Mechanical Ventilation• The mechanical ventilator device functions as a substitute for the bellows action of the thoracic cage and diaphragm.• The mechanical ventilator can maintain ventilation automatically for prolonged periods.• It is indicated when the patient is unable to maintain safe levels of oxygen or CO2 by spontaneous breathing even with the assistance of other oxygen delivery devices.• When a patient is unable to maintain a patent airway, adequate gas exchange, or both, despite aggressive pulmonary management, more invasive support with intubation and mechanical ventilation must be considered.
The Goal• The goal of mechanical ventilation is to maintain alveolar ventilation appropriate for the patient’s metabolic needs and to correct hypoxemia and maximize oxygen transport.Desired clinical outcomes of mechanical ventilation may include:• Reversal of hypoxemia• Reversal of acute respiratory acidosis• Relief of respiratory distress• Prevention or reversal of atelectasis• Resting of ventilatory muscles• Reduction in systemic oxygen consumption, myocardial oxygen consumption, or both• Stabilization of the chest wall
Clinical Indications of MechanicalVentilation• Failure of Ventilation• Neuromuscular disease• Central nervous system (CNS) disease• CNS depression (drug intoxication, respiratory depressants, cardiac arrest)• Musculoskeletal disease• Inefficiency of thoracic cage in generating pressure gradients necessary for ventilation (chest injury, thoracic malformation)Disorders of Pulmonary Gas Exchange• Acute respiratory failure• Chronic respiratory failure• Left ventricular failure• Pulmonary diseases resulting in diffusion abnormality• Pulmonary diseases resulting in ventilation-perfusion mismatch.
Overview of Mechanical Ventilation• Ventilators are classified as either negative-pressure or positive-pressure ventilators.• Negative-pressure ventilators encase the patient’s body and exert negative pressure that pulls the thoracic cage outward to initiate inspiration.• In current clinical practice, use of negative-pressure ventilators is limited.• Positive-pressure ventilators, which are much more commonly used, deliver air by pumping it in to the patient’s lungs. With positive-pressure ventilation, the normal relationship between intrapulmonary pressures during inspiration and expiration is reversed (ie, pressures during inspiration are positive and pressures during expiration are negative).
There are three major modes of positive-pressure ventilation:• Volume ventilation. With volume ventilation, a designated volume of air (tidal volume) is delivered with each breath. Volume ventilation is commonly used in critical care settings.• Pressure ventilation. With pressure ventilation, a selected gas pressure is delivered to the patient and sustained throughout the phase of ventilation.• High-frequency ventilation.• Accomplishes oxygenation by the diffusion of oxygen and carbon dioxide from high to low gradients of concentration.• Diffusion is increased when the kinetic energy of the gas molecules is increased.• High-frequency ventilation uses small tidal volumes (1–3 mL/kg) at frequencies greater than 100 breaths/minute.• The breathing pattern of a person receiving high-frequency ventilation is somewhat analogous to that of panting, which entails moving small volumes of air at a very fast rate ( High-frequency ventilation is used to achieve lower peak ventilatory pressures, which reduces the risk for lung injury caused by high pressures.
Ventilator SettingsAlthough the respiratory therapist may share or have complete responsibility for managing the ventilator settings, the nurse must still assess and understand the ventilator settings to provide effective nursing care.Common settings include: Fraction of inspired oxygen (FiO2).• The FiO2 is the percentage of oxygen in the air delivered to the patient.• The FiO2 is adjusted to maintain an SaO2 of greater than 90%.• Initially, the patient is placed on a high level of FiO2 (60% or higher), but because oxygen toxicity is a concern when anFiO2 of greater than 60% is required for more than 24 hours, strategies are implemented to maintain the FiO2 at 60% or less after the initial intubation.• Subsequent changes in FiO2 are based on arterial blood gases and the SaO2.
Tidal volume.The tidal volume is the amount of air to be delivered with each breath.With volume ventilators, the tidal volume is set by the clinician. Tidalvolumes of 5 to 8 mL/kg of body weight are recommended.Respiratory rate.• The respiratory rate (ie, the number of breaths per minute deliveredto the patient) is set on most ventilator models.•Because minute ventilation, which determines alveolar ventilation, isequal to the respiratory rate multiplied by the tidal volume,adjustments in either of these parameters affect the PaCO2.•Increasing the minute ventilation decreases the PaCO2, whereasdecreasing it increases the PaCO2.•Slowing the respiratory rate may also be necessary to enhancepatient comfort or when rapid rates cause air trapping in the lungs(due to decreased exhalation time).
