What is a Mechanical Ventilator?
A mechanical ventilator is a vital life support system in critical care, functioning as a breathing apparatus that delivers oxygen and removes carbon dioxide from patients unable to breathe adequately on their own. These devices utilize positive or negative pressure to facilitate respiration over extended periods. Typically, patients require endotracheal intubation or tracheostomy before ventilator connection, ensuring a secure airway. An endotracheal tube or tracheostomy tube is then connected to the ventilator via oxygen tubing. Mechanical ventilation becomes necessary in cases of respiratory failure or compromised airways, often indicated by a persistent decline in blood oxygen levels (PaO2), elevated arterial carbon dioxide levels (PaCO2), and ongoing acidosis (decreased pH).
Mechanical ventilators are broadly categorized by their ventilation support method, falling into negative-pressure and positive-pressure types.
Positive-Pressure Ventilators (PPVs)
Positive-pressure ventilators are the more commonly used type, operating by exerting positive pressure to inflate the lungs. They push air into the airway, forcing the alveoli to expand during inhalation. This method generally necessitates endotracheal intubation or tracheostomy to ensure airway control and effective ventilation.
- Volume-Cycled Ventilators: These ventilators are designed to deliver a predetermined volume of air with each breath. Once this set volume is administered, the ventilator cycles off, allowing for passive exhalation. The consistency in air volume delivery is a key feature of this type.
- Pressure-Cycled Ventilators: In contrast, pressure-cycled ventilators deliver airflow until a preset pressure is reached within the patient’s airway. Upon reaching this pressure, the ventilator cycles off, and expiration occurs passively.
- High-Frequency Oscillatory Support Ventilators: These specialized ventilators provide exceptionally rapid respiratory rates, ranging from 180 to 900 breaths per minute. They utilize very small tidal volumes combined with high airway pressures to facilitate gas exchange. Small, oxygen-rich air pulses are directed down the airway center, enabling alveolar air to exit along the airway margins.
- Noninvasive Positive-Pressure Ventilation (NIPPV): NIPPV offers positive-pressure ventilation without the need for invasive intubation. It is administered through facemasks (covering nose and mouth), nasal masks, or oral/nasal devices like nasal pillows. NIPPV reduces the risks associated with intubation, such as nosocomial infections like pneumonia. Pressure-controlled ventilation with pressure support is a comfortable and effective NIPPV mode, reducing breathing effort and improving gas exchange.
Negative-Pressure Ventilators (NPVs)
Negative-pressure ventilators function externally, applying negative pressure to the thorax and abdomen to induce lung inflation. By expanding the rib cage and abdomen, they mimic natural breathing mechanics. While less common than PPVs today, NPVs were historically significant, especially during the mid-20th century polio epidemic.
- Iron-Lung or Tank Ventilators: These are historical devices, large cylindrical tanks where patients lie enclosed, with only their heads exposed through a sealed opening. Air pressure fluctuations within the tank cause the patient’s chest to rise and fall, simulating breathing.
- Cuirass Ventilator: A more compact version of the iron lung, also known as a chest shell ventilator. It encases only the torso, sealed at the neck and waist, and uses an external pump to cycle pressure.
- Exovent Ventilator: A modern NPV, developed in response to the COVID-19 pandemic. Similar in concept to the cuirass, it provides non-invasive negative pressure ventilation.
- Jacket Ventilator: Also called poncho or raincoat ventilator, this is a lighter, more portable NPV. Made from airtight material with internal grids and a suction pump, it applies negative pressure to the torso.
Ventilator modes dictate how breaths are delivered. Common modes include controlled mechanical ventilation, assist-control (A/C), intermittent mandatory ventilation (IMV), synchronized intermittent mandatory ventilation (SIMV), pressure support ventilation, and airway pressure release ventilation, each tailored to specific patient needs.
Critical Care Nursing Plans and Management
The primary objectives in nursing care for patients on mechanical ventilation with endotracheal intubation or tracheostomy are to enhance gas exchange, maintain a clear airway, prevent complications like trauma, facilitate effective communication, minimize anxiety, and prevent cardiac and pulmonary issues. Critical care nurses play a pivotal role in achieving these goals through diligent monitoring, timely interventions, and collaborative care.
Critical Care Nursing Problem Priorities
Prioritizing care for mechanically ventilated patients is essential for optimal outcomes. Key nursing priorities include:
- Ensuring a Patent Airway and Correct Endotracheal Tube Placement: This is paramount to effective ventilation and patient safety.
- Monitoring and Managing Respiratory Status: Continuous assessment of lung sounds, oxygen saturation, and end-tidal carbon dioxide (EtCO2) levels is crucial.
- Managing Sedation and Pain: Balancing patient comfort with ventilator synchrony through careful sedation and analgesia management.
- Early Detection and Management of Complications: Promptly identifying and addressing potential emergencies like tube dislodgement, pneumothorax, or airway obstruction is vital.
- Preventing Ventilation-Associated Complications: Implementing preventive measures against ventilator-associated pneumonia (VAP) and ventilator-induced lung injury (VILI).
- Collaborative Ventilator Management: Working with the healthcare team to optimize ventilator settings, weaning protocols, and extubation readiness, while providing patient and family support and education.
Critical Care Nursing Assessment
Comprehensive assessment is the foundation of effective nursing care for patients undergoing mechanical ventilation. Critical care nurses must diligently monitor both subjective and objective data to identify potential problems early and intervene promptly.
