NURSING PROCESS: THE PATIENT ON A VENTILATOR
The nurse has a vital role in assessing the patient’s status and the functioning of the ventilator.
In assessing the patient, the nurse evaluates the patient’s phys-iologic status and how he or she is coping with mechanical ven-tilation. Physical assessment includes systematic assessment of all body systems, with an in-depth focus on the respiratory system. Respiratory assessment includes vital signs, respiratory rate and pattern, breath sounds, evaluation of spontaneous ventilatory ef-fort, and potential evidence of hypoxia. Increased adventitious breath sounds may indicate a need for suctioning. The nurse also evaluates the settings and functioning of the mechanical ventila-tor, as described previously.
Assessment also addresses the patient’s neurologic status and effectiveness of coping with the need for assisted ventilation and the changes that accompany it. The nurse should assess the pa-tient’s comfort level and ability to communicate as well. Finally, weaning from mechanical ventilation requires adequate nutrition. Therefore, it is important to assess the function of the gastro-intestinal system and nutritional status.
Based on the assessment data, the patient’s major nursing diagnoses may include:
• Impaired gas exchange related to underlying illness, or ven-tilator setting adjustment during stabilization or weaning.
• Ineffective airway clearance related to increased mucus pro-duction associated with continuous positive-pressure me-chanical ventilation
• Risk for trauma and infection related to endotracheal intu-bation or tracheostomy
• Impaired physical mobility related to ventilator dependency
• Impaired verbal communication related to endotracheal tube and attachment to ventilator
• Defensive coping and powerlessness related to ventilator dependency
Based on assessment data, potential complications may include:
· Alterations in cardiac function
· Barotrauma (trauma to the alveoli) and pneumothorax
· Pulmonary infection
The major goals for the patient may include achievement of optimal gas exchange, maintenance of a patent airway, absence of trauma or infection, attainment of optimal mobility, adjust-ment to nonverbal methods of communication, acquisition of successful coping measures, and absence of complications.
Nursing care of the mechanically ventilated patient requires ex-pert technical and interpersonal skills. Nursing interventions are similar regardless of the setting; however, the frequency of inter-ventions and the stability of the patient vary from setting to setting. Nursing interventions for the mechanically ventilated pa-tient are not uniquely different from other pulmonary patients, but astute nursing assessment and a therapeutic nurse–patient relationship are critical. The specific interventions used by the nurse are determined by the underlying disease process and the patient’s response.
Two general nursing interventions important in the care of the mechanically ventilated patient are pulmonary auscultation and interpretation of arterial blood gas measurements. The nurse is often the first to note changes in physical assessment findings or significant trends in blood gases that signal the development of a serious problem (eg, pneumothorax, tube displacement, pul-monary embolus).
The purpose of mechanical ventilation is to optimize gas exchange by maintaining alveolar ventilation and oxygen delivery. The al-teration in gas exchange may be due to the underlying illness or to mechanical factors related to the adjustment of the machine to the patient. The health care team, including the nurse, physician, and respiratory therapist, continually assesses the patient for adequate gas exchange, signs and symptoms of hypoxia, and response to treatment. Thus, the nursing diagnosis impaired gas exchange is, by its complex nature, multidisciplinary and collaborative. The team members must share goals and information freely. All other goals directly or indirectly relate to this primary goal.
Nursing interventions to promote optimal gas exchange include judicious administration of analgesic agents to relieve pain without suppressing the respiratory drive and frequent repositioning to di-minish the pulmonary effects of immobility. The nurse also mon-itors for adequate fluid balance by assessing for the presence of peripheral edema, calculating daily intake and output, and moni-toring daily weights. The nurse administers medications prescribed to control the primary disease and monitors for their side effects.
Continuous positive-pressure ventilation increases the production of secretions regardless of the patient’s underlying condition. The nurse assesses for the presence of secretions by lung auscultation at least every 2 to 4 hours. Measures to clear the airway of secretions include suctioning, chest physiotherapy, frequent position changes, and increased mobility as soon as possible. Frequency of suction-ing should be determined by patient assessment. If excessive secre-tions are identified by inspection or auscultation techniques, suctioning should be performed. Sputum is not produced contin-uously or every 1 to 2 hours but as a response to a pathologic con-dition. Therefore, there is no rationale for routine suctioning of all patients every 1 to 2 hours. Although suctioning is used to aid in the clearance of secretions, it can damage the airway mucosa and impair cilia action (Scanlan, Wilkins & Stoller, 1999).
