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Critical Care Exam 1 Guide
Nursing Assessments
Acute respiratory failure
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Diagnostic Tests
o ABGs, Chest x-rays, CT, pulmonary function tests, end tidal CO2 monitoring, bronchoscopy.
Assessments
o Lung sounds, work of breathing, use of accessory muscles, chest expansion, nasal flaring,
respiratory rate, pulse ox
Interventions
o Ineffective airway clearance reposition patient
o ARF
Causes: pulmonary edema, atelectasis, pneumonia, COPD, asthma, ARDS, thoracic,
spinal or head injuries, drug overdose, neuromuscular disorders
Type 1 - hypoxemic or oxygenation failure
• PAO2 less th
• an 60 MMHG
o Normal PaO2 = 80 - 100
• Hypoventilation
o Hyperventilation causes further issues when trying to correct this
• Intrapulmonary shunting
o Blood did not get oxygenated and dispersed to rest of body system
o Blood that is shunted from the right side of the heart to the left
without oxygenation.
o Based on rate ventilation and perfusion: Rate of ventilation= rate of
perfusion; ratio of VQ = 1
o Based on amount of ventilation and perfusion:
Normal ventilation (V) IS 4 L/MIN
Normal perfusion (Q) IS 5L/Min
Normal V/Q Ratio IS 4/5 or 0.8
VQ scan patient must lie for 30 minutes
o Tissue hypoxia anaerobic metabolism and lactic acidosis
o Normal Cardiac output
600 – 1000 ML/MIN of O2
Low cardiac output decrease O2 blood to tissues anaerobic
metabolism production of lactic acid metabolic acidosis
Type 2 - hypercapnic or ventilator failure
• PACO2 > 50 MM HG
• Increase in PaCO2 (hypercapnia) due to decrease O2 in body and CO2 can be
blown off
• Increase in ventilation excess CO2 blown off (hypocapnia)
• VQ mismatch not 1:1
Assessment of respirator failure: most common hypoxemia restlessness
Medical management: O2, bronchodilators, corticosteroids, ventilators, transfusion,
nutritional support, hemodynamic monitoring
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HGB 12- 16
• Anemic is less than 8 HGB
o Respiratory failure causes
Failure to ventilate
Failure to oxygenate
Failure to protect airway
Acute Respiratory Distress Syndrome (ARDS)
• Noncardiogenic pulmonary edema- pulmonary edema not caused by a cardiac problem.
• Diagnostic criteria
o 1. PaO2/FiO2(decimal) ratio of less than 200 – PaO2 divided by Fi02 … 100 divided 21 =
Optimal Ratio 476.19
***Decreasing PA02 levels despite increased FIO2 administration
o 2. Bilateral infiltrates not explained by something else. (Normally air should be black, you will
see white puffy stuff all over if you have this)
• Risk Factors. 4 Factors
o Sepsis #1***
o Pneumonia
o Trauma
o Aspiration of Gastric contents
• Pathophysiology
o Basic underlying patho: damage to type II pneumocyte, which produces surfactant
o 4 steps
1. Injury to the lung that stimulates the inflammatory response (either direct or indirect)
with stimulates inflammatory response. Inflammatory cells and their mediators damage
the alveolocapillary membrane.
2. Onset of pulmonary edema (blood cell, cell debris, stuff)
3. Alveoli start to collapse. Production of surfactant stop and alveoli collapse. Lungs
become less compliant.
4.Lungs become stiff and noncompliant. Lung becomes fibrotic. Severe gas exchange
impairment.
• Diagnostic Tests
o Chest x-ray
• Symptoms or ARDS:
o Dyspnea and tachypnea and hypoxemia, that does not improve with supplemental oxygen
therapy.
o Elevated PACO2 > 50 MM of HG
o Decreased PAO2 < 60 MM of HG
o V/Q mismatch
o O2 Satureation < 90%
o Hyperventilation with normal breath sounds
o Respiratory alkalosis
o Increased temperature and pulse
o Worsening chest x-rays that progress to “white out”
o Increased PIP on ventilation
o Eventual severe hypoxemia not improved with O2 therapy
o Late stages -> Eventually will hypoventilate -> respiratory acidosis
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Treatment of ARDS
o Treat the cause, more supportive care
o Oxygenation and ventilation**KEY to treating ARDS
Positive end-expiratory pressure (PEEP) – high amounts of PEEP 10-15cm of peep.