Positive end-expiratory pressure (PEEP)•PEEP control adjusts the pressure that is maintained in the lungs atthe end of expiration.•PEEP increases the functional residual capacity (FRC) by re-inflatingcollapsed alveoli, maintaining the alveoli in an open position, andimproving lung compliance.•This decreases shunting and improves oxygenation.•It is common practice to use low levels of PEEP (5 cm H2O) in theintubated patient.•PEEP is increased in 2- to 5-cm H2O increments when FiO2 levelsgreater than 50% are required to attain an acceptable SaO2 (greaterthan 90%) or PaO2 (greater than 60 to 70 mm Hg).•High levels of PEEP should rarely be interrupted (eg, by disconnectingthe ventilator tubing from the airway) because it may take severalhours to recruit alveoli again and restore the FRC.•Reduction of PEEP is considered when the patient has a PaO2 of 80 to100 mm Hg or an FiO2 of 50% or less, is hemodynamically stable, and
Peak flow.Peak flow is the velocity of gas flow per unit of time and is expressedas liters per minute. On many volume ventilators, peak flow can be setdirectly. Very high peak flow is associated with increased turbulence(reflected by increasing airway pressures), shallow inspirations, anduneven distribution of volume.Peak inspiratory pressure limit (high-pressure alarm).•The peak inspiratory pressure (PIP) limit is the highest pressureallowed in the ventilator circuit.•With volume ventilators, once the high pressure limit is reached, thehigh-pressure alarm sounds and the inspiration is terminated.•If the inspiratory pressure limit is being constantly reached, thepatient will not receive the designated tidal volume, steps must betaken to identify and address the underlying cause•(eg, coughing, accumulation of secretions, kinked ventilatortubing, pneumothorax, decreasing compliance, or a high pressurealarm that is set too low).
Sensitivity.•The sensitivity function controls the amount of patient effort needed to initiate aninspiration, as measured by negative inspiratory effort.•Increasing the sensitivity (requiring less negative force) decreases the amount ofwork the patient must do to initiate a ventilator breath.•decreasing the sensitivity increases the amount of negative pressure that thepatient needs to initiate inspiration and increases the work of breathing.Inspiratory:expiratory (I:E) ratio.•Most ventilators operate with a short inspiratory time and a long expiratory time(1:2 or 1:3 ratio).This allows time for air to passively exit the lungs, lowering pressures in the thoraciccavity and allowing for increased venous return.•However, in conditions of reduced compliance (eg, acute respiratory distresssyndrome [ARDS], sarcoidosis), the I:E ratio may be reversed so that the inspiratorytime is equal to, or greater than, the expiratory time (eg, 1:1, 2:1, 3:1, 4:1).•The inverse I:E ratio improves oxygenation by expanding stiff alveoli using longerinspiratory times, thereby providing more opportunity for gas exchange andpreventing alveolar collapse.
Ventilatory Common Uses Advantages Disadvantages NursingMode ConsiderationsVolume Modes As an initial Ensures ventilator Increased risk for Work ofA/C mode of support during hyperventilation breathing mayA respiratory ventilation every breath and air trapping berate and tidal For patients too Delivers consistent May require increased ifvolume are weak to tidal volumes sedation and sensitivity orpreset. perform Allows patient to Paralysis, flow rate is too the work of rest Ventilatory low.If the patient breathing muscle atrophyattempts to with longer use.initiate breath,the ventilatoris triggeredand deliversthe full presettidal volumewith everybreath
Ventilatory Common Uses Advantages Disadvantages NursingMode ConsiderationsSIMV As a long-term Allows spontaneous Patient– Work of mode of breaths ventilator breathing mayAs with the ventilation (tidal volume asynchrony beA/C mode the As a weaning determined by possible increased ifrespiratory mode patient) between Work of sensitivity orrate and tidal ventilator breathing is flow rate is toovolume are breaths increased low.preset, Allows patient to through use own artificial airwayIf the patient respiratory muscles,attempts to preventing muscleinitiate a atrophybreath abovethis presetrate , theventilatorallows apatient to takespontaneousbreath.