The sigh mechanism on the ventilator may be adjusted to de-liver at least one to three sighs per hour at 1.5 times the tidal vol-ume if the patient is on assist–control. Because of the risk of hyperventilation and trauma to pulmonary tissue from excess ventilator pressure (barotrauma, pneumothorax), this feature is not being used as frequently today. If the patient is on the syn-chronized intermittent mandatory ventilation (SIMV) mode, the mandatory ventilations act as sighs because they are of greater vol-ume than the patient’s spontaneous breaths. Periodic sighing pre-vents atelectasis and the further retention of secretions.
Humidification of the airway via the ventilator is maintained to help liquefy secretions so they are more easily removed. Bron-chodilators are administered to dilate the bronchioles and are classified as adrenergic or anticholinergic. Adrenergic broncho-dilators are mostly inhaled and work by stimulating the beta-receptor sites, mimicking the effects of epinephrine in the body. The desired effect is smooth muscle relaxation, thus dilating the constricted bronchial tubes. Medications include albuterol (Proventil, Ventolin), isoetharine (Bronkosol), isoproterenol (Isuprel), metaproterenol (Alupent, Metaprel), pirbuterol acetate (Maxair), salmeterol (Serevent), and terbutaline (Brethine, Brethaire, Bricanyl). Tachycardia, heart palpitations, and tremors are side effects that have been reported with use of these medica-tions (Zang & Allender, 1999). Anticholinergic bronchodilators such as ipratropium (Atrovent) and ipratropium with albuterol (Combivent) produce airway relaxation by blocking cholinergic-induced bronchoconstriction. Patients receiving bronchodilator therapy of either type should be monitored for adverse effects in-cluding dizziness, nausea, decreased oxygen saturation, hy-pokalemia, increased heart rate, and urine retention. Mucolytic agents such as acetylcysteine (Mucomyst) are administered as prescribed to liquefy secretions so that they are more easily mo-bilized. Nursing management of patients receiving mucolytic therapy includes assessment for an adequate cough reflex, sputum characteristics, and improvement in incentive spirometry (McK-enry & Salerno, 2001). Side effects include nausea, vomiting, bronchospasm, stomatitis (oral ulcers), urticaria, and runny nose (LeFever & Hayes, 2000).
Airway management must involve maintaining the endotracheal or tracheostomy tube. The nurse positions the ventilator tubing so that there is minimal pulling or distortion of the tube in the trachea; this reduces the risk of trauma to the trachea. Cuff pres-sure is monitored every 8 hours to maintain the pressure at less than 25 cm H2O. The nurse evaluates for the presence of a cuff leak at the same time.
Patients with endotracheal intubation or a tracheostomy tube do not have the normal defenses of the upper airway. In addition, these patients frequently have multiple additional body system dis-turbances that lead to immunocompromise. Tracheostomy care is performed at least every 8 hours, and more frequently if needed, because of the increased risk of infection. The ventilator circuit and in-line suction tubing is replaced periodically, according to infec-tion control guidelines, to decrease the risk of infection.
The nurse administers oral hygiene frequently because the oral cavity is a primary source of contamination of the lungs in the in-tubated and compromised patient. The presence of a nasogastric tube in the intubated patient can increase the risk for aspiration, leading to nosocomial pneumonia. The nurse positions the pa-tient with the head elevated above the stomach as much as possi-ble. Antiulcer medications such as sucralfate (Carafate) are given to maintain normal gastric pH; research has demonstrated a lower incidence of aspiration pneumonia when sucralfate is adminis-tered (Scanlan, Wilkins & Stoller, 1999).
The patient’s mobility is limited because he or she is connected to the ventilator. The nurse should assist a patient whose condi-tion has become stable to get out of bed and to a chair as soon as possible. Mobility and muscle activity are beneficial because they stimulate respirations and improve morale. If the patient cannot get out of bed, the nurse encourages the patient to perform active range-of-motion exercises every 6 to 8 hours. If the patient can-not perform these exercises, the nurse performs passive range-of-motion exercises every 8 hours to prevent contractures and venous stasis.
