Republic of the Philippines Mariano Marcos State University College of Health Sciences DEPARTMENT OF NURSING City of Batac

Telefax: +6377 7923882; E-mail address: mmsu_chs_2009@yahoo.com Website: www.mmsu.edu.ph

Mechanical Ventilator, Intubation & Drug Study with Titrations

Prepared by: ERLYN B. Agullana Jeselmark Kevin P. Lived VANESSA M. PAGUIRIGAN Janel loyz t. Raquepo SAMUEL T. RUBIO BS nursing IV - D

Submitted to: Mr. ELMER A. SANTOS, RN., MAN. Clinical Instructor

January 9, 2012

Medical Procedures in the Intensive Care Unit

Mechanical Ventilator
Definition: It is a positive- or negative-pressure breathing device that supports ventilation and oxygenation. Purpose: It is done to deliver oxygen, eliminate carbon dioxide, and to ease the work of breathing. It is only considered when there are clinical or laboratory signs that the patient cannot maintain an airway or adequate oxygenation or ventilation Nursing Responsibilities: 1. Verify the physicians order such as the settings and adjustments. To determine the indication of the procedure and to avoid error since the nurse is the patients advocate; and also to prevent complications to occur like lung collapse and lung damage. 2. Determine the indication of the procedure based from patients condition. To be able to note for the appropriate ventilator to be used and to be able to meet the needs required by the patient. 3. Assess/monitor the ventilator properly (Type of ventilator, controlling mode, tidal volume and rate settings, FiO2 setting, inspiratory pressure reached and pressure limit, sensitivity, inspiratory-expiratory ratio, minute volume, sigh settings, tubing defects, humidification and alarms). The ventilator needs to be assessed to make sure that it is functioning properly and that the settings are appropriate (although it is the responsibility

of the respiratory therapist), it is the responsible of the nurse to the patient the need to evaluate how the ventilator affects the patients overall status. 4. Explain to the patient (whether conscious/unconscious) as well as to the significant others the indication of the procedure. To allay anxiety on either part of the patient and significant others and also to respect their rights to information and medical interventions. 5. Perform the procedure aseptically, provide frequent mouth care and optimize nutritional status. To prevent infection. 6. Adjust the mechanical ventilator based from the physicians order and should be in synchronized with the breaths of the patient. Proper adjustment of the ventilator promotes comfort on the part of the patient and also to attain satisfactory blood gas values and lessen cardiovascular compromise. 7. Record necessary data (settings, etc.). Documentation is a part of the legal responsibilities of a nurse. It is also important to perform accurate documentation since this will be used as basis for continuity of care. 8. Place patient comfortably in a semi-upright position depending on the condition. Proper positioning promotes oxygenation and release of carbon dioxide hence potentiating the purpose of the ventilator. 9. Assess patients lung sounds and oxygen saturation as well as the ABG results. To evaluate the effectiveness of the ventilator and how well the patient responds to therapy. 10. Always keep the manual resuscitation bag on reach. Whenever the ventilator system malfunctions and the problem cannot be identified and corrected immediately, the manual resuscitation bag is used to ventilate the patient until problem is resolved.

11. Assess for adequate volume status by measuring heart rate, blood pressure, central venous pressure, pulmonary capillary wedge pressure, and urine output; and notify the physician if values are abnormal. Abnormality on the result of the previously stated assessment means the patient is now having cardiovascular compromise. 12. Perform careful assessments in determining whether the patient is ready to be removed from mechanical ventilation. Assess patient for weaning criteria such as vital capacity of 10-15 mL/kg; maximum inspiratory pressure (MIP) of at least -20cmH20; tidal volume of 7-9mL/kg; minute ventilation of 6L/min; and rapid shallow breathing index of below 100bpm/L; PaO2 of >60mmHg with FiO2 less than 40%. Respiratory weaning should be done to gradually lessen the patients dependence to mechanical ventilator; hence promoting normal patients respiratory response.