Ventilatory Common Uses Advantages Disadvanta NursingMode ges ConsiderationsPressure PCV For patients with Lower peak Patient– Monitor tidal volumes.Modes conditions inspiratory ventilator Monitor for barotraumaPCV in which compliance is pressures asynchrony and decreased and the risk reduce risk for necessitats hemodynamic instability for barotrauma is high barotraumas sedation/ For patients with Improved paralysis persistent hypoxemia oxygenation. despite a high FiO2PSV As a weaning mode, Decreases work Patient must have an and in some of breathing intact respiratory drive. cases of dyssynchrony Increases PSV mode cannot be Used in combination patient comfort used in patients with with SIMV ---- acute bronchospasm. to decrease work of Monitor respiratory rate breathing by helping and tidal volume at to overcome least resistance created by hourly. the endotracheal tube Monitor for changes in compliance, which can cause tidal volume to
Ventilatory Common Uses Advantages Disadvantages NursingMode ConsiderationsIRV (Inverse Used to improve Longer inspiratory Almost always Usually used inratio oxygenation time provides requires conjunctionventilation) in patients with more opportunity sedation/ with PCV conditions for gas paralysis Monitor for characterized by exchange and Auto-PEEP may auto-PEEP, decreased shorter develop barotrauma, and compliance expiratory times hemodynamic prevent instability. alveolar collapse.APRV(Airway For patients Allows lungPressure with high protective strategiesRelease airway by limiting plateauVentilation) pressures to and peak pressures reduce airway Allows spontaneous pressure and breathing ----- ---- lower minute Need for volume while paralysis/sedation is allowing decreased spontaneous breathing As a weaning
Ventilatory Common Uses Advantages Disadvantages NursingMode ConsiderationsVGPO (Volume For acutely ill, Ensures a Requires Monitor for auto-guaranteed unstable patients delivered sophisticated PEEP,pressure to provide tidal volume knowledge of the barotrauma, andoptions) pressure while mode and hemodynamic ventilation while limiting waveform instability guaranteeing pressures analysis tidal volume and minute ventilation at a set rate.PEEP( Positive Used to maintain Improves High levels of Monitor total PEEPend expiratory alveoli infl ation oxygenation PEEP may (set PEEP and auto-pressure) at end expiration Increases cause barotrauma PEEP) and decrease FRC, Increases and hemodynamics the work of allowing intrathoracic Limit disconnection breathing lower pressures, leading from ventilator For patients on FiO2 levels to decreased (eg,for suctioning), high levels of venous because of time FiO2 return and required to with refractory cardiac reestablish PEEP. hypoxemia output
Ventilatory Common Uses Advantages Disadvantages NursingMode ConsiderationsCPAP For spontaneously May be On some Monitor for breathing patients to used in systems, no increased work improve oxygenation intubated alarm if of breathing. As a weaning mode or respiratory For nocturnal nonintubat rate decreases ventilation to prevent ed upper airway patients obstruction in patients with sleep apneaNoninvasive For nocturnal No need Patient Thick or copiousBiPap hypoventilation in for artificial discomfort or secretions patients with airway claustrophobia and poor cough neuromuscular disease, Use of full may be relative chest wall deformity, facemask contraindications obstructive sleep apnea, increases risk for BiPap. and COPD for aspiration Monitor for To prevent intubation and gastric To prevent re-intubation rebreathing distention, initially after extubation carbon dioxide. air leaks from mouth, aspiration risk.
Collaborative Nursing Care INTERVENTIONSOUTCOMESOxygenation/Ventilation • Auscultate breath sounds q2–4h and PRN.A patent airway is maintained. • Suction as needed for crackles, coughing, orLungs are clear to auscultation. oxygen desaturation.Patient is without evidence of atelectasis. • Hyperoxygenate before and after eachPeak, mean, and plateau pressures are suction pass.within normal limits. • Monitor airway pressures q1–2h.ABGs are within normal limits • Monitor airway pressures after suctioning. • Administer bronchodilators and mucolytics as ordered. • Perform chest physiotherapy if indicated by clinical examination or chest x-ray. • Turn side to side q2h. • Consider kinetic therapy or prone positioning as indicated by clinical scenario. • Get patient out of bed to chair or standing position when stable. • Monitor pulse oximetry and end-tidal CO2. • Monitor ABGs as indicated by changes in noninvasive parameters,patient status, or weaning protocol.
