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Intensive Care
Evidence Based Practice Guidelines
2003

Nursing Care Of The Ventilated Patient

Principles:
The registered nurse is responsible for the assessment, planning and delivery of care to the patient. Care of the ventilated patient can vary from the basic nursing care of activities of daily living to caring for highly technical invasive monitoring equipment and managing and monitoring the effects of interventions.

Care of the airway:

It is of paramount importance that all cares and procedures are carried out with maintaining a patent airway always in mind. Always check the patient first. Observe the patients facial expression, colour, respiratory effort, vital signs and ECG tracing. Ensure the endotracheal tube (ETT) or tracheostomy tube is held securely in position but not too tightly to result in pressure area lesions. Check the placement of the ETT by listening for equal bilateral breath sounds, checking the CXR and noting the distance marks on the tube @ the teeth, checking the previously documented level. Check and adjust (if necessary) the cuff pressure of the ETT/trachi. In order to minimize tracheal damage, the cuff pressure should be at the lowest pressure necessary to prevent an air leak.

Check the bedside emergency equipment: An alternative means of ventilation eg. Laerdel bag must be available & functional Yankeur sucker, suction catheters and functioning suction unit, airways and masks
should be available.

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Intensive Care Evidence Based Practice Guidelines

2003

Nursing Care Of The Ventilated Patient

Ventilation:
Ensure the ventilation tubing is not kinked and that it is adequately supported so as not drag on the ETT/trachi. Take care of the tube while turning or moving the patient. Check the ventilator and document the settings. Look at the alarm parameters and reset if necessary. Ensure the ventilator and the cardiac monitor are plugged into emergency power supply in case of power failure. Ensure that you have enough room to access the head of the bed in an emergency. Check the type of humidification, and when the filters and ventilation tubing were last changed. HME filters and end expiratory filters are changed routinely (and marked with the date and time) every 24 hours or more frequently if there is condensation visible. Ventilator circuits are changed weekly. Indications for an actively humidified circuit (Westmead ICU): minute volume greater than 10 litres chest trauma with pulmonary contusion airway burns severe asthma hypothermia (<340 C) pulmonary haemorrhage severe sputum plugging/pulmonary oedema leading to HME occlusion consultant order Pooled secretions above the ETT/trachi cuff are associated with ventilator associated pneumonia (VAP). This is a result of aspiration of bacteria colonizing the oropharynx or GIT and subsequently leaking below the cuff into the trachea. Therefore thorough oropharyngeal suctioning should be performed before letting down the cuff to reposition the ETT or to check cuff pressure.

Suction of an Artificial Airway:

To maintain a patent airway To promote improved gas exchange To obtain tracheal aspirate specimens To prevent effects of retained secretions eg. infection, consolidation , atelectasis, increased airway pressures or a blocked tube. It is important to oxygenate before and after suctioning

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Intensive Care Evidence Based Practice Guidelines

2003

Nursing Care Of The Ventilated Patient

Closed suction catheters should be rinsed post suctioning to remove mucous and to reduce the likelihood of bacterial growth. Tracheal suctioning should be attended 2 - 3 hourly, more often if necessary (See Suctioning an Artificial Airway Guideline). Suction the oropharynx to remove potentially infected secretions.

Monitors:
Check the level of any invasive monitoring transducers and zero them. (Haemodynamic
Monitoring Guideline).

Check the alarm parameters and reset if necessary Document the patients vital signs hourly and when there is a deviation from the usual. Check and document a manual blood pressure to assess the accuracy of the arterial trace once a shift.

Oral Care:
The aim of oral care and assessment is to promote normal hygiene while preventing infection and trauma. The presence of an ETT can cause hyper salivation in some patients and an uncomfortably dry mouth in others. A soft toothbrush can be used for oral hygiene and a small amount of toothpaste can help the cleansing action. Using large amounts of toothpaste may leave a residual coating and produce a burning sensation if it is not rinsed away properly. Properly diluted sodium bicarbonate may be used to remove resistant coating on the tongue, debris or tenacious secretions but again overuse may cause superficial burns. The lips should be kept moisturized to stop them becoming sore and cracked. 2nd hourly oral care is recommended, using water, not saline, and oral swabs and thorough suctioning of oral secretions, a toothbrush & paste should be used at least once a shift and more often if indicated.

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Intensive Care Evidence Based Practice Guidelines

2003

Nursing Care Of The Ventilated Patient Eye Care:

The unconscious, sedated or paralyzed patient is at risk of developing eye problems ranging from mild conjunctivitis to serious corneal injury and ulceration. Permanent eye damage may result from ulceration, perforation, vascularization and scarring of the cornea. Sedation and muscle relaxants can lead to inadequate closure of the eye, lack of random eye movements and a loss of the blink reflex, all of which can lead to complications. Fluid imbalances and increased permeability can promote conjunctival oedema. Constrictive securing tapes can compromise venous return from the head leading to venous congestion and maybe an increase in interocular pressure and therefore an increase in conjunctival oedema. 2nd hourly eye care using saline soaked gauze to clean the eye and the application of lactrilube regularly in the ventilated patient is recommended to help reduce the risk of complications.

