Respiratory 3 Rd Handout Pg 56- 69

7/30/2019 Respiratory 3 Rd Handout Pg 56- 69

1/16

VENTILATOR ASSESSMENT

The following should be included in your initial assessment and documentation of aventilated patient:

ETT size, length at lip or teeth (teeth is frequently better in trauma patientsdue to swelling of lips), position in mouth, and date of insertion

If a patient is trached, note the size of the trach, date of insertion, stomacondition, presence of oozing around site; dressing condition

Cuff Pressure (< 25 mm Hg is optimal)

Vent parameters - both set and measured

Breathing: Spontaneous resps over ventilator?

Tolerance (synchrony, work of breathing, comfort)

Suctioning: Colour, amount, viscosity

Alarms

Hourly assessments include all values:

Peak Pressures

Resp Rate any spontaneous breaths?

Tidal Volumes

Minute Volumes

WOB

Dont accept CIS data from the ventilator unless you have reviewed it. Its veryimportant that you are aware of changing measurements so that you can interveneas appropriate. Look for changes up or down and relate these to the patientscondition. Recognize how these changes may affect his ventilation or oxygenation you may need to do an ABG.

When you change the ETT position you need to document where you moved it toand whether it remains at the same marker level at the lip/teeth. Before retapingthe tube you must listen for equal bilateral breath sounds to ensure you have notdislodged it. When you do your trach dressing you need to document how youcleaned it and what the site looks like, and if you took any additional measures (ienotified the MD if it appears infected).

Additional items to note during your assessment:

How much dead space is there? Can the tube be trimmed? Can the cathetermount be shrunk?

Is the patient trying to initiate his own breaths but unsuccessful? Have yourRT look at the sensitivity level and adjust if necessary or, if the patient is notsupposed to be breathing, consider increased sedation

Graphics: Use this workbook and study your graphics daily to see if you canrecognize issues with ventilation. Ive placed a Ventilator Graphics Handoutin your shared folder.

RECRUITMENT MANOEUVERS (RMs)


2/16

Recruitment manoeuvres are done by creating a sustained increase in pressure as ameans of recruiting the collapsed alveoli. Recruitment manoeuvres are doctor-ordered and done by the doctor or the RT at this time.

There are 3 parts to a recruitment manoeuvre:

1. Inflation: this step helps to open as much of the lung as possible. Its done byincreasing the pressures for a sustained period. This can be done a few ways:

a. Sustained CPAP of 30-40 for about 40 secondsb. Inspiratory Hold: While patient is inhaling you hold the air in, delaying

exhalation and thereby keeping the alveoli expanded for a bit longerc. Set the pressure to 20 above the PEEP for 10-12 breaths, then increase

PEEP so Peak Pressure is 40 for about 40-60 secondsd. Increase PEEP by 5 for several minutes

2. Deflation: By looking at the graphs, this helps you determine the pressurewhere most units re-collapse

A= Point of collapse of alveoliduring

ExhalationB= Point of opening of alveoli

duringInspiration

3. Re-inflation: You can now choose your new PEEP settings based on the above-

measured deflation value

RMs should be done at least once per shift. However, good ventilation therapyincludes doing a recruitment manoeuvre every time PEEP is broken, followingsuction, or following a leak in the system.Caution: This increases intrathoracic pressure for up to 60 seconds so beware ofbarotrauma.


3/16

In summary, study the ventilator daily. Look at the ventilator readings regularlyand with each nursing intervention to see how your patient reacts. Interpret yourABGs and decide how you would adjust the ventilator, and then see if it coincideswith what the RT or the MD does. Does this change make sense based on the biggerpicture? Remember, you are the only one who will know that because you are theonly one at the beside for 12 hours. Ventilation affects all other systems andinfluences the speed of recovery. By ensuring you are optimizing ventilation youcan help your patient recover faster and avoid complications. Understanding

ventilation is the difference between an average ICU nurse and an exceptional one.

WEANING

Weaning from ventilation should be done as soon as possible to avoidcomplications. There are certain basic criteria for weaning:

1. Reason for Intubation: Has the original reason for intubation resolved?Always consider why the patient was intubated in the first place. It theseissues are still present, weaning is not recommended.

2. Measurable Criteria: There are certain measurable parameters one canlook at to determine readiness for weaning. Some of these are directly

related to ventilation measurements while others relate to a patients overallcondition. For instance:

CLINICAL PARAMETERS:

Acid-base balanceAnemiaTempCardiac issuesElectrolyte balance

Exercise tolerance(up in chair)Fluid balancePain

Psychological issuesSleep deprivationInfectionGlycemic stabilityLevel of

ConsciousnessAbility to protectand clear airway

VENTILATION PARAMETERS:


4/16

Minute Volume

Documents

Respiratory 3 Rd Handout Pg 56- 69