Subjective and Objective Data to Assess:
- Adventitious breath sounds (wheezes, crackles, rhonchi)
- Apnea
- Apprehension and restlessness
- Arterial pH less than 7.35 (indicating acidosis)
- Decreased tidal volume
- Decreased oxygen saturation (SpO2 < 92%)
- Decreased PaO2 level (< 60 mm Hg)
- Diminished lung sounds
- Dyspnea
- Forced vital capacity less than 10 mL/kg
- Increased PaCO2 level (> 50 mm Hg, indicating hypercapnia)
- Increased or decreased respiratory rate
- Inability to maintain airway (due to emesis, depressed gag, depressed cough)
- Excessive secretions
- Increased peak airway pressure
- Ineffective cough
Factors Related to Mechanical Ventilation to Assess:
- Acute respiratory failure
- Noncompliant lung tissue (e.g., in ARDS)
- Respiratory muscle weakness or paralysis
- Altered ventilation-perfusion ratio (V/Q mismatch)
- Decreased energy and fatigue
- Endotracheal intubation or tracheostomy
- Stasis of secretions
Critical Care Nursing Diagnoses
Based on thorough assessment findings, critical care nurses formulate nursing diagnoses to guide individualized patient care. These diagnoses reflect the patient’s specific health challenges related to mechanical ventilation. While nursing diagnoses provide a structured framework for care planning, their application in practice is guided by the nurse’s clinical judgment and the patient’s unique needs. In critical care settings, while specific diagnostic labels might be less formally emphasized, the underlying principles of identifying patient problems and planning care remain central to nursing practice.
Potential critical care nursing diagnoses for patients on mechanical ventilation include:
- Impaired Gas Exchange related to altered oxygen supply, alveolar-capillary membrane changes, and ventilation-perfusion mismatch.
- Ineffective Airway Clearance related to presence of artificial airway, decreased cough reflex, and increased secretions.
- Risk for Infection related to invasive procedures (intubation, tracheostomy), suppressed immune response, and stasis of secretions.
- Ineffective Breathing Pattern related to neuromuscular impairment, pain, anxiety, and ventilator dependence.
- Risk for Injury related to ventilator malfunction, tube displacement, and barotrauma.
- Impaired Verbal Communication related to endotracheal tube or tracheostomy.
- Anxiety related to inability to communicate, dependence on ventilator, and critical illness environment.
- Deficient Fluid Volume related to insensible fluid loss, decreased oral intake, and effects of positive pressure ventilation.
- Imbalanced Nutrition: Less Than Body Requirements related to increased metabolic demands, decreased oral intake, and inability to eat orally.
- Decreased Cardiac Output related to increased intrathoracic pressure and effects of positive pressure ventilation.
These diagnoses provide a starting point, and nurses must tailor them based on the comprehensive assessment and the individual patient’s clinical presentation. The focus should always be on prioritizing the most critical issues and developing a care plan that addresses the patient’s immediate and long-term needs.
Critical Care Nursing Goals
Establishing clear and measurable goals is crucial for guiding nursing interventions and evaluating patient progress. For patients on mechanical ventilation, primary goals include:
- Optimal Gas Exchange: Patient will maintain adequate oxygenation and ventilation, evidenced by SpO2 within target range and arterial blood gases (ABGs) within acceptable parameters.
- Patent Airway: Patient will maintain a clear and patent airway, as evidenced by clear breath sounds and effective secretion management.
- Prevention of Complications: Patient will experience no preventable complications related to mechanical ventilation, such as VAP, VILI, or tube displacement.
- Effective Communication: Patient will establish effective methods of communication and have their needs understood.
- Reduced Anxiety: Patient will demonstrate reduced anxiety and increased comfort while on mechanical ventilation.
- Hemodynamic Stability: Patient will maintain stable cardiac function and hemodynamic parameters.
- Nutritional Adequacy: Patient will receive adequate nutritional support to meet metabolic needs and promote recovery.
- Successful Weaning: Patient will progress toward successful weaning from mechanical ventilation when clinically appropriate.
These goals are individualized and continuously evaluated and revised based on the patient’s response to treatment and changing clinical status. Collaborative goal setting with the patient (if possible), family, and interdisciplinary team is essential for patient-centered care.
Critical Care Nursing Interventions and Actions
Critical care nursing interventions for mechanically ventilated patients are multifaceted, demanding both technical proficiency and strong interpersonal skills. While specific interventions are tailored to each patient’s condition and care setting, core elements include meticulous respiratory assessment and interpretation of arterial blood gas results. Critical care nurses are pivotal in detecting subtle changes in patient status and identifying potential complications early. Astute clinical judgment, combined with a therapeutic nurse-patient relationship, is paramount in delivering optimal care.
1. Managing Mechanical Ventilation
Maintaining spontaneous breathing in patients with acute respiratory failure receiving ventilatory support offers numerous benefits, such as improved oxygenation, prevention of muscle atrophy, diaphragm protection, reduced sedation needs, and decreased delirium incidence. However, in conditions like ARDS or COVID-19, respiratory drive can be affected by lung inflammation or viral invasion, impacting inspiratory effort.
Critical Care Nursing Interventions for Managing Mechanical Ventilation:
Prior to Intubation Assessment:
1. Investigate the Etiology of Respiratory Failure: Understanding the underlying cause is crucial for guiding ventilator management and predicting patient prognosis. Mechanical ventilation is supportive, not curative, and addressing the root cause is paramount. For example, is it pneumonia, COPD exacerbation, or a neurological event?
2. Observe Changes in Level of Consciousness: Early hypoxia signs include disorientation, irritability, and restlessness. Late signs are lethargy, stupor, and somnolence. Changes in mental status can be subtle early indicators of worsening respiratory status.
3. Assess Respiratory Rate, Depth, and Pattern: Monitor for tachypnea, bradypnea, shallow breathing, and use of accessory muscles. These are early indicators of respiratory distress. Mechanical ventilation is indicated when spontaneous ventilation is insufficient to sustain life or to control breathing in critically ill patients.
4. Assess Heart Rate and Blood Pressure: Tachycardia can be an early sign of hypoxia. Blood pressure may initially increase and then decrease as hypoxia worsens. These are compensatory mechanisms that can indicate deteriorating respiratory function.