It is important to develop alternative methods of communication for the patient on a ventilator. The nurse assesses the patient’s communication abilities to evaluate for limitations. Questions to consider when assessing the ventilator-dependent patient’s abil-ity to communicate include the following:
· Is the patient conscious and able to communicate? Can the patient nod or shake the head?
· Is the patient’s mouth unobstructed by the tube so that words can be mouthed?
· Is the patient’s hand strong and available for writing? (For ex-ample, if the patient is right-handed, the intravenous line is placed in the left arm if possible so that the right hand is free.)
Once the patient’s limitations are known, the nurse offers sev-eral appropriate communication approaches: lip reading (use sin-gle key words), pad and pencil or Magic Slate, communication board, gesturing, or electric larynx. Use of a “talking” or fenes-trated tracheostomy tube may be suggested to the physician; this allows the patient to talk while on the ventilator. If indicated, the nurse should make sure that the patient’s eyeglasses and hearing aid and a translator are available to enhance the patient’s ability to communicate.
The patient must be assisted to find the most suitable commu-nication method. Some methods may be frustrating to the patient, family, and nurse; these need to be identified and minimized. A speech therapist can assist in determining the most appropriate method.
Dependence on a ventilator is frightening to both the patient and family and disrupts even the most stable families. Encouraging the family to verbalize their feelings about the ventilator, the pa-tient’s condition, and the environment in general is beneficial. Explaining procedures every time they are performed helps to re-duce anxiety and familiarizes the patient with ventilator proce-dures. To restore a sense of control, the nurse encourages the patient to participate in decisions about care, schedules, and treat-ment when possible. The patient may become withdrawn or de-pressed while on mechanical ventilation, especially if its use is prolonged. To promote effective coping, the nurse informs the patient about progress when appropriate. It is important to pro-vide diversions such as watching television, playing music, or tak-ing a walk (if appropriate and possible). Stress reduction techniques (eg, a backrub, relaxation measures) help relieve tension and help the patient to deal with anxieties and fears about both the condi-tion and the dependence on the ventilator.
Alterations in cardiac output may occur as a result of positive-pressure ventilation. The positive intrathoracic pressure during inspiration compresses the heart and great vessels, thereby reduc-ing venous return and cardiac output. This is usually corrected during exhalation when the positive pressure is off. Patients may have decreased cardiac output and resultant decreased tissue per-fusion and oxygenation.
To evaluate cardiac function, the nurse first looks for signs and symptoms of hypoxia (restlessness, apprehension, confusion, tachycardia, tachypnea, labored breathing, pallor progressing to cyanosis, diaphoresis, transient hypertension, and decreased urine output). If a pulmonary artery catheter is in place, cardiac out-put, cardiac index, and other hemodynamic values can be used to assess the patient’s status.
Excessive positive pressure may cause barotrauma, which results in a spontaneous pneumothorax. This may quickly develop into a tension pneumothorax, further compromising venous return, cardiac output, and blood pressure. The nurse should consider any sudden onset of changes in oxygen saturation or respiratory distress to be a life-threatening emergency requiring immediate action.
The patient is at high risk for infection, as described above. The nurse should report fever or a change in the color or odor of sputum to the physician for follow-up.
Expected patient outcomes may include:
1) Exhibits adequate gas exchange, as evidenced by normal breath sounds, acceptable arterial blood gas levels, and vital signs
2) Demonstrates adequate ventilation with minimal mucus accumulation
3) Is free of injury or infection, as evidenced by normal tem-perature and white blood count
4) Is mobile within limits of ability
a) Gets out of bed to chair, bears weight, or ambulates as soon as possible
b) Performs range-of-motion exercises every 6 to 8 hours
5) Communicates effectively through written messages, ges-tures, or other communication strategies
6) Copes effectively
a) Verbalizes fears and concerns about condition and equipment
b) Participates in decision making when possible
c) Uses stress reduction techniques when necessary
7) Absence of complications
a) Absence of cardiac compromise, as evidenced by stable vital signs and adequate urine output
b) Absence of pneumothorax, as evidenced by bilateral chest excursion, normal chest x-ray, and adequate oxy-genation
c) Absence of pulmonary infection, as evidenced by nor-mal temperature, clear pulmonary secretions, and neg-ative sputum cultures
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