OUTCOMES INTERVENTIONSCirculation/Perfusion • Assess hemodynamic effects of initiatingBlood pressure, heart rate, cardiac positive-pressure ventilationoutput, central venous pressure, and (eg, potential for decreased venous returnpulmonary artery pressure remain and cardiac output).stable on mechanical ventilation • Monitor ECG for dysrhythmias related to hypoxemia. • Assess effects of ventilator setting changes (inspiratory pressures, tidal volume, PEEP, and FiO2) on hemodynamic and oxygenation parameters. • Administer intravascular volume as ordered to maintain preload.Fluids/Electrolytes • Monitor hydration status in relation toI & O measurements are balanced. clinical examination, auscultation,Electrolyte values are within normal amount and viscosity of lung secretions.limits. • Assess patient weight, I & O totals, urine specific gravity, or serum osmolality to evaluate fluid balance. • Administer electrolyte replacements (IV or enteral) per physician’s order.
OUTCOMES INTERVENTIONSMobility • Collaborate with physical/occupationalPatient maintains or regains therapy staff to encouragebaseline patient effort/participation to increase mobility.functional status related to • Progress activity to sitting up in chair,mobility and self-care. standing at bedside, ambulating with Joint range of motion is assistance as soon as possible.maintained • Assist patient with active or passive range-of-motion exercises of all extremities at least every shift. • Keep extremities in physiologically neutral position using pillows or appropriate splint/support devices as indicated.
OUTCOMES INTERVENTIONSSafety • Securely stabilize endotracheal tube inEndotracheal tube will remain in position.proper • Note and record the “cm” line onposition. endotracheal tube position at lip or teeth.Proper inflation of endotracheal tube • Use restraints or sedation per hospitalcuff is maintained. protocol.Ventilator alarm system remains • Evaluate endotracheal tube position onactivated chest x-ray daily (by viewing film or by report). • Keep emergency airway equipment and manual resuscitation bag readily available, and check each shift. • Inflate cuff using minimal leak technique, or pressure <25 mm Hg by manometer. • Monitor cuff inflation/leak every shift and PRN. • Protect pilot balloon from damage. • Perform ventilator setting and alarm checks q4h (minimum) or per facility protocol.
OUTCOMES INTERVENTIONSSkin Integrity • Assess and document skin integrity atPatient is without evidence of skin least every shift.breakdown. • Turn side to side q2h; reassess bony prominences for evidence of pressure injury. • When patient is out of bed to chair, provide pressure relief to sitting surfaces at least q1h. • Remove self-protective devices from wrists, and monitor skin per hospital policy.Nutrition • Consult dietitian for metabolic needsNutritional intake meets calculated assessment and recommendations.metabolic need (eg, basal energy • Provide early nutritional support by enteral or parenteral feeding, start within 48 hours ofexpenditure equation). intubation.Patient will establish regular bowel • Monitor actual delivery of nutrition daily withelimination pattern I&O calculations. • Weigh patient daily. • Administer bowel regimen medications as ordered, along with adequate hydration.
OUTCOMES INTERVENTIONSComfort/Pain Control • Document pain assessment, usingPatients will indicate/exhibit numerical pain rating or similar scaleadequaterelief of discomfort/pain while on when possible.mechanical ventilation • Provide analgesia as appropriate, document efficacy after each dose. • Prevent pulling and jarring of the ventilator tubing and endotracheal or tracheostomy tube. • Provide meticulous oral care q1–2h with oropharynx suctioning and application of mouth moisturizer as needed; teeth brushing scheduled at least three times daily; antimicrobial rinse twice daily; oral assessment at least daily. • Administer sedation as indicated.
OUTCOMES INTERVENTIONSPsychosocial • Encourage patient to move in bed and attempt to meetPatient participates in self-care own basic comfort/hygiene needs independently.and • Establish a daily schedule for bathing, time out of bed,decision making related to own treatments, and so forth with patient input.ADLs • Provide a means for patient to write notes and use(eg, turning, bathing). Patient visual tools to facilitate communication.communicates with healthcare • Encourage visitor conversations with patient in normalproviders and visitors. tone of voice and subject matter. • Teach visitors to assist with range-of-motion and other simple care delivery tasks, to facilitate normal patterns of interaction.Teaching/Discharge Planning • Provide explanations to patient and family regarding:Patient cooperates with and • Rationale for use of mechanical ventilationindicates • Procedures such as suctioning, airway care, chestunderstanding of need for physiotherapymechanical ventilation. • Plan for and progress toward weaning and extubationPotential discharge needs are • Initiate early social work to screen for needs, resources,assessed. and support systems.