5. Auscultate Lungs for Breath Sounds: Adventitious sounds like wheezes, crackles, and rhonchi indicate respiratory issues. Absent unilateral breath sounds can suggest pneumothorax or pleural effusion. Clear lung fields with hypoxia may raise suspicion of pulmonary embolism.
6. Assess Skin Color and Lips/Nailbeds for Cyanosis: Cyanosis, a bluish discoloration, indicates severe hypoxemia and ineffective oxygenation. It is a late sign of respiratory compromise, highlighting the need for prompt intervention.
7. Monitor Oxygen Saturation via Pulse Oximetry: Pulse oximetry detects early changes in oxygenation. Normal SpO2 for adults without respiratory issues is 92-98%. Desaturation below 95% or exercise desaturation >5% is abnormal and warrants further investigation.
8. Monitor Arterial Blood Gases (ABGs): ABGs provide crucial data on oxygenation (PaO2), ventilation (PaCO2), and acid-base balance (pH). Increasing PaCO2 and decreasing PaO2 indicate respiratory failure and the need for or adjustment of mechanical ventilation.
Post-Intubation Assessment:
9. Verify Endotracheal Tube (ET) Placement: Confirm correct placement by observing symmetrical chest rise, auscultating bilateral breath sounds, and obtaining X-ray confirmation. Malpositioning can lead to ineffective ventilation and complications.
10. Assess Patient Comfort and Cooperation: Discomfort or agitation (“fighting the ventilator”) may indicate incorrect ventilator settings or inadequate oxygenation. Patient-ventilator synchrony is essential for effective ventilation and comfort.
11. Hourly Ventilator Setting and Alarm System Checks: Ensure settings are accurate and alarms are functional. Never disable alarms, even during suctioning. Ventilator alarms (oxygen, low volume, apnea, high pressure, I:E ratio) are critical safety features.
12. Monitor Respiratory Rate and Compare to Ventilator Settings: Patient’s respiratory rate should be coordinated with the ventilator. Rapid breathing can cause alkalosis, while slow breathing can lead to acidosis. Assess for patient’s spontaneous breaths versus ventilator-delivered breaths.
13. Maintain Airway Patency: Use oral or nasal airways as needed to prevent tongue obstruction. Artificial airways maintain oropharyngeal patency, especially in patients with reduced consciousness.
14. Maintain High-Fowler’s Position: Elevate the head of the bed to 30-45 degrees (High-Fowler’s) unless contraindicated. This promotes lung expansion and reduces aspiration risk. Avoid patient sliding down, which can compress the diaphragm.
Preparation for Endotracheal Intubation:
15. Notify Respiratory Therapist: Request a mechanical ventilator and respiratory therapist assistance. Respiratory therapists are integral to ventilator management and troubleshooting.
16. Prepare Intubation Equipment: Gather ET tubes of various sizes, laryngoscope, blades, stylet, syringe, benzoin, waterproof tape, and local anesthetic agents (e.g., lidocaine spray, benzocaine spray). Having all equipment readily available ensures a smooth and timely intubation process.
17. Administer Sedation as Ordered: Sedation facilitates patient comfort and intubation ease. Pretreatment agents (LOAD: Lidocaine, Opioid, Atropine, Defasciculating agent) may be used to mitigate physiological responses to laryngoscopy and intubation.
Assisting with Intubation:
18. Position Patient Supine with Neck Hyperextended (unless contraindicated): Align oropharynx, posterior oropharynx, and trachea for optimal visualization of vocal cords. The “sniffing position” (neck flexion, head extension) or simple head extension facilitates intubation.
19. Apply Cricoid Pressure (Sellick Maneuver) as Directed: Cricoid pressure may help prevent regurgitation during rapid sequence intubation. While evidence is debated, it is often used to minimize aspiration risk during intubation.
20. Preoxygenate Patient: Administer 100% oxygen via non-rebreather mask for 3 minutes for nitrogen washout. Preoxygenation prevents desaturation during apnea following paralytic administration. Use bag-valve-mask (BVM) ventilation only if needed to maintain SpO2 ≥ 90%.
21. Verify ET Tube Placement with End-Tidal CO2 Detector: Use calorimetric capnometer (purple to yellow with CO2) or quantitative capnometer. Yellow color change within 1-2 breaths confirms tracheal intubation. Capnography is the gold standard for initial placement confirmation.
22. Continue Manual Ambu Bag Ventilation: Maintain manual ventilation with Ambu bag until ET tube is secured and mechanical ventilation initiated. Stabilization is necessary before transitioning to mechanical ventilation. Use high-flow oxygen via non-rebreather or BVM with 100% oxygen if desaturation occurs.
23. Document ET Tube Position: Note centimeter marking at the lip for reference. Documentation provides a baseline for monitoring tube displacement. Typical depth is 21cm for women and 23cm for men at the lips.
24. Initiate Mechanical Ventilation with Prescribed Settings: Set ventilator mode (AC, SIMV), tidal volume, rate, FiO2, PEEP, and pressure support as ordered. Initial mode is often Assist-Control (AC). Settings are tailored to patient’s condition and ABGs.
25. Anticipate Need for Nasogastric/Orogastric Suction: Abdominal distention may indicate esophageal intubation or air insufflation during resuscitation. Suction prevents distention and aspiration. Orogastric suction may reduce sinusitis risk.
26. Administer Medications as Ordered: Muscle-paralyzing agents, sedatives, and opioid analgesics may be needed to facilitate ventilation and patient comfort. See Pharmacologic Management section for details.
27. Examine Cuff Volume and Pressure: Check for air leaks around the tube. Inflate cuff until no leak is detected. Notify respiratory therapist to check cuff pressure. Cuff pressure should be 20-30 mm Hg to prevent tracheal injury and aspiration.
