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 ..
Call Girls Hyderabad Just Call 9907093804 Top Class Call Girl Service Available
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
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