Abnormal Arterial Blood Gases in the Mechanically Ventilated PatientAbnormality Possible Causes ActionHypoxemia Patient-related Suction. Increase FiO2. Secretions Evaluate patient and chest Increase in disease pathology radiograph. Positive fluid balance Evaluate intake and output.Hypocapnia Patient-related Evaluate ABGs and patient. Hypoxia Evaluate for wean potential. Increased lung compliance’ Decrease respiratory rate, Increased minute ventilation tidal volume, or minute Ventilator-related ventilation. Incorrect ventilator settingsHypercapnia Patient-related Increase respiratory rate or Sedation tidal volume settings. Fatigue Increase respiratory rate, tidal Decreased minute ventilation volume, or minute Ventilator-related ventilation. Incorrect ventilator settings
Troubleshooting the VentilatorProblem Possible Causes ActionVolume or low Patient-related Reconnect STAT.pressure Patient disconnected from •Auscultate neck for possible leakalarm Ventilator Loss of delivered around endotracheal tube cuff. tidal volume Decrease in •Review chest film for endotracheal patient-initiated breaths tube placement—may be too high. Increased compliance •Check for loss of tidal volume through Ventilator-related chest tube. Leaks •Evaluate patient for cause: check respiratory rate, ABGs, last sedation. •Evaluate patient for clearing of secretions or relief of bronchospasms. •Check all tubing for loss of connection, starting at patient and moving toward humidifier. •Check for change in ventilator settings. (Note: If problem is not corrected STAT, use MRB until ventilator problem is corrected.)
Troubleshooting the VentilatorProblem Possible Causes ActionHigh-pressure Patient-related •Suction patient.or Decreased compliance •Administer inhaled β-agonists.peak-pressure Decreased dynamic •If sudden, evaluate for pneumothorax.alarm Compliance •Evaluate chest film for endotracheal tube Decreased static displacement in right mainstem bronchus. compliance Ventilator-related •Sedate if patient is bucking the ventilator Tubing kinked or biting the endotracheal tube. Tubing filled with water •Evaluate ABGs for hypoxia, fluids for Patient–ventilator overload, chest film for atelectasis. asynchrony •Auscultate breath sounds. •Check tubing. •Empty water into a receptacle. •Recheck sensitivity and peak flow settings. •Provide sedation/paralysis if indicated.
Troubleshooting the VentilatorProblem Possible Causes ActionHeater alarm Adding cold water to Wait. humidifier. Reset. Altered setting Redirect airflow. Cold air blowing on humidifier
Complications of Mechanical VentilationAirway• Aspiration• Ventilator-acquired pneumonia (VAP)• Complications of endotracheal intubation or tracheostomyMechanical• Lung injury (eg, barotrauma, volutrauma)• Atelectasis (resulting from hypoventilation)• Hypocapnia and respiratory alkalosis (resulting from hyperventilation)• Hyperthermia (resulting from overheated inspired air)• Hypercapnia and respiratory acidosis (hypoventilation)Physiological• Depressed cardiac function, resulting in hypotension• Fluid overload• Respiratory muscle weakness and atrophy• Complications of immobility• Gastrointestinal problems (eg, paralytic ileus, stress ulcers, distention)
Nursing Action RationaleObtain baseline samples for blood gas Baseline measurements serve as a guide indeterminations (pH, PaO2, Paco2, HCO3-) and determining progress of therapy.chest X-rayGive a brief explanation to the patient Emphasize that mechanical ventilation is a temporary measure. The patient should be prepared psychologically for weaning at the time the ventilator is first used.Establish the airway by means of a cuffed A closed system between the ventilator andendotracheal or tracheostomy tube patient lower airway is necessary for positive pressure ventilationPrepare the ventilator. (Respiratory therapistdoes this in many facilities.)Set up desired circuitry.Connect oxygen and compressed air sourceTurn on power.