28. Elevate Head of Bed: Position patient with head of bed elevated (≥ 30 degrees) to reduce aspiration risk and improve oxygenation. Semi-recumbent position reduces VAP risk compared to supine.
29. Inflate ET Tube Cuff Properly: Ensure proper cuff inflation to deliver tidal volume and prevent aspiration. Monitor cuff pressure every 4-8 hours, maintaining 20-30 cm H2O.
30. Note Inspired Humidity and Temperature: Use heat moisture exchanger (HME) or heated humidifier. Intubation bypasses natural humidification, leading to dehydration and thickened secretions. Maintain inspired air temperature near body temperature to prevent cilia damage.
2. Promoting Patent Airway Clearance
In mechanically ventilated patients, natural secretion clearance mechanisms are impaired. Artificial airways, inadequate humidification, and immobility contribute to secretion retention. Effective airway clearance is critical to prevent complications and optimize gas exchange.
Critical Care Nursing Interventions to Promote Patent Airway Clearance:
1. Assess Airway Patency: Obstruction can be caused by secretions, mucous plugs, hemorrhage, bronchospasm, or tube malposition. Secretion accumulation leads to ventilation-perfusion mismatch and increased work of breathing.
2. Observe Sputum Characteristics: Note color, odor, quantity, and consistency. Thick, tenacious secretions increase airway resistance. Discolored, odorous sputum suggests infection. Retained secretions promote bacterial growth and pneumonia risk.
3. Auscultate Lungs for Breath Sounds: Diminished or adventitious sounds indicate airway obstruction and need for suctioning. Assess for rhonchi, labored breathing, tachypnea, mental status changes, restlessness, cyanosis, and fever, all signs of respiratory compromise.
4. Monitor Oxygen Saturation Before and After Suctioning: Pulse oximetry assesses therapy effectiveness. SpO2 ≤ 92% suggests hypoxia and need for oxygen supplementation or further evaluation.
5. Assess Arterial Blood Gases (ABGs): Decreasing PaO2 and increasing PaCO2 indicate respiratory compromise. ABGs are often checked 10-15 minutes post-intubation and as needed to guide ventilator adjustments.
6. Monitor Peak Airway Pressures and Airway Resistance: Increases signal secretion/fluid accumulation or airway obstruction. Elevated peak and plateau pressures may indicate increased risk of barotrauma.
7. Monitor ET Tube Placement: Tube can slip into the right mainstem bronchus, obstructing left lung ventilation and causing tension pneumothorax risk. Check lip line marking against documented placement.
8. Note Signs of Secretion Accumulation: Excessive coughing, increased dyspnea, high-pressure ventilator alarms, and visible secretions in the tube all indicate need for suctioning. Intubated patients often have ineffective cough reflexes.
9. Explain Suctioning Procedure and Reassure Patient: Suctioning can be frightening. Explain the need for airway clearance and provide reassurance. Administer sedation and analgesia as needed. Endotracheal suctioning removes secretions from large airways but is limited to the third-generation bronchi.
10. Encourage Deep Breathing and Coughing Exercises (if possible) and Early Ambulation: These expand alveoli and mobilize secretions. Anesthesia and immobility can cause atelectasis and pneumonia risk. Ambulation is more effective than turning, coughing, and deep breathing alone.
11. Turn Patient Every Two Hours: Turning mobilizes secretions and helps prevent VAP. Promotes drainage and ventilation of all lung segments, reducing atelectasis.
12. Institute Airway Suctioning as Indicated: Suction based on assessment findings (adventitious sounds, increased pressures), not routine schedules. Over-suctioning can cause hypoxia and airway trauma. Shallow suctioning, limited to the artificial airway tip, is recommended.
13. Use Closed In-Line Suction: Reduces infection risk, may decrease hypoxia, and can be cost-effective. Sterile technique is essential. Closed systems maintain oxygenation and PEEP during suctioning.
14. Hyperoxygenate Before Suctioning: Preoxygenation with 100% oxygen before, during, and after suctioning minimizes hypoxia and dysrhythmias. Compensates for oxygen interruption during suctioning.
15. Instruct in Coughing Techniques (if possible): Teach splinting, breathing techniques, and “step-cough” to enhance cough effectiveness. Step-cough (weak coughs followed by a strong cough) may stimulate productive coughing.
16. Administer IV Fluids and Aerosol Bronchodilators: Hydration thins secretions and enhances ciliary action. Bronchodilators relax smooth muscles and improve ventilation, aiding secretion removal.
17. Administer Humidified Oxygen: Humidification prevents drying of airways and secretions. Supplements oxygen delivery.
18. Consult Respiratory Therapist for Chest Physiotherapy: Chest physiotherapy (postural drainage, chest percussion) loosens and mobilizes secretions, promoting drainage and ventilation of lung segments.
3. Reducing Anxiety and Fear
Ventilator dependence is frightening for patients and families, disrupting routines and creating stress. Patients may become withdrawn or depressed. Addressing anxiety is crucial for patient well-being and ventilator synchrony.
Critical Care Nursing Interventions to Reduce Anxiety and Fear:
1. Assess Patient Understanding of Mechanical Ventilation: Evaluate patient’s comprehension of the need for ventilation and the situation’s severity. Accurate understanding facilitates appropriate coping strategies.
2. Assess for Signs of Anxiety: Being on a ventilator is a major life change causing high anxiety. Anxiety can manifest as restlessness, agitation, rapid breathing, and ventilator dyssynchrony. Dyspnea and anxiety are interlinked in ventilated patients.
3. Observe Physical Responses: Restlessness, repetitive movements, and changes in vital signs (tachycardia, hypertension) can indicate anxiety. Physical signs complement verbal reports in assessing anxiety levels.
4. Assess Coping Strengths: Identify past coping mechanisms and current areas of control. Focusing on past successes can enhance self-efficacy and sense of control. Humor, spirituality, social support, communication, and hope are important coping factors for ICU survivors.