Possible non-traditional modes of ventilation – oscillator or nvrp
Decrease Oxygen consumption
o Comfort
Sedation
Pain relief
Neuromuscular blockade
o Positioning
Prone positioning
• Better profusion to posterior part of the lung. Takes weight of heart off of the
lungs
• Protect airway! Face down.. In regular bed patient will be with head on side.
• Skin integrity – different pressure points (hips, knees)
Continuous lateral rotation therapy
Complications: DIC, long term pulmonary affect, organ failure, death
o Fluid and electrolyte balance
o Adequate nutrition
o Psychosocial support – more for family
o Prevention of complications
Thrombus or embolus formation, DIC, death, Organ failure, pulmonary affects
Acute Respiratory Failure as a result of Underlying Disease
o Several conditions both acute and chronic can result in Acute Respiratory Failure
COPD
Asthma Exacerbation
Pneumonia - All types
Pulmonary Embolism pulmonary angiogram is a definitive diagnosis
o Treatment of ARF in Chronic Diseases (not really going to study this)
Treat the underlying cause
• COPD - Bronchodilators, corticosteroids, antibiotics (infection)
• Asthma - IV corticosteroids, bronchodilators
• Pneumonia - Antibiotics, fluids
• Pulmonary Embolism - DVT prophylaxis, thrombolytics, heparin, vena cava filter
Maintain Oxygenation - Administer oxygen, ventilate if needed, minimize demands
Ventilation
• Indications for ventilation: To support patient’s respiratory system until the cause of the respiratory
failure has been treated. This is a temporary treatment. Patients are not meant to be on ventilator forever.
• Reasons to be Ventilated:
o Hypoxemia - PaO2 ≤ 60 mm Hg on FiO2 > .50
o Hypercapnea - PCO2 ≥ 50 mm Hg with pH ≤ 7.25
o Norms:
PAO2: 80 – 100
SaO2 90 – 100%
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pH 7.35 – 7.45
PaCO2 35 – 45
HCO3 – 22 - 26
o Progressive deterioration (changes in vitals, using accessory muscles)
Increasing RR
Decreasing VT
Increase WOB
Positive pressure ventilation
o Opposite of how we normally breath making it somewhat uncomfortable
o Air is pushed into the lungs instead of drawn in this is positive pressure.
o Movement of gases into lungs through positive pressure
o Normal breathing is negative pressure.
Ventilator Settings
o FiO2
Fraction of inspired O2 or amount of O2 the machine gives (how much oxygen are we
breathing)
Room air = 21%
Ventilator can be set to 30-100%
• Sp02 – pulse ox – 02 on Hgb
• Pa02: ABG – oxygen in arterial system
o Tidal Volume (VT)
How much air will the patient get with each breath or How much volume am I taking in.
Normal is 350 - 550 – Taken off height and weight.
Adjusted according to peak and plateau pressure
o Respiratory rate:
10 -m20 breaths initially, usually 12-14 – How many breaths am I taking in.
Cheyne stokes- cyclical with apneic periods
Bios – cluster breathing
Kussmaul – deep, regular and rapid
o I: E Ratio Inspiration: Expiration ratio; normal 1:2 ( 1 sec of inhale to 2 sec of exhale). We take
more time on exhalation.
o Positive end-expiratory pressure (PEEP)
Instills a small amount of pressure into the patients lungs at the end of expiration.
Purpose: Helps to keep airway and keep alveoli open to improve gas exchange.
5-20 cm H2O
Can cause reduced cardiac output if high and blocks venous return. Hyperinflation of the
lungs increases thoracic pressure and compresses the heart
High levels can pop alveoli and cause pneumothorax
Keep alveoli to improve gas exchange
o Sensitivity
Amount of patient effort. How hard the pt has to work to get flow of O2 from the
ventilator (how hard does the patient have to work to get oxygen from the ventilator.
Goal is to avoid patient-ventilator dyssynchrony (“fighting the ventilator”)
Data to Monitor During Mechanical Ventilation
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o Exhaled tidal volume (EVT) – how much your patient is exhaling, how much is coming out of the
patients lungs.
Amount exhaled should be equal to amount going in Ex: If you are getting 250 then you
want 250 out. Could be air trapping.. there is something going on.
Should not be more than 50 mL different from set VT
o Peak inspiratory pressure (PIP)
How hard the ventilator has to work to deliver a breath.
