the oxygen
Monitor CBC. carrying capacity
available.
Decreases work of
Administer oxygen as
breathing and supplies
ordered.
supplemental oxygen.
Observe for tube
May result in inadequate
obstruction; suction prn;
ventilation or mucous
ensure adequate
plug.
humidification.
Repositioning helps all
Reposition patient q. 1-2 lobes of the lung to be
h. adequately perfused and
ventilated.
Potential altered nutritional status:
Monitor lymphocytes Indicates adequate
less than body requirements r/t
and albumin. visceral protein.
NPO status
Calories, minerals,
Provide nutrition as
vitamins, and protein are
ordered, e.g. TPN, lipids
needed for energy and
or enteral feedings.
tissue repair.
Provides guidance and
Obtain nutrition consult.
continued surveillance.
Potential for pulmonary infection r/t Secure airway and Prevent mucosal
compromised tissue integrity. support ventialtor damage.
 tubing.
Provide good oral care q.
4 h.; suction when need
indicated using sterile
technique; handwashing
Measures aimed at
with antimicrobial for 30
prevention of
seconds before and after
nosocomial infections.
patient contact; do not
empty condensation in
tubing back into
cascade.
Use disposable saline
irrigation units to rinse
in-line suction; ensure
ventilator tubing IAW Infection Control
changed q. 7 days, in- Policy and Respiratory
line suction changed q. Therapy Standards of
24 h.; ambu bags Care for CCNS.
changes between
patients and whenever
become soiled.
Dependency on
ventilator with increased
anxiety when weaning;
Potential for complications r/t Assess for psychosocial
decreased ability to
immobility. alterations.
communicate; social
isolation/alteration in
family dynamics.
Assess for GI problems.
Preventative measures
include relieving
Most serious is stress
anxiety, antacids or H2
ulcer. May develop
receptor antagonist
constipation.
therapy, adequate sleep
cycles, adequate
communication system.
Observe skin integrity Patient is at high risk for
for pressure ulcers; developing pressure
preventative measures ulcers due to immobility
include turning patient at and decreased tissue
least q. 2 h.; keep HOB perfusion.
< 30 degrees with a 30
degree side-lying
position; use pressure
relief mattress or turning
bed if indicated; follow
 prevention of pressure
ulcers plan of care;
maintain nutritional
needs.
Maintain muscle
strength with Patient is at risk for
active/active- developing contractures
assistive/passive ROM due to immobility, use of
and prevent contractures paralytics and ventilator
with use of span-aids or related deficiencies.
splints.
Explain
purpose/mode/and all
treatments; encourage
patient to relax and
breath with the
ventilator; explain Reduce anxiety, gain
Knowledge deficit r/t intubation alarms; teach importance cooperation and
and mechanical ventilation of deep breathing; participation in plan of
provide alternate method care.
of communication; keep
call bell within reach;
keep informed of results
of studies/progress;
demonstrate confidence.