5. Encourage Expression of Fears: Allow patients and families to verbalize fears and concerns. Acknowledging their feelings validates their experience and reduces anxiety to manageable levels.
6. Reduce Distracting Stimuli: Create a quiet environment to promote rest. Noise, excessive conversation, and equipment can exacerbate anxiety. Explain ventilator alarms and reassure patient of prompt staff response. Ventilator alarms, while essential, can contribute to alarm fatigue and anxiety.
7. Educate on Safety Precautions: Discuss backup power, oxygen supplies, and suction equipment. Knowledge of safety measures reduces anxiety about potential emergencies and unknown situations. Family engagement and education are crucial for empowerment.
8. Maintain Calm and Confident Demeanor: Project a calm, understanding attitude and be readily available for support and explanations. Presence of a trusted nurse provides comfort and reduces anxiety. Explain procedures before performing them to reduce anxiety.
9. Provide Relaxation Techniques: Teach and encourage relaxation techniques. Music therapy, for example, has shown benefits in reducing anxiety and sedation needs in ventilated patients.
10. Encourage Diversional Activities: Promote sedentary diversions like TV, music, crafts, or reading. Activities enhance quality of life and help pass time. Encourage activities that are normal and desired by the individual.
11. Encourage Family and Friend Visits: Social support from loved ones enhances security and well-being. Support family optimism while providing realistic clinical information to decrease psychological stress.
12. Promote Spiritual Care: Offer spiritual care options like chaplain visits or Reiki therapy. Spiritual care can be beneficial in reducing anxiety. Reiki is a hand-laying technique to channel positive energy.
13. Reinforce Cognitive Behavioral Therapy (CBT): CBT can be helpful in managing anxiety. CBT targets unhelpful thoughts and behaviors. Case studies show CBT can aid weaning from mechanical ventilation by addressing psychological barriers.
14. Refer to Specialists: Consult psychiatric liaison, clinical nurse specialist, psychiatrist, or hospital chaplain as needed. Specialized expertise can provide broader treatment options for anxiety management. Multidisciplinary family engagement supports families during critical illness.
4. Administering Medications and Pharmacological Support
Medications in mechanical ventilation aim to optimize respiratory function and ensure patient comfort. Sedatives and analgesics manage discomfort, neuromuscular blocking agents enhance ventilator synchrony, and bronchodilators/mucolytics improve airway clearance.
Critical Care Medications Used During Mechanical Ventilation:
1. Induction Agents: Induce rapid unconsciousness for intubation.
- **1.1. Etomidate:** Rapid onset, short duration, cerebroprotective, minimal blood pressure drop. Hemodynamically stable compared to thiopental.
- **1.2. Ketamine:** Dissociative state, analgesic, bronchodilator, may decrease intracranial pressure.2. Paralyzing Agents: Neuromuscular blockade after induction. These agents do not provide sedation or analgesia, so induction agents are essential.
- **2.1. Succinylcholine:** Rapid onset (45-60 seconds), shortest duration (8-10 minutes).
- **2.2. Rocuronium:** Slightly longer onset (60-75 seconds), longer duration (30-60 minutes).3. Opioids: Manage pain and discomfort. Close monitoring is crucial for respiratory depression and over-sedation.
- **3.1. Morphine:** Potent analgesic, reduces pain perception.
- **3.2. Fentanyl:** Potent, rapid-acting analgesic, provides pain relief and sedation, reduces agitation.4. Diuretics: Manage fluid balance, especially in fluid overload.
- Loop diuretics (e.g., furosemide) are FDA-approved for edema and volume overload.5. Vasopressors and Inotropes: Support cardiac output.
- Vasopressors (e.g., norepinephrine) cause vasoconstriction.
- Inotropes (e.g., dobutamine) increase cardiac contractility.6. Broad-Spectrum Antibiotics: Treat or prevent infections, especially VAP.
- Examples: ceftriaxone, cefepime, piperacillin-tazobactam. Cover a range of gram-positive and gram-negative bacteria.7. Vancomycin and Linezolid: Target MRSA infections.
- Effective against methicillin-resistant Staphylococcus aureus (MRSA), a common VAP pathogen.8. Antifungal Agents: Treat or prevent fungal infections.
- Examples: fluconazole, voriconazole. Used in high-risk patients or suspected fungal pneumonia.5. Preventing Respiratory Injury Risk
Ventilator-induced lung injury (VILI), including barotrauma and volutrauma, is a significant complication. Barotrauma is alveolar rupture with air leak into pleural space. Volutrauma is alveolar overdistention. Prevention is paramount.
Critical Care Nursing Interventions to Prevent Respiratory Injury Risk:
1. Hourly Ventilator Setting Review: Check tidal volume and plateau pressures. Report discrepancies immediately. High tidal volumes and plateau pressures increase barotrauma risk. Plateau pressure should be kept < 30 cm H2O.
2. Assess Respiratory Rate and Rhythm: Monitor for patient-ventilator dyssynchrony (“bucking”). Adjust ventilator settings or sedation to improve synchrony and reduce work of breathing.
3. Assess Arterial Blood Gases and Oxygen Saturation: ABGs guide ventilator settings and detect barotrauma consequences. ABGs assess oxygenation, ventilation, and acid-base status.
4. Assess for Barotrauma Signs: Crepitus, subcutaneous emphysema, altered chest excursion, asymmetrical chest, abnormal ABGs, tracheal deviation, restlessness, pneumothorax on X-ray. Barotrauma can occur anytime, even in heavily sedated patients.
5. Auscultate Breath Sounds: Decreased breath sounds on one side may indicate pneumothorax. Tracheal deviation away from pneumothorax occurs with tension pneumothorax. Palpate trachea for deviation above sternal notch.