Should be less than 40 mm Hg
High PIP can be caused by three main reasons.
• 2. Mucous plug
• 1. Noncompliant or stiff lungs due to ARDS or pulmonary fibrosis
• 3. Pt is biting the tube. Usually use oral airway to prevent this used as bit block.
o Total respiratory rate – What the patient is doing, we set the ventilator rate but patient can take
more breaths then we set the machine at.
Count total rate, which accounts for set rate and patient effort
Ventilator Modes
o Volume Assist/Control (V-A/C) – 40%, 12 Rate (3)
Ventilator does most of the work because the patient cannot
Given to wean a patient off to SIMV patient who codes goes straight to AC first
Pt can take additional breaths but they get the same tidal volume as when ventilator
initiates the breath Ex: patient who just has surgery and is still sedated, brain injuries
Set a rate, set a tidal volume, Fi02, and peak
Every minute 12 breaths AC 12
• RR should be 12 or higher
If patient wants to take additional breaths that is fine
When the patient initiates a breath, the ventilator will assist them to get whatever the set
tidal volume, The ventilator is assisting the patient with every breath.
Tidal volume will be the same for both ventilator and pt. breath.
*Key is that when patient initiates a breathe, the ventilator will assist them to get
whatever the set tidal volume is
o Synchronized intermittent mandatory ventilation (SIMV) – 40% 12 Rate
Patient does most of the work ** When patient initiates breath they will get the tidal
volume that they alone can take, the ventilator will not assist them.
Set a rate, set a tidal volume, Fi02, and peak
When ventilator takes a breath you are going to get a set volume but when patient takes a
breath you are only going to get the tidal volume that they alone can take.
On SIMV the ventilator will synchronize the breaths. Ex: 12 min 5- V, 10 - V P – 13, 18 V, 23 - V. It will retime itself to how you are breathing so it doesn’t give you to many
breaths.
Pt can take additional breaths but they only get the volume they can take in not the
amount the ventilator gives on the breaths they initiate.
Ventilator then synchronizes next breath after the pt initiated breath. If rate is every 5
seconds, then the machine schedules next breath for 5 seconds after the patient takes their
own breath.
*Key is that when pt initiates a breath they will get the tidal volume that they alone can
take, ventilator will not assist them.
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o Pressure Ventilation
Patient has to be able to breathe on their own, initiate breath on their own
Ventilator set to allow air flow until preset pressure is reached
VT is variable
PIP can be better controlled
Only gets pressure during inspiration
Risk of hypoventilation and respiratory acidosis
Includes CPAP, pressure support (PSV), pressure A/C, inverse-ratio ventilation, and
airway pressure release (APRV)
o Pressure Support (PS) – have to be able to breathe on own, the machine will not give any
breaths. Used of weaning. Will only get pressure during inspiration. 40%, Rate varies. Pressure
5-20 cm H20 on inspiration
Patient’s spontaneous effort is assisted by preset amount of positive pressure
• 6 to 12 cm H2O
Decreases WOB with spontaneous breaths
Also useful in weaning
Pressure support ventilation requires the patient to trigger each breath, which is then
supported by pressure on inspiration
Patient may vary amount of time in inspiration, respiratory rate, and tidal volume (VT)
o Advanced Modes
Pt is very sick and has non-compliant lungs(lungs are very stiff) – Usually seen with
ARDS
Inverse ratio
• Longer inspiration and short expiration 2:1 instead of 1:2
• Pt has to be sedated to be on this mode.
APRV
• Similar to inverse ratio except you set 2 levels of pressure.
• More comfortable that inverse ratio – patient should be sedated.
Oscillatory Ventilation
• Give very high ventilator and respiratory rates with small tidal volumes – high
resp. rate with low tidal volume.
• 300-400 RR (breaths for minute) – usually give in the nicu. We give this for
adults because we are trying to get more air to the lungs.
