List six indications for mechanical ventilation.
upper airway obstruction, apnea, aspiration risk, ineffective clearance of secretions, respiratory distress including ARDS, anesthesia
What is the first thing you need to have before intubation and mechanical ventilation?
consent discussing risks associated with intubation and mechanical ventilation
You patient has coded. Who will perform the intubation?
it varies - respiratory therapist, anesthesia, or MD
What is the standard size of an ET tube?
7.5
You patient has coded and CPR has been initiated by your colleagues. You suspect your patient will require intubation. The MD has just arrived to the room. Who should you call now? Why?
x-ray; to order a chest x-ray to ensure correct placement of the ET tube
Your patient requires intubation. You have been directed to gather supplies. What seven items will you be sure that you have?
bag valve mask hooked up to 12L O2; suction; intubation tray (scope, stylet, ET tube, syringe); end tidal CO2 detector; stethoscope; ventilator at the bedside ready to be connected to the ET tub; tape or ET tube securing device
How will you communicate with your intubated patient?
white boards or computers
Your colleague's patient has coded and is receiving CPR. Your colleague is frazzled and is struggling to prepare her patient for intubation. In your astute observation of the room, you notice Polident by the sink. How can you help your colleague in this situation?
remove the patient's dentures as they can obstruct the airway
A resident is performing intubation on your patient. He is very aggressive and chips your patient's tooth. What do you want to assess in this scenario?
where is the chipped remnant of the tooth; you do not want it to fall back into the airway
The medical team has rushed into your patient's room during a code. Your colleagues are performing CPR and you have gathered all your supplies needed for intubation. What additional four things would you ensure that have done to your patient in preparation for intubation?
IV access (>18G); monitoring (cardiac, BP, pulse ox); positioning; baseline labs
You have grabbed a rapid sequence intubation kit. What three classes of medications does it contain?
sedatives/hypnotics (versed, amidate, ativan, diprovan); narcotics (fentanyl); paralytics (anectine)
Your rapid sequence intubation kit contains three classes of medications. One class must be administered second?
paralytics
What other drugs would you like to have in addition to those in your rapid sequence intubation kit?
reversals such as Narcan
What position should your patient be in for intubation?
sniffing position
You are lecturing a class about the steps for intubation placement. What eight steps do you emphasize?
put in sniffing position; sedate; preoxygenate 100% O2 for 3-5 minutes; place ET tube; check placement; connect to O2 source; measure position; secure ET tube
Your patient was recently intubated. The chest x-ray is ready and shows that the ET tube is in the appropriate location. What order do suspect next? When does it need to be done?
an ABG; within 20 minutes of the intubation
How do you checked for appropriate placement of an ET tube? Name three ways.
auscultate the stomach and lungs (you shouldn't hear air movement in the stomach); end tidal CO2 detection; chest x-ray
Your patient's MD has just inserted the ET tube. You record the time and what other observation?
the location of the ET tube; for example, 22 at the lip or 23 at the teeth
Your patient has been administered sedatives and an eager resident grabs the laryngoscope and begins to depress the patients tongue. What do you need to do to advocate for your patient?
remind the resident that he needs to preoxygenate the patient at 100% O2 for at least 3-5 minutes
What is PEEP?
positive end-expiratory pressure; applied at the end of expiration of vented breaths to prevent alveoli shrinkage/collapse; 3-5cm H2O
What is the difference between volume control and pressure control modes?
with volume control, tidal volume is predetermined and the amount of pressured needed to deliver breaths varies; with pressure control, tidal volume varies and pressure is predetermined
What is important to monitor with pressure modes?
hypoventilation and hyperventilation
How will you decide on whether to use a volume or pressure mode?
respiratory rate, depth, and drive; ABGs
Which mode is used most commonly?
synchronized intermittent mandatory ventilation (SIMV)
What is controlled mandatory ventilation (CMV)?
breaths delivered at preset rate and a present tidal volume independent of a patient's ventilation efforts; the machine is doing all the work
What type of patients would require controlled mandatory ventilation (CMV)?
patient under anesthesia or patients who are paralyzed
How many breaths would you set for controlled mandatory ventilation (CMV)?
12
What is assist control/assisted mandatory ventilation (AMV)?
a preset frequency and tidal volume delivered when the patient patient initiates spontaneous breath
What type of patients would require assist control/assisted mandatory ventilation?
patients with pulmonary edema, neuromuscular disorders, and acute respiratory failure
Your patient can breath 5 times a minute on their own. She is receiving AMV. How many breaths per minute would you set the ventilator?