6. Daily Chest X-ray and Stat X-ray if Barotrauma Suspected: Daily chest X-rays monitor for barotrauma. Stat portable chest X-ray is needed if barotrauma is suspected. X-ray may be the first indicator of barotrauma, especially in asymptomatic patients.
7. Monitor Plateau Pressures with Respiratory Therapist: Plateau pressure reflects alveolar pressure at end-inspiration. High plateau pressures increase barotrauma risk. Lower tidal volumes reduce barotrauma incidence.
8. Ensure Ventilator Alarms are On: Alarms alert caregivers to ventilation problems. Never disable alarms. Alarm safety is a National Patient Safety Goal.
9. Listen for Alarms and Troubleshoot: Respond promptly to alarms. Apnea alarm: disconnection or no breaths. Low exhale alarm: leak or disconnection. Low-pressure alarm: disconnection/malfunction. High peak pressure alarm: bronchospasm, secretions, obstruction, ARDS, pneumothorax.
10. Suction Only When Necessary: Avoid routine suctioning. Controversial in barotrauma management. Suction may be used to evacuate pleural air, but continuous suction may prolong bronchopleural fistula.
11. Lower Tidal Volume Settings: Use lower tidal volumes (8-10 mL/kg) to reduce alveolar overdistention risk. Low tidal volumes improve ventilator-free days and reduce non-pulmonary organ failure.
12. Provide Early Nutritional Support: Respiratory muscles weaken with prolonged ventilation and inadequate nutrition. Adequate protein intake (25% of daily kilojoules) is crucial for respiratory muscle strength. Limit carbohydrate intake to ≤ 25%.
13. Ensure Proper Sedation and Pain Management: Daily assessment of sedation needs is crucial. Sedation enhances comfort and minimizes patient-ventilator dyssynchrony. Neuromuscular blockade can improve synchrony and oxygenation.
14. Assist with Chest Tube Insertion (Tube Thoracostomy) or Needle Thoracostomy: Prompt evacuation of pleural air is needed for barotrauma management. Emergency needle thoracostomy for tension pneumothorax.
15. Observe Chest Tube Water-Seal Chamber for Air Leaks: Bedside check for air leak in water seal. Air leak with each inspiration in mechanically ventilated patient indicates persistent leak.
16. Clamp Tubing to Determine Air Leak Origin: If air leak persists, clamp chest tube near chest wall exit to differentiate pleural leak from system leak. Leak continuing with clamp indicates system leak.
6. Optimizing Cardiac Function
Mechanical ventilation impacts cardiac function due to increased intrathoracic pressure. This can decrease cardiac output by reducing venous return, affecting right ventricular function, and altering left ventricular distensibility.
Critical Care Nursing Interventions to Optimize Cardiac Function:
1. Assess Hemodynamic Status: Monitor level of consciousness, blood pressure, heart rate, central venous pressure (CVP), pulmonary artery diastolic pressure (PADP), pulmonary capillary wedge pressure (PCWP), and cardiac output. Mechanical ventilation can decrease venous return, leading to hypotension, tachycardia, and decreased cardiac output. Monitor closely during ventilator changes.
2. Assess Peripheral Circulation: Check capillary refill, skin temperature, and peripheral pulses. Weak pulses and slow capillary refill indicate reduced cardiac output. Cold, clammy skin is a compensatory response to low cardiac output and hypoxemia.
3. Monitor for Dysrhythmias: Dysrhythmias can result from hypoperfusion, acidosis, or hypoxia. Decreased cardiac output due to reduced right ventricular preload is more pronounced in hypovolemic patients and those with low ejection fraction.
4. Auscultate Heart Sounds: Decreased cardiac output causes diminished, weak, or thready pulses. Irregular heart sounds suggest dysrhythmias.
5. Monitor Fluid Balance and Urine Output: Maintain optimal hydration. Positive pressure ventilation can decrease renal blood flow, reducing urine output. Brain may release ADH in response to decreased blood flow, further reducing urine output.
6. Assess Activity Tolerance and Promote Rest: Overexertion increases oxygen demand and can compromise cardiac function. Dyspnea on exertion is a common symptom of cardiac compromise.
7. Monitor Liver Function Tests: Decreased cardiac output, increased hepatic vascular resistance, and elevated bile duct pressure can impair liver function.
8. Maintain Optimal Fluid Balance: Volume therapy may be needed to optimize cardiac output. However, fluid restriction may be necessary if PADP/PCWP increases and cardiac output remains low. Positive pressure ventilation can reduce renal function, urine volume, and sodium excretion.
9. Provide Small, Easily Digested Meals and Limit Caffeine: Large meals increase myocardial workload and vagal stimulation. Caffeine is a cardiac stimulant and may increase heart rate.
10. Measure Cardiac Output Parameters: Use thoracic electrical bioimpedance (TEB) to noninvasively monitor cardiac index, preload, afterload, contractility, and cardiac work. Useful for evaluating response to therapies.
11. Notify Healthcare Provider of Decreased Cardiac Output Signs: Report hypotension and decreased cardiac output promptly. Ventilator settings or PEEP may need adjustment. Exaggerated respiratory variation in arterial pressure waveform suggests ventilation is significantly impacting venous return and cardiac output.
12. Assist with Swan-Ganz Catheter Insertion and PEEP Studies: Swan-Ganz catheter allows hemodynamic monitoring and PEEP studies. PEEP studies involve adjusting PEEP levels and monitoring oxygenation and cardiac output to optimize settings.
13. Administer Medications as Ordered: Diuretics, inotropic agents, and vasopressors may be prescribed to manage fluid balance and support cardiac function. See Pharmacologic Management section.
7. Facilitating Weaning Process
Weaning from mechanical ventilation involves gradual withdrawal of ventilator support, ET tube removal, and finally oxygen therapy independence. Early weaning is crucial when safe and involves a collaborative approach.