Noninvasive Positive-Pressure Ventilation (NPPV) – we give positive pressure vent. With a mask.
o Delivery of positive-pressure ventilation (PPV) without artificial airway
Via face mask, nasal pillow
Key: Mask has to have a tight seal and has to have a intact resp. drive (has to be able to
breathe on own), able to protect airway
Intact respiratory drive
Useful in patients: COPD, Heart Failure, Palliative Care
o Reduces complications associated with MV
o Examples
Nasal Continuous Positive Airway Pressure (CPAP)
BiLevel Continuous Airway Pressure (BiPAP)
o Useful in many patients
COPD – difficult to get patients off ventilation
Heart failure, Palliative care (DNR)
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o Requirements
Tight seal of mask
Intact respiratory drive (breathe on their own)
Able to protect airway (pts with lots of secretions or vomit) prevent aspiration
o Contraindicated
Pts with dementia
Anxious patients
Claustrophobia
Pts with fragile skin
Facial trauma or burns
Sedated patient
ABGs
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PH
7.35 (acidic) – 7.45 (basic)
PaCO2
45 (acidic) – 35 (basic)
HCO3
PaO2
22 (acidic) – 26 (basic)
80-100
7.35-7.39 acidic
7.4 neutral
7.41-7.45 basic
RR = CO2
RR = CO2
>80 = hypoxemic
Compensations
o Uncompensated or none
pH – abnormal, CO2 or HCO3 – one or the other abnormal but not both.
o Partial compensation
pH/Everything is abnormal and CO2 and HCO3 are opposite
o Fully compensated
pH – normal, HCO3 and CO2 are opposite
o Compensation happens using either Kidneys or Lungs
Imbalanced States
o Respiratory Acidosis hypoventilating, asthma, & impaired gas exchange, COPD and narcotics
o Metabolic Acidosis diarrhea, DKA, low bicarb
o Respiratory Alkalosis hyperventilating, fever, respiratory infection, anxiety
o Metabolic Alkalosis ingestion, high bicarb, prolong vomiting, loss of stomach acid
o ***Uncompensated Combined Acidosis/alkalosis (both respiratory and metabolic). When Both
CO2 and HCO3 are acidic/basic
Oxygen and Oxygen Delivery
Purpose of Oxygen: To treat or prevent hypoxia.
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21% of 02 is room air.
Humidification - To prevent dryness of mucous membranes. More than 4L of 02 you need to put on
humidification.
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High flow nasal cannula-thicker and can go up to 15 liters- 40 liters needs humidifier
Nursing Implications: monitor o2 saturations, respiratory rate, accurately documents how much oxygen
patient is on, skin care – skin break down top of the ears bottom of the chin. Make sure nasal cannula is
in the patients nose.
If patient does not have an order you cannot put oxygen on: It is considered a medication.
Oxygen Device
Amount of Oxygen
Delivered
Nursing Considerations
Nasal Cannula
1L to 6L/min (24-44%
FiO2)
Humidification is added for rates greater than 4L/min.
Flow rates greater than 6L are not effective. If
oxygenation is not restored at 6L than another device
is required.
Simple Face Mask
5L-12L (30-60% FiO2)
Secure fit, monitor for skin breakdown and teach the
patient to wear the mask. Do not use less then 5 L
Venturi Mask
24-40% FiO2
Appears as a simple face mask with an adapter. The
adapter determines the FiO2 and the amount of oxygen
that should be set in L/min. Given when need a
SPECIFIC amount of oxygen.
Partial Nonrebreather Mask
35-60% FiO2
Contains a reservoir bag to allow for more oxygen.
Contains 1 one-way valve to ensure that the patient
breaths in a higher concentration of oxygen.
Important: The bag needs to inflate.
Nonrebreather Mask
60-80% FiO2
Contains a reservoir bag to allow for more oxygen.
Contains 2 one-way valves to ensure that the patient
breaths in a higher concentration of oxygen.
Important: The bag needs to inflate.
Aerosol and Humidity
Delivery Systems
10 L/min and FiO2 is
adjusted
Humidity face mask for patients without an artificial
airway. T-Piece is used for a patient with an
endotracheal tube. Trach collar is used for a patient
with tracheostomy. Usually for Extubated patients/
after we have removed a breathing tube. Humidifies
airway.
Manual Resuscitation Bag
(aka ambu bag)
15 L/min
Used to manually deliver breaths to the patient who is
either not breathing or is breathing ineffectively
Face Tent:
High humidity also, patient how has a laryngial
resections, some type of nasal packing, if you cant use
nasal cannula. Sits under chin.
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Trach Collar:
Someone with a tracheostomy needs O2
T Piece:
Used when somebody is going be taken of artificial
ventilator, use to see if patient can maintain his or her
own airway safely. If patient can do the work of
breathing they can be extabated. Usually used for
weaning.
