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By: Ms. Shanta Peter
Caring patient on
Mechanical Ventilator
1
Indications for Mech. Vent
• PaO2 <50 mm Hg with FiO2 > 0.60
• PaO2<50mmHg with pH <7.25
• Vital Capacity <2 times TV
• Ne...
• Pt has continuous ↓in oxygenation (PaO2 )
• Increase in PaCO2
• Persistent acidosis ( Decreased pH)
• Abdominal/ Thorasi...
Mechanical ventilator … Nursing
Interventions
Unique technical and
interpersonal skill
Assess patient first
then ventilato...
GOAL
• Patient will be supported on mechanical
ventilation without complication- then weaned ,
extubated . The complicatio...
Two important Nsg interventions while caring
a patent on ventilator are :
Interpretation of ABG
&
Pulmonary Auscultation
6
General Nursing Interventions
• Assess for decreased cardiac output and
administer appropriate Nursing Care
• Monitor for ...
Nsg Intervention .…
• Monitor for barotrauma – tension pneumothorax
• Assess ventilator checking every 4 hrs
• Auscultate ...
Gas Exchange
• Judicious administration of analgesics
without suppressing the respiratory
drive
• Frequent re-positioning ...
Promoting Effective Airway Clearance
Positive pressure increase secretion
• Auscultate lungs Q2-4 hrs
• Suctioning – physi...
Preventing trauma and infection
• Maintain ET /tracheostomy tube – position
ventilator --- no pulling on tube
• Monitor cu...
Promote optimal level of mobility
• When stable -after weaning -- assist him to
sit up in chair
• Mobility of muscle activ...
Promote optimal Communication
• Evaluate his abilities—Conscious?- can
communicate ? he node or move hand ?
• Can he write...
Promoting coping ability
• Encourage family to communicate – and
verbalize fears
• Explain procedures every time to patien...
Nurse should assess /monitor
the ventilator
• Check type of ventilator—Volume cycled, Pres
Cycled, -ve pres
• Controlling ...
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...
BUCKING the Ventilator
Patient struggles out of phase of ventilator
• Patient try to breathe out during the
ventilators in...
Bucking the ventilator …contd
Correct these problems before giving
paralyzing agents …..otherwise the underlying
problem w...
ALARMS……Causes
High pressure alarms
• Increased secretions in airway
• Decreased A Way size due to wheezing or
bronchospas...
COMPLICATIONS
• Hypotension caused by +ve pressure – which increase
intra thoracic pressure and inhibit blood return to
he...
WEANING …………….
The process of going OFF from ventilator dependence
to spontaneous breathing
3 stages………pt gradually weaned...
Criteria for weaning
The ventilator capacities include—
Ability to generate Vital Capacity of 10-15 ml/kg
(The minimum req...
Patient Preparation
must consider patient as a whole
Consider factors that--
• impair the deliver the O2
• impair eliminat...
Methods of WEANING
• There is NO BEST method –
success depends on –
• Adequate patient preparation ,
• Available equipment...
Traditional method:
• T-Piece trials( one or more)
Used with short vent assistance ( <2 days) and pt is awake,
alert and b...
When on T-piece – observe
for signs & Symptoms of
Hypoxia, increasing fatigue, manifested as:
• Tachy cardia- PVCs, Ischem...
If tolerating T –piece trial……….ABG – 20mts
after spont. breathing at a constant FiO2
( Alveolar-Arterial equalization occ...
SIMV – Method
In pts who – satisfies all criteria for weaning but cannot
have spontaneous breathing for long time
SIMV for...
Successful weaning is supplemented by
intensive pulm care like---
• O2 therapy
• ABG evaluation
• Pulse oxymetry
• Broncho...
Weaning from Tube
ET/TT removed only if following criterion met
• Spontaneous ventilation is adequate
• Pharyngeal and lar...
Weaning from O2
• Pt successfully weaned---- and has adequate
respiratory function – weaned from O2
FIO2 is gradually redu...
• Long tern ventilated pt need aggressive-
judicious NUTRITIONAL support as
Resp. musculature( Diaphragm & intercostal
mus...
What you know about
OXYGEN supplies
& accessories ?
33
34
Through bulk liquid O2 system which store O2 @-
34C (-29F) and deliver it as gas through wall
outlets
Gas Cylinders
Com...
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--2...
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 du...
GOAL:
• Patient will be supported on mechanical
ventilation without complication- then
weaned , extubated .
• The complica...
Thank youAll
38
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Caring patient on Mechanical Ventilator

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. 1. By: Ms. Shanta Peter Caring patient on Mechanical Ventilator 1
  2. 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. 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. 4. Mechanical ventilator … Nursing Interventions Unique technical and interpersonal skill Assess patient first then ventilator 4
  5. 5. GOAL • Patient will be supported on mechanical ventilation without complication- then weaned , extubated . The complications will be detected, treated timely 5
  6. 6. Two important Nsg interventions while caring a patent on ventilator are : Interpretation of ABG & Pulmonary Auscultation 6
  7. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 33. What you know about OXYGEN supplies & accessories ? 33
  34. 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. 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. 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. 37. GOAL: • Patient will be supported on mechanical ventilation without complication- then weaned , extubated . • The complications will be detected , treated timely 37
  38. 38. Thank youAll 38

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