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Ventilated patient nursing care requires a lot of observation, preparation and monitoring. This is not just specific to monitor readings…the patient needs to be evaluated as a whole in conjunction to the readings being provided.

Safety Checks

When working in a critical care setting, at the beginning of each shift:

1. check that the manual ventilation bag is connected to oxygen supply
2. check that the suctioning equipment is in good working order
3. check for availability of equipment and drugs required for re-intubation and resuscitation
4. check that the ventilator settings are the same as documented and mentioned in handover

Whenever you move or turn your patient:

1. check that the endotracheal tube or the tracheostomy tube are secure
2. check that any other catheters/lines are in place and still secure

Constant safety checks:

1. monitor the patient’s haemodynamic stability
2. monitor the patient’s respiratory stability
3. ensure that alarms are set sensibly
4. DO NOT IGNORE ALARMS!

Airway Management of the Ventilated Patient

Ventilated patient nursing care includes:

• care of the endotracheal tube or tracheostomy
• humidification
• suctioning
• cuff pressure management
• patient communication
• patient swallowing ability
• weaning from mechanical ventilation

Ventilated Patient Monitoring

Ventilated patient monitoring is crucial, especially since deterioration can happen fast. Monitoring requirements include monitoring the patient’s:

• haemodynamic stability
• pulse oxymetry
• capnography
• level of consciousness
• pain and agitation

Sedation and Analgesia

A ventilated patient can benefit from sedation and/or analgesia since these:

• provide the patient with comfort and tube tolerance
• reduce oxygen consumption by promoting patient-ventilator synchronisation whilst reducing dyspnoea and anxiety
• reduce the risk of complications such as self-extubation and laryngeal damage
• reduce the need of muscle relaxants

NOTE: Muscle relaxants may still be necessary in patients with head injuries and/or with excessive airway pressure; when administering muscle relaxants ensure that the patient is fully sedated.

sedation disadvantages

• vasodilation – patient may need IV fluids and inotropes eg. norepinephrine, epinephrine, and vasopressin
• sedative accumulation – sedatives with long half-life are not ideal for patients with hepatic or renal failure
• over-sedation – prolongs ventilation period and lengthens the patient’s stay in the critical care setting

NOTE: sedation breaks may lead to shorter duration of mechanical ventilation and shorter stay in the critical care setting.

NOTE: sedation scores such as the Ramsay Sedation Scale, the Richmond Agitation-Sedation Scale (RASS), and the Nursing Instrument for the Communication of Sedation (NICS) can help prevent over-sedation.

Analgosedation

Patient Comfort Guidance

E-CASH – early comfort with the use of analgesia, minimum sedation and maximum care.

ABCDEF BUNDLE:

• A = ASSESS, prevent, and manage pain
• B = BOTH Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT)
• C = CHOICE of analgesia and sedation
• D = DELIRIUM – assess, prevent and manage
• E = EARLY mobility and exercise
• F = FAMILY engagement and empowerment

Ventilated Patient Personal Care

Mouth Care

• clean patient’s teeth using a small soft toothbrush and toothpaste twice daily
• use antiseptic liquid or gel between brushing for oral cleansing and moisturising; this helps prevent plaque formation whilst reducing oral colonisation of Gram-negative bacteria and resulting respiratory infections
• provide frequent oropharyngeal suctioning for the hypersalivating patient due to endotracheal tube use; this reduces the risk of central line contamination and risk of micro-aspiration

Eye Care

• provide artificial eye lubricant (methyl cellulose) – a patient on sedation loses the blink reflex, making the eyes exposed to corneal drying, infection, abrasion and dust
• apply eye pads and/or tape if required
• assess regularly for infection and conjunctival oedema

Nutritional Care

While the patient is Nil-By-Mouth, a nasogastric tube is usually used so that abdominal distension is prevented, since it hinders ventilation.

• ensure that the patient is started on enteral nutrition early since this promotes gut integrity whilst reducing GI complications; it also helps provide the patient with caloric and protein required for mechanical ventilation, prevents muscle atrophy, as well as helps during the weaning process
• prop the patient up in a semi-raised position to prevent aspiration; aspirate the patient’s stomach regularly to assess absorption
• assess for need of a PEG or TPN
• stress ulcer prophylaxis may be prescribed

Elimination & Related Care

• document patient intake and output on proper charting sheets to ensure patient fluid and electrolyte balance; document any abnormal stools
• constipation may result from use of drugs, diet changes and immobility, which may cause abdominal distension; to avoid problems with diaphragmatic and ventilatory capacity consider using glycerin suppositories and enemas
• diarrhoea may result from antibiotic resistance and enteral feed intolerance; take stool specimens for culture and sensitivity testing and Cl. difficile, apply barrier cream to prevent moisture lesion formation, and ensure fluid and electrolyte balance are maintained

Psychosocial Care

• assist patient to use alternate means of communication since this is a common trigger for patient frustration
• provide constant orientation and reassurance
• provide health literacy to the patient’s family in simple terms free from medical jargon
• involve relatives in patient care – encourage touch and patient reassurance, communication and orientation, and lip care

Patient positioning

• ensure that no lines, wires and catheters are left under the patient
• provide regular position changes for pressure relief and movement of secretions; this also helps provide a conscious patient with a different perspective of surroundings
• splints, passive and active ROM (range of motion) exercises
• ensure patient is seen by physiotherapist and that chest physio in the form of percussion, vibration, and postural drainage is provided (unless contraindicated as with neurological patients)
• whenever possible help the patient into prone position since this optimises alveolar recruitment by expanding the dorsal aspect of the lungs, and improves oxygenation and survival in ARDS (acute respiratory distress syndrome) patients

NOTE: with prone positioning, caution needs to be exerted: ensure an adequate amount of personnel are available to reposition patient, ensure that the patient’s airway is protected at all times, ensure that the ETT, IV lines and tubes are all secure, ensure adequate pressure area care, and provision of mouth and eye care as well as suctioning as required.

The HOTSPUD Ventilator Care Bundle

1. Head of bed elevated 30-45 degrees
2. Oral care performed frequently
3. Turn patient from side to back to side every 2 hours
4. Sedation vacation – adjust sedation so as to wake patient up once every 24 hours
5. Peptic Ulcer prophylaxis to be administered to high risk patients
6. Deep vein thrombosis prophylaxis in the form of drugs or leg compression

Other Ventilation Strategies

ECMO – Extra-Corporeal membrane oxygenation

• blood oxygenation outside of the body
• allows lung rest without exposure to high pressure oxygen levels

Permissive Hypercapnia

• tolerate higher carbon dioxide levels to provide protection to the lung from barotrauma

High Frequency Ventilation HFV

• very high frequency ventilation of 60-2000breaths/min
• very low tidal volume of 1-5ml/kg

Preventing Ventilator-Associated Pneumonia (VAP)

• avoid intubation unless absolutely necessary
• extubate as soon as possible
• perform meticulous hand washing and gloving
• ensure correct endotracheal tube cuff pressure is maintained
• use HME (heat and moisture exchanger filters)
• remove any condensation formation from ventilator circuits
• avoid unplanned extubation
• perform endotracheal and supraglottic suctioning

High Flow Nasal Cannula

High Flow Nasal Cannula is a light cannula with soft pliable prongs, warmed and humidified, with a Flow of up to 60L/min and FiO2 up to 100%. The HFNC:

• improves oxygenation
• reduces breathing work
• provides a continuous flow of fresh gas at high flow rates, replacing the patient’s pharyngeal dead space
• washes out the patient’s re-breathes of carbon dioxide and replaces it with oxygen

Respiratory Support Progression

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