Critical Care Nursing Interventions to Facilitate Weaning Process:
1. Assess Vital Signs: Stable vital signs and improvement in underlying condition are prerequisites for weaning. Defer weaning if tachycardia, pulmonary crackles, or hypertension are present. Fever increases metabolic rate and oxygen demand.
2. Assess Nutritional Status and Muscle Strength: Weaning is physically demanding. Patient must have stamina to breathe spontaneously. Early and aggressive nutritional support is crucial for long-term ventilator dependence weaning.
3. Determine Psychological Readiness: Anxiety about breathing independently can hinder weaning. Reassurance and support are needed. Fear of failure can impede progress.
4. Monitor for Weaning Intolerance Signs: Restlessness, changes in BP/HR/RR, accessory muscle use, discoordinated breathing, inability to cooperate, and skin color changes indicate weaning intolerance. Slow down or stop weaning if these signs occur. Monitor closely during T-piece trials for hypoxia signs.
5. Monitor Cardiopulmonary Response to Activity: Assess oxygen consumption and demand. Rapid shallow breathing index (RSBI) < 105 suggests weaning success. Clinical judgment remains crucial.
6. Monitor Laboratory Tests: CBC, serum albumin, prealbumin, transferrin, total iron-binding capacity, and electrolytes assess nutritional status and readiness for weaning.
7. Review Chest Radiograph and ABGs: Chest X-ray should show clear lungs or improved congestion/infiltrates. ABGs should show adequate oxygenation on FiO2 ≤ 40%.
8. Clarify Weaning Techniques: Explain SIMV, PSV, and spontaneous breathing trial (SBT). SBT is the preferred weaning method. Educate patient and family about weaning process to reduce anxiety.
9. Schedule Rest and Sleep: Maximize rest and sleep periods. Weaning is exhausting; adequate energy reserves are crucial. Weaning involves decreasing mandatory breaths and gradually increasing respiratory muscle workload.
10. Provide Encouragement and Recognition: Positive feedback and encouragement support patient efforts. Responsiveness to patient wishes and experiences is important. Build trust and address physical and mental needs during weaning.
11. Collaborate with Dietitian: Adjust diet as needed. Respiratory muscles weaken with malnutrition. Adequate protein is crucial, but excessive intake can increase carbon dioxide production and hinder weaning.
12. Terminate Weaning if Adverse Reactions Occur: Stop weaning if HR increase > 20 bpm, SBP increase > 20 mmHg, SpO2 < 90%, RR < 8 or > 20, ventricular arrhythmias, fatigue, panic, cyanosis, erratic breathing. Avoid respiratory failure and delayed extubation.
8. Promoting Communication & Alternative Communication Methods
Mechanical ventilation impairs voice production, causing significant communication challenges. Inability to communicate is highly stressful and can lead to anxiety, depression, and decreased self-esteem.
Critical Care Nursing Interventions for Promoting Communication:
1. Assess Communication Abilities: Evaluate patient’s ability to communicate using alternative methods (writing, gestures). Communication methods must be individualized based on patient’s alertness and physical abilities.
2. Evaluate Need for Talking Tracheostomy Tube: Patients with adequate cognition and motor skills may use a talking tracheostomy tube. Talking tubes allow speech while on ventilation.
3. Assess Communication Barriers in Mechanically Ventilated Patients: ICU nurses may experience uncertainty caring for awake, ventilated patients. Calming agitated patients can be challenging.
4. Establish Communication Means: Eye contact, yes/no questions, head nods, eye blinks, simple gestures, letter boards, picture boards. Use methods that are least tiring and frustrating for the patient. Family can assist in interpreting needs.
5. Educate on Communication Systems: Explain augmentative and alternative communication (AAC) systems. Aided AAC (electronic or non-electronic devices) and unaided AAC (gestures, body language). Speech-language pathologists are experts in AAC.
6. Plan IV Line Placement: Avoid placing IV lines in the dominant hand/wrist if possible to facilitate writing. Consider patient’s handedness when placing IV lines.
7. Place Call Light Within Reach: Ensure call light is accessible and answer promptly. Vigilant responsiveness increases patient safety and reduces anxiety of being unable to call for help.
8. Inform Staff of Communication Impairment: Alert all staff that patient cannot speak. Ensure staff responds at bedside, not via intercom. Positive staff interactions are crucial for patient experience.
9. Encourage Family Communication: Encourage family to talk to the patient, even in one-sided conversations. Family presence maintains patient connection to reality and family unit. Include daily happenings to keep patient informed.
10. Consult Speech Therapist: Refer to speech therapist for AAC assessment and recommendations. Speech therapists can train nurses on communication strategies and resources.
9. Initiating Measures for Infection Control & Management
Patients with artificial airways are at high risk for infection, particularly ventilator-associated pneumonia (VAP). VAP is a serious, life-threatening complication with high mortality. Infection control is critical.
Critical Care Nursing Interventions for Infection Control & Management:
1. Identify Infection Risk Factors: Intubation bypasses natural airway defenses. ET tubes impair mucociliary transport. Secretions accumulating above cuff are a bacterial growth medium.
2. Assess Sputum Characteristics: Purulent, odorous sputum suggests infection. Thick, tenacious sputum indicates dehydration. VAP is suspected with new infiltrate, fever, leukocytosis, and purulent secretions.
3. Auscultate Breath Sounds: Rhonchi and wheezes suggest retained secretions, increasing infection risk. Early detection enables prompt intervention.
4. Assess for Pulmonary Infection Signs: Fever, purulent secretions, elevated WBC count, positive cultures, pulmonary infiltrates on chest X-ray. VAP occurs in up to 28% of ventilated patients. Diagnostic triad for VAP: pulmonary infection, bacteriologic evidence, and radiologic evidence.
