Monitoring The Ventilated Patient : Implication of Nursing Care

Respiratory_therapist
–    General monitoring of the patient on continues ventilatory support include:
1- Patient Assessment.
2- Monitoring of ventilator setting.
3- ABGs
4- Lab. Studies.
5- Radiological studies.

1- Patient Assessment
A- Neurological status:
–    level of consciousness, anxiety, pain?
–    Is the patient fighting the ventilator?
–    Evaluate nonverbal communications is meeting needs

B- Respiratory status:
–    Evaluate airway patency, RR and pattern of breathing, Endotracheal tube for leak from the balloon .
–    Assess bilateral breathing sounds & chest movement

C- Cardiovascular status:
–    Assess  HR and sounds, peripheral pulses , neck veins distention, arterial pressure.

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D- Renal status:
–    Assess fluid and electrolyte balances, daily weight, intake and output.

E- Gastrointestinal status:
–    NG tube for gastric decompression.
–    Monitor gastric secretion for bleeding (stress ulcer result M.V.)
–    Patient under M.V.  need energy support to meet demands.

2- Monitoring of ventilator setting
–    Minute volume (ventilation)
–    RR (machine and patient)
–    Oxygen concentration by ABGs monitoring
–    I:E ratio usually I:E= 1:2
–    Airway pressure E.x.:
–    If ↑there may be secretions may be or tube kinking.
–    if ↓ there may be disconnection or leak
–    Alarm system (should never be turned off)
–    Humidity

3- ABGs
–    The pH and PaCO2 are correlated with minute ventilation.
–    PaO2 and O2 saturation correlated with FiO2
–    ABGs should be checked 30 minute after changes in ventilator setting.
4- Lab. studies
–    Hematological study; Hb, Hct, CBC.
–    Blood chemistry ; serum electrolyte; BUN, Creatinin, Glucose.
Nursing Care Of The Mechanical Ventilated Patient
»    Maintain patent airway by:
»    Bronchial hygiene (suctioning ETT):
»    Assess for S&S of complications
»    Carry out medical management
»    Document in nursing notes
1. Maintain patent airway by:
A.    Proper ETT placement, because it may slip into right main bronchus.
B.    Taping and fixation by special tape and plaster to defined level.
C.    Inflate ETT balloon (cuff), over inflation may cause tracheal tissue necrosis, or it may herniate and obstruct the tube (partially or completely)
2. Bronchial hygiene (suctioning ETT):
–    Pre-oxygenate the patient with 100% oxygen and manual hyperinflation. Continuously monitor the patient  in both Pulse oxymeter and Monitor.
–    Suction the trachea:
–    Use careful sterile technique and a suction catheter less than or equal to one half the diameter of the tracheal tube
–    Insert the catheter without  suction past the tracheal tube until obstruction is met, then withdraw slightly.
–    Withdraw the catheter using intermittent suction and by rotating the catheter
–    Limit suction to 10 to 15 seconds and to 80 to 120 mm Hg suction pressure .
–    Limit interruption of ventilation to 20 second
–    Re-oxygenate the patient with 100% oxygen delivered by manual inflations, and wait until vital signs have returned to normal .
–    Repeat steps 1 through 3 until the secretions are cleaned.
–    Suction the mouth and nose, and dispose of the suction catheter .

3. Assess for signs and symptoms of complications
–    E.g. barotraumas (pnuemothorax) manifested by :
–    Asymmetrical chest movement, diminished breath sounds on affected side, tachycarida, cyanosis, decrease CO2 and hypotention, accumulation of air under the skin,  displacement of trachea.
4. Carry out medical management
–    Arterial lines and ABGs
–    Administration of fluids
–    Bronchodilators
–    Sedatives
–    Antibiotics and other supportive measures and drugs.
5. Document in nursing notes
–    Mode of respiration (IMV, SIMV,—– )
–    Tidal volume , RR ( patient and machine )
–    Fio2
–    O2 saturation
–    Airway pressure
–    Minute volume
–    I: E ratio .

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