Intubation
Definition: It refers to the insertion or placement of a tube into a body structure or passageway. It involves passing an endotracheal tube through the mouth or nose into the trachea. Purpose: It provides a patent airway when the patient is having respiratory distress that cannot be treated with simpler methods. Also to provide airway for patients who cannot maintain an adequate airway on their own, for patients needing mechanical ventilation, and for suctioning secretions from the pulmonary tree. Nursing Responsibilities: 1. Determine the need for intubation. As a part of the nurses responsibility is patient advocacy. 2. Explain to the patient as well as the significant others the indication of intubation. To allay anxiety and to respect the rights of the patient and significant others to information and medical interventions. 3. Prepare all the materials needed such as:  Laryngoscopes. Check light regularly and before use and have spare blades, lights and batteries within reach to facilitate accuracy in providing patent airway.  Manual resuscitation bag. This is essential to pump ample volume of oxygen just after intubation to lessen the distress.  Endotracheal tube with appropriate size. Inflate the tube before inserting it to ensure there are no leaks.

 Gloves. It is needed to protect the health care professional and the patient from acquiring infection.  A rigid oral suctioning catheter. This is important to remove excessive secretions in the mouth that hinders the intubation.  Water-soluble lubrication. To decrease possibility of injuring the mucusa and to facilitate ease and accuracy in intubation.  10ml syringe, artery forceps, tape. These materials are useful to keep the intubation intact and to prevent it from accidental removal.  Stethoscope. This is used to determine whether the tube is accurately placed or not.  Checked and working ventilator. It is vital to prepare a checked and working ventilator on bedside to be able to address the respiratory needs of the client emergently.  Resuscitation equipment immediately available in case complications occur. 4. Ensure that the patient is attached to adequate monitoring equipment - ECG, arterial line and saturation probe - and suction and oxygen should be checked and available to evaluate patients response. The patient should have patent intravenous access since this will be utilized for sedatives or other drugs useful to lessen the patients discomfort. 5. Discuss to the patient together with the significant others about what is about to happen, and they should then be pre-oxygenated. Intubation should take no longer than 30 seconds and should be preceded by ventilation with a high concentration of oxygen, ideally at least 85%, for a minimum of 15 seconds.

6. Ensure they stay calm they have a hand-held facial mask over the nose and mouth, medical/nursing staff standing behind them issuing instructions, and a change of position to facilitate the process is needed. 7. A small pad/pillow should be placed under the occiput. Extend the head at the atlantooccipital joint, which aligns the oral, pharyngeal, and laryngeal axis so that the passage from the lips to the glottic opening is virtually a straight line and the patient adopts the classic 'sniffing the morning air' position. 8. Indicate when the patient last ate, and whether a nasogastric tube is in situ, when it was aspirated and what volume of gastric contents the patient has produced. 9. Do not apply cricoid pressure to a vomiting patient, as this can cause damage to the esophagus. 10. Calmly describe the vital-signs status of the patient regularly as the anaesthetist will be focused on the airway, not the monitor. Be prepared to pass the ET tube and other equipment to the person intubating. Be alert all the time as complications are common. 11. The patient's chest should be observed for equal expansion and auscultation performed at the mid-axillary line. Be suspicious if only one side of the chest expands, as this may indicate that the tube has been pushed in too far. 12. The tube should be secured properly, the patient attached to an appropriate ventilator and a check X-ray ordered. A high concentration of oxygen should continue and arterial blood gases should be taken. Appropriate humidification is required, as the tube bypasses the upper airway - responsible for warming, moistening and filtering inhaled air. Finally, the patient should be cared for on a one-to-one basis and closely monitored.

13. Perform suctioning as needed. To decrease possibility of aspiration pneumonia, hence facilitating a clear and patent airway. 14. Administer sedatives as prescribed. To lessen the discomforts as experienced by the patient. 15. Document relevant data. To reduce foreseeable errors that may occur and to facilitate continuity of care.