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
·
Sepsis
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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