Amub Bag
When it is connected to oxygen it will provide 100%
O2. Every patient in ICU should have this bed side
Ventilator:
Provides breathing oxygen,
o Continuous Positive Airway Pressure (CPAP) – CPAP when patient is on the ventilator 40%,
rate varies, pressure 5-20 cm continuously
Patient has to be able to initiate breath and breathe on their own** Ventilator will not give
any breaths. Used for weaning
Used for sleep apnea or individual who is healthy
• BIPAP – improves gas exchange if patient is near 90%, patient intubation
RR and Tidal volume varies bc pt is taking their own breaths
Continuous positive airway pressure throughout respiratory cycle to patient who is
spontaneously breathing.
• Similar to PEEP
• Via ventilator or nasal or face mask
• Option for patients with sleep apnea
May facilitate weaning
Can also be used to prevent re-intubation
Positive pressure at end expiration splints alveoli and supports oxygenation
Pressure does not fall to zero, indicating the level of CPAP. Continuous pressure
o Bilevel positive airway pressure (BiPAP) – decrease work of breathing
Used because CO2 is too high and needs to be decreased
o Propfalol used for intubating no half life
o RASS scale (richmen agitation) titrate to -2 or -4 depending on sedation
o 3 step process
Look and listen – 1)see bilateral chest rise 2)auscultate breath sounds
3)Should change to yellow if it is in trachea calorimetric CO2 detector
• Changes yellow because CO 2 is blowing off
• XRAY done immediately
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3 cm above carina notify PCP
that
pulmonary specialist
notified
nurse charts
Airway Management
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Devices
o Oral Airway or Oropharyngeal.
o Nasopharyngeal Airway also called nasal trumpets.
Inserted through the nose
Used when oral airway is contraindicated
Used in awake patients because it is better tolerated better
o Endotracheal Intubation
Usually ETT inserted through the mouth due to infections reasons if inserted in the nose
– mouth or nose but usually in mouth.
Has a cuff near base of tube to keep it in place
Some have suction ports in order to suction secretions and prevent Ventilator Acquired
Pneumonia (VAPs)
Tube has CM markings to monitor for proper placement
Functions: Maintain an airway, Remove secretions, Prevent aspiration, Provide
mechanical ventilation
Sucks out secretion balloon of endotracheal tube.
Aspiration of oropharyngeal secretions is one of the leading causes of a VAP (Ventilator
associated pneumonia)
Intubation
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Placement is done by physicians, can be done by paramedics and nurse anesthetist. Not done by nurses.
Some respiratory therapists are trained.
Intubation is official term for putting an endotracheal tube in a patient
ABG needed radial artery pH must be below 7.35 or above 7.45 CO2 35 – 45 HCO3 22
– 26 PaO2 80 – 100 SaO2 90 -100
o pH 6.8 patient is incompatible with life
Nurses responsibility
o #1 Need to know what equipment is used and where to find it
o Call respiratory therapist for ventilator
o Make sure suction equipment works and is at bedside.
o Position the patient. Usually intubation is done from the HOB (as close to the head of the bed as
possible) – sometimes might need to remove the head board.
o Remove anything that may cause aspiration (dentures, tongue rings, etc.) Anything in the
patients mouth that could be dislodged.
o Insert or maintain function IV for medication administration (Most common drugs used:
profolol, verstatin/versed) – Important to sedate patient.
Never give analgesics to manage sedation
Neuromuscular paralyze given with sedative to not harm patient
Verifying tube placement
o End tidal CO2 detector - changes color as CO2 reaches the tube so you know it is in the lung.
o 1) Auscultation – clear breath sounds in both lungs. If in esophagus you might hear gurgling, you
wont hear breath sounds. If you hear breath sounds on the right and not the left it has gone down
to far Bilateral Breath Sounds.
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o 2) Calometric tester – should be yellow then 3) X-ray
o Esophageal detector device
o Chest x-ray – best method to verify placement. Tip or end of tube should be placed 3-4cm
above the carina (where trachea splits/bifurcates) this is important so we are oxygenated both
lungs. If it is too low pull it out.
Strategies for Securing ETT
o Tape or securement device – it just depends on what the resp. prefers.
o Usually done by respiratory therapist.
o Problem with securement device is skin integrity!