7 breaths
Your patient is on AMV. He has been receiving treatments and responding well. The ventilator is alarming. What do you suspect?
the patient have begun to breath more breaths per minute on their own and the machine needs to be reset
This is a negative consequence of AMV.
hyperventilation
What is synchronized intermittent mandatory ventilation (SIMV)?
preset tidal volume and present frequency in synchrony with patient's breathing; the patient is able to breathe spontaneously between ventilator delivered breaths; the breaths by the patient will not take in tidal volume, they will only take in what the patient takes in
Which volume mode is best for weaning?
synchronized intermittent mandatory ventilation (SIMV)
What is pressure support ventilation (PSV)?
preset level of positive pressure applied during inspiration used in conjunction with patient's spontaneous respirations; patient determines inspiratory length, tidal volume, and respiratory rate; patient must be able to spontaneously initiate a breath
Which pressure mode is best for weaning?
pressure support ventilation (PSV)
This ventilation is similar to PEEP and can be used in conjunction with PEEP.
pressure support ventilation (PSV)
Can a patient be receiving volume and pressure mode ventilation? Give an example.
yes; SIMV with PSV
What is CPAP?
continuous positive airway pressure; non-invasive pressure delivered continuously during spontaneous breathing
Which patients commonly receive CPAP?
patients with sleep apnea
What is BIPAP?
bi-level positive airway pressure; non-invasive higher inspiratory positive airway pressure and lower expiratory positive airway pressure
Why don't you get CO2 overload with CPAP and BIPAP?
there is a release valve
True or False. Ventilators have a CPAP function.
true
What is high-frequency oscillary ventilation (HFOV)?
tiny tidal volumes delivered at increased respiratory rates; 180-900 breaths per minute; rapid ventilation with smaller volumes helps to keep alveoli open; most commonly accepted for premature infants; currently being studied for use with patients with ARDS; adult patients will likely not be able to wean off these ventilators
True or False. You can get a ventilated patient up and walking.
true
How will you monitor that the ET tube has not moved?
observe if the marking on the tube is at the initial location (teeth or lip)
Your patient's family has been complaining that the ventilator alarms are constantly sounding. They want you to silence them for a couple hours. How do you respond?
remind the family that these alarms are critical to monitor the patient's respiratory status and must be kept on
What nursing diagnoses would you foresee for a ventilated patient?
impaired respiratory status related to secretions; impaired oral care; impaired skin integrity; impaired nutritional status
How will a ventilated patient receive nutrition?
enteral (g-tube) or parenteral supplementation
The wife of your ventilated patient is clearly distraught. She feels disconnected and helpless. What can you do for her?
teach her to do ROM so that she feels as though she is participating in her husbands care
ABGs will be regularly monitored in the ventilated patient. Which intervention will make these draws easier?
arterial line
Your patient's ventilator has begun to alarm. You cannot figure out why. What should you do?
manually ventilate him and call the respiratory therapist
The high pressure alarm on your patient's ventilator has begun to sound. What might you consider to be the problem? Consider five problems.
patient coughing; secretions or mucus in the airway; patient biting tube; airway problems; patient fighting the ventilator
The low pressure alarm on your patient's ventilator has begun to sound. What might you consider to be the problem? Consider three problems.
patient disconnection, circuit leaks, airway leaks
Your patient is confused and pulls out his ET tube. You must re-intubate him. What will you advocate for this time?
sedatives
Why is the ventilated patient at increased risk for pneumonia?
the ET tube impedes normal defenses by the glottis thereby making aspiration more likely
It is 4:00pm and you are doing a scheduled assessment of your ventilated patient. Before leaving the room, what else should you inspect?
if the ventilator is functioning properly
What is barotrauma?
rupture of over-distended alveoli during mechanical ventilation
How do we prevent barotrauma?
ventilate with smaller tidal volumes
How do we prevent stress ulcers of the ventilated patient? Consider three strategies.
correct predisposing conditions; treat prophylactically with antiulcer agents; initiate enteral nutrition early
What are two strategies used to prevent ventilator-associated pneumonia?
strict infection control and elevation of the HOB to 45 degrees or more
Where should the ET tube be located in the respiratory tree?
the main bronchus
The night nurse is giving you report about a ventilated patient. She tells you that her ET tube spontaneously traveled away from the main bronchus. Where do you suspect it traveled? Why?
right bronchus because it is more vertical in presentation than the left bronchus
Your ventilated patient's trachea appears displaced to the left. What do you suspect?
tension pneumothorax caused by air trapping in the pleural space
What aspect of a ventilated patient's care relies the most heavily on a multidisciplinary approach? Who is included in this approach?
weaning; MD, RT, dietitian, patient, family
How do you know how aggressively to wean a ventilated patient?
institutional parameters and guidelines
What do you need to have prior to extubation of the ventilated patient?
an acceptable ABG; spontaneous breathing on their own (usually with CPAP); alertness; titrated medications; respiratory rate WNL; test of muscle strength (negative inspiratory force using a manometer); hyperoxygenation; suction and bag valve mask at the bedside
How do you extubate a ventilated patient?
instruct the patient to take a deep breath; deflated the cuff at the peak of inspiration; remove the tube in one motion; monitor vital signs