G.I.T:

Intubated patients must have a nasogastric tube for gastric decompression or nutritional support. The presence of bowel sounds and the turgor of the abdomen should be assessed during the initial assessment. Nutrition and hydration are essential to build respiratory muscle strength necessary when a patient is being weaned from a ventilator. Patients who have inadequate nutritional stores are prone to infection, fluid and electrolyte imbalance, intestinal fluid retention, weight loss, pressure areas and poor wound healing. Patients with a functioning GI tract should be fed enterally. TPN may be used if there are contraindications to enteral feeding. The enterally fed patient should be monitored for diarrhoea, dehydration, fluid overload, constipation or abdominal cramping. These observations can be a guide in determining the strength and rate of increase of the feeds. NG tubes should be flushed with 20-30 mls of water before and after administering medications. Fine bore tubes can not be aspirated but should be flushed 4 hourly with water.

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Intensive Care Evidence Based Practice Guidelines

2003

Nursing Care Of The Ventilated Patient

If the patient is not being fed enterally the NG tube should be on free drainage and aspirated and flushed 6 hourly with water. If the enterally fed patient has large aspirates (>200mls or > 4 hours feed) consult with medical staff regarding reducing the feed and/or discarding the aspirate. Otherwise the aspirate is generally returned if less that 200 mls or < 4 hours feed. Elevating the head of the bed to 30 - 45 degrees (unless contraindicated) is effective in reducing the risk of aspiration. Elimination should be recorded and aperients given if necessary.

Genital/Urinary Tract:
IDCs predisposes urinary tract infections. Routine urinalysis should be twice a day Regular penil/perineum catheter care should be done. The catheter should be secured to the leg carefully and repositioned as necessary to prevent pressure areas. Hourly urine monitoring is carried out and medical staff informed of abnormally high or low measurements. Aim for a urine output of 0.5ml/kg.

Repositioning And Pressure Area Care:

Attending to the patients hygiene protects the skin and ensures dignity and comfort Ventilated patients are at a higher risk of developing nosocomial infections and pressure areas due to their immobility, their underlying disease process and the presence of invasive monitoring lines and equipment. Repositioning the patient regularly has a number of positive effects: routine turning and positioning assists in the mobilization of secretions prevents the development of pressure areas, joint stiffness and deformities improves oxygenation and can encourage weaning from the ventilator. provides a different view on the environment for the patient the patient should be repositioned 2nd hourly if possible, taking care to position the limbs in proper alignment and supporting them to prevent dependant oedema. If the patient has leg splints on they should be on for 2 hours and off for 2 hours. They should not be bandaged and the skin integrity should be checked with each turn.

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Intensive Care Evidence Based Practice Guidelines

2003

Nursing Care Of The Ventilated Patient

The ETT and other lines should be safeguarded during turning and care should be taken to ensure that there are no lines or other equipment under the patient turned. The skin should be kept dry and should be inspected with each change of position, including under restraints. (Refer to Restraints Guideline) The head of the bed should be elevated if the patients condition allows to help prevent aspiration and improve oxygenation. If the patient has any signs of developing pressure areas he/she should be nursed on an air mattress. (Refer to Pressure Area Care Guideline). The ETT should be repositioned at alternate sides of the mouth to prevent pressure areas developing. The NG tube should be secured in such a way as to minimize pressure on the nares and changed at least daily. If the patient has a hard collar it should be changed to an Aspen collar as soon as possible and the back of the head and neck checked once a shift for the presence of pressure areas.

References: 1. Anonymous. (2002) Eye care for intensive care patients, Best Practice Vol 6 (1) ISSN 1329-1874. 2. Ashurst,S. (1997) Nursing care of the mechanically ventilated patient in ITU: 1, British Journal of Nursing Vol 6 (9) Nov, 447-454. 3. Blackwood, B. (1998) The practice and perception of intensive care staff using the closed suction system, Journal of Advanced Nursing Vol 28 (5) Nov,1020-1029. 4. Greifzu, S. (2002) Caring for the chronically critically ill, RN Vol 65 (7) July, 42-44, 46, 48-49. 5. Hickson,S, Sole,M.L, King,T. (98) Nursing Strategies to prevent Ventilator-Associated Pneumonia, AACN Clinical Issues Vol 9 (1) Feb, 76-90. 6. Schwenker,D, Ferrin,M, Gift,A. (1998) A survey of Endotracheal suctioning with instillation of NaCl, American Journal of Critical Care Vol 7 (4) 256. 7.Stamm,A.M. (1998) Ventilator- associated pneumonia and frequency of circuit changes, American Journal of Infection Control Vol 26 (1) Feb, 71-73. 8. Tan,I.K.S, Oh,T.E.(1997) Intensive Care Manual, 4th ed, p.246, Bath, Butterworth & Heinemann.

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