Document important information
o That patient was intubated
o Important: Document centimeters marking where the lips meet the tube to monitor for proper
placement. – In case the tube moves. Ex: you document at 13cm… you come back later and it is
at 15cm.. Call the doctor you need to get an xray to see where the tube is.
o Post intubation assessment
o Inform physician if patient needs chest x-ray
Tracheostomy
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Indications: Either Long-term ventilator support airway support - For someone who cant get off the
ventilator or someone who can’t protect there away. Usually about 10- 14 days. But no set time depends
on the patient.
Can be done in the OR or at the bedside
Important have at bed side: Always have extra trach tube in case one falls out.
Also have obturator (used to keep airway open) at bedside in case patient removes trach if confused. You
need to put this in when patient takes it out so the hole doesn’t close.
Endotracheal Suctioning
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Done as indicated by assessment
o Pt is coughing, visible secretions, change in lung sounds, changes in vitals (Pulse Ox, RR),
cyanotic,
Conventional Suction: The way we learned in funds
Self Suction ETT: Prevents VAPS
Select All: Vents:
Closed suction
o Always attached to trach tube
o Closed system and stays sterile – Used on all vent patients
o Feed tube into ET tube until you hit resistance or patient starts coughing and hold button down
and pull out you can go in and out don’t ever have to change it unless it gets gross
Suctioning
o 2-3 times for no more than 10 seconds
o Hyperoxygenate before suctioning
o Avoid instilling NS which can get into the lungs and cause pneumonia
o Bp Drops during suction what do you do? Stop and hyper oxygenate
Alarms
o Alarms
o Never turn off – they are there for a reason.
Manually ventilate if unsure of problem and call for help
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Complications of Mechanical Ventilation
o ETT malposition – important to document measurement at lip line
o Unplanned extubation patients might be try to pull out tube due to confusion.
o Laryngeal/Tracheal Injury – Due to size of cuff (over inflation)
o Mucosal Damage – no oral care, intubation process
o Barotrauma (too much pressure) Pneumothorax Trauma to alveoli from too much pressure (too
much peep
o Volutrauma –) trauma to actual lung tissue due to too much tidal volume
o Acid Base Imbalances – depending on different moves
o Ventilator Associated Events (Infection)
o Aspiration
o Stress Ulcers/GI Bleed
o Hypotension
o Psychosocial
• Ventilator Associated Events
o Ventilator Associated pneumonia (VAP)
Normal protective mechanisms bypassed by ETT tube
Every patient on ventilator needs a ventilator bundle
o Ventilator bundle*** - will help decrease risk of developing a Ventilator Associated pneumonia
Head of bed 30 degrees
Awaken daily and assess readiness to wean (sedation vacation)
Stress ulcer prophylaxis (PPI, Pecid, Protonix)
DVT prophylaxis (anticoagulants(heparin), SCDs)
Oral care (chlorhexidine in some bundles once a shift) – Every 2 hours
Reduces risk of VAP and VAE
• Weaning
o Determine: Readiness to wean
Was underlying cause treated? The cause of resp. failure has it been treated
Are they hemodynamically stable
Adequate muscle strength
Mentally ready – just as important as the other 3.
Patient has to be alert, awake, and able to follow commands in order to wean them off a
ventilator.
Educate patient on what to expect
o Weaning Trial – Dr. order.
20 minutes average
Weaning Methods
• SIMV, Pressure Support, CPAP, T-Piece (1 of these ways)
• Depends on physicians preference
Assessment
• Nurse and respiratory therapist need to stay in the room during weaning trial
because they need to assess if the patient is tolerating the weaning.
• Not tolerating weaning Signs
o High RR or Very Slow, Labored respiration or use of accessory muscles,
Changes in VS decreased b/p increased HR, changes in LOC, increased
anxiety – If patient has any of these signs you need to STOP and put
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patient on full ventilator support. Some times you will see these signs right
away and sometimes it will take a few minutes,
o Termination
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If not tolerated and placed back on ventilator support, try again next day
If after 20min to 30 min patient is okay then call the doctor to get tube out.
Extubation – Exhibit out the tube
o If weaning trial successful after 20 minutes
o Done by respiratory therapist, monitored by nurse.
o Determine need for secretion management
o Assess – Determine need for secretion management.
Stridor (narrowing of the airway causing high pitch whistling sound), if present
reintubate(put tube back in) – Resp. will take out the tube and then listen to this,
Hoarseness – irritation to vocal cords in long term intubation May or may not
Change in vital signs
Low oxygen saturation
o NPPV may prevent need for re-intubation
o Intubated longer than 24 hours, need a swallow eval before they are allowed to drink ***