Set tidal volume (usually 5-7 mL/kg body Adjusted according to pH and Paco2weight) or peak pressure.Set oxygen concentration Adjusted according to PaO2Set ventilator sensitivitySet rate at 12-14 breaths/minute (variable). This setting approximates normal ventilation. These machines settings are subject to change according to the patients condition and response, and the ventilator type being used.Adjust flow rate (velocity of gas flow during The slower the flow, the lower the peakinspiration). Usually set at 40-60 L/minute. airway pressure will result from set volumeDepends on rate and tidal volume. Set to delivery. This results in lower intrathoracicavoid inverse inspiratory:expiratory (I:E) ratio. pressure and less impedance of venousUsual I:E ratio is 1:2. return. However, a flow that is too low for the rate selected may result in inverse inspiratory: expiratory ratios
Select mode of ventilation.Check machine functionâ€”measure tidal Ensures safe functionvolume, rate, I:E ratio, analyze oxygen, checkall alarms.Couple the patients airway to the ventilator Make sure all connections are secure. Prevent ventilator tubing from â€œpullingâ€• on artificial airway, possibly resulting in tube dislodgement or tracheal damage.Assess patient for adequate chest movement Ensures proper function of equipmentand rate. Note peak airway pressure andPEEP. Adjust gas flow if necessary to providesafe I:E ratio.Set airway pressure alarms according topatients baselineHigh pressure alarm High airway pressure or â€œpop offâ€• pressure is set at 10-15 cm H2O above peak airway pressure. An alarm sounds if airway pressure selected is exceeded. Alarm activation indicates decreased lung compliance (worsening pulmonary disease); decreased lung volume (such as pneumothorax, tension pneumothorax, hemothorax, pleural effusion); increased airway resistance (secretions,
Low pressure alarm Low airway pressure alarm set at 5-10 cm H2O below peak airway pressure. Alarm activation indicates inability to build up airway pressure because of disconnection or leak, or inability to build up airway pressure because of insufficient gas flow to meet the patients inspiratory needs.Assess frequently for change in respiratorystatus by way of ABGs, pulse oximetry,spontaneous rate, use of accessory muscles,breath sounds, and vital signs. Other means ofassessing are through the use of exhaledcarbon dioxide (see â€œCapnography,â€•â€œMixed venous oxygen saturationmonitoring,â€•). If change is noted, notifyappropriate personnelMonitor and troubleshoot alarm conditions. Priority is ventilation and oxygenation of theEnsure appropriate ventilation at all times. patient. In alarm conditions that cannot be immediately corrected, disconnect the patient from mechanical ventilation and manually ventilate with resuscitation bag.
Positioning For patients on long-term ventilation, thisTurn patient from side to side every 2 hours, may result in sleep deprivation. Follow aor more frequently if possible. Consider turning schedule best suited to a particularcontinuous lateral rotational therapy (CLRT) as patients condition. Reposition may improveearly intervention to improve outcome. secretion clearance and reduce atelectasisLateral turns are desirable; from rightsemiprone to left semiprone.Sit the patient upright at regular intervals if Upright posture increases lung compliancepossibleCarry out passive range-of-motion exercises of To prevent contracturesall extremities for patients unable to do so.Assess for need of suctioning at least every 2 Patients with artificial airways on mechanicalhours ventilation are unable to clear secretions on their own. Suctioning may help to clear secretions and stimulate the cough reflex.Assess breath sounds every 2 hours:Listen with stethoscope ot the chest in all Auscultation of the chest is a means oflobes bilaterally. assessing airway patency and ventilatory distribution. It also confirms the proper
Humidification. Humidity may improve secretion mobilizationAssess airway pressures at frequent intervals Monitor for changes in compliance, or onset of conditions that may cause airway pressure to increase or decreaseMonitor cardiovascular function. Assess forabnormalities.Monitor for pulmonary infection This technique allows for the earliest detection of infection or change in infecting organisms in the tracheobronchial tree.Evaluate need for sedation or muscle Sedatives may be prescribed to decreaserelaxants anxiety, or to relax the patient to prevent â€œcompetingâ€• with the ventilator. At times, pharmacologically induced paralysis may be necessary to permit mechanical ventilationReport intake and output precisely and obtainan accurate daily weight to monitor fluidbalanceMonitor nutritional status
Test all stools and gastric drainage for occult Stress may cause some patients requiringblood mechanical ventilation to develop GI bleeding.Measure abdominal girth daily. Abdominal distention occurs frequently with respiratory failure and further hinders respiration by elevation of the diaphragm. Measurement of abdominal girth provides objective assessment of the degree of distention.Maintain a flow sheet to record ventilation Establishes means of assessing effectivenesspatterns, ABGs, venous chemical and progress of treatment.determinations, hemoglobin and hematocrit,status of fluid balance, weight, andassessment of the patients condition. Notifyappropriate personnel of changes in thepatients condition.Change ventilator circuitry every 24 hours; Prevents contamination of lower airwaysassess ventilators function every 4 hours ormore frequently if problem occurs.