5. Obtain Sputum Culture: Identify pathogens and guide antibiotic therapy. Bronchoscopy or non-bronchoscopic techniques can obtain respiratory secretion samples.
6. Promote Hand Hygiene: Encourage hand washing and alcohol-based hand rubs for staff, visitors, and patient (if able). Wear appropriate PPE. Hand hygiene is the simplest and most important infection prevention measure.
7. Encourage Deep Breathing and Coughing Exercises: Maximize lung expansion and secretion mobilization. Prevent atelectasis and secretion stasis.
8. Provide Oral Hygiene Every 2 Hours: Use dental oral antibiotic rinse. Proper oral hygiene reduces oral bacterial load, which can be aspirated. Encourage toothbrushing and chlorhexidine mouthwash. Suction toothbrushes facilitate oral care. Teach secretion disposal.
9. Limit Visitors and Avoid Contact with Respiratory Infections: Reduce exposure to pathogens. VAP is the most common ICU infection, prolonging ICU stay and increasing costs.
10. Elevate Head of Bed 30-45 Degrees: Promotes lung expansion and reduces gastric reflux and aspiration. Semi-recumbent position reduces hospital-acquired pneumonia risk, especially during enteral feeding.
11. Use Continuous Subglottic Suction ET Tube: For intubation expected > 24 hours. Prevents secretion accumulation above cuff and reduces aspiration.
12. Use Sterile Suctioning Procedures: Reduce microorganism introduction into airway. CDC recommends changing ventilator tubing no more than every 48 hours; less frequent changes (5-7 days) may be acceptable.
13. Promote Humidification: Use heat moisture exchangers (HMEs) or heated humidifiers. HMEs are preferred to reduce circuit colonization. Prevent condensate from entering ET tube.
14. Spontaneous Awakening Trial (SAT): Per facility protocol. Promotes early extubation and reduces sedation. SAT involves reducing sedation until patient awakens and can follow commands. Reduced sedation time decreases VAP risk.
15. Administer Antibiotics or Antifungals as Prescribed: Empiric antibiotics for early-onset VAP (ceftriaxone, fluoroquinolones, etc.). Early and appropriate antibiotic therapy improves VAP outcomes. See Pharmacologic Management section.
10. Promoting Optimal Nutrition Balance
Nutritional support in ventilated patients is challenging due to anesthesia, airway compromise, and aspiration risk. Gastric mucosal ischemia and bleeding are potential concerns. Adequate nutrition is crucial for recovery.
Critical Care Nursing Interventions to Promote Optimal Nutrition:
1. Weigh Patient Regularly: Monitor for weight loss (7-10% body weight), indicating catabolism and poor nutrition. Malnutrition prolongs mechanical ventilation duration.
2. Evaluate Eating Ability: Patients with tracheostomy may eat, but ET tubes require tube feeding or parenteral nutrition. Nutrition is a predictor of ventilation duration.
3. Observe for Muscle Wasting and Subcutaneous Fat Loss: These indicate muscle energy depletion and respiratory muscle weakness. Malnutrition is common in chronic diseases and impairs respiratory function.
4. Auscultate Bowel Sounds and Measure Abdominal Girth: Monitor GI function. Mechanically ventilated patients are at risk for abdominal distention, ileus, and stress ulcer bleeding.
5. Monitor Gastric Residual Volumes: If enteral feeding, monitor residuals to prevent distention and regurgitation risk.
6. Offer Desired Foods: Poor appetite is common. Offer favorite foods to enhance oral intake when oral feeding is appropriate.
7. Provide Small, Frequent Meals: Soft, easily digested foods prevent fatigue and gastric distress. Adequate protein is crucial for wound healing, immune function, and lean body mass.
8. Encourage Oral Fluid Intake: At least 2500 mL/day (if tolerated). Prevents dehydration and constipation.
9. Provide Diet to Meet Respiratory Needs: High protein, high calorie diet may be needed during ventilation. Reduce carbohydrates and increase fat before weaning to minimize carbon dioxide production. ASPEN guidelines recommend adequate protein and energy delivery within the first 7 days.
10. Administer Early Enteral Feedings: Start enteral nutrition within 24-48 hours of admission or resuscitation to maintain immune function and organ structure.
11. Provide Parenteral Feedings if Enteral Intolerance: Parenteral nutrition is used if enteral feeding is not tolerated. However, parenteral nutrition increases risks of hyperglycemia, infections, and electrolyte imbalances. Use judiciously, especially in malnourished patients.
11. Providing Patient Education & Health Teachings
Education for patients and families prepares them for home care and ventilator management. Topics include suctioning, tracheostomy care, infection signs, cuff management, and vital sign assessment.
Critical Care Nursing Interventions for Patient Education & Health Teachings:
1. Assess Patient/Caregiver Understanding: Evaluate current knowledge of mechanical ventilation. Address knowledge gaps and misconceptions. Family caregivers need to understand modifiable factors, treatments, and clinical progress.
2. Assess Readiness and Ability to Learn: Consider learning limitations, motivation, and needs. Acute illness, fatigue, pain, and anxiety can impair learning. Caregivers may be overwhelmed and anxious about machinery and care responsibilities.
3. Encourage Questions and Expression of Feelings: Open communication facilitates learning and addresses concerns. Detached HCP behavior can increase uncertainty. Proactive emotional support is crucial.
4. Schedule Teaching Sessions: Quiet, non-stressful times. Pace information to learner’s ability. Ensure participants are rested. Progress from simple to complex information. Avoid overwhelming learners.
5. Use Multiple Teaching Formats: Books, pamphlets, audiovisuals, demonstrations, take-home sheets. Multi-sensory learning enhances retention. Provide resources for review after discharge. Video-based education is beneficial.
6. Discuss Lifestyle Impact of Ventilator Dependence: Home ventilation is a 24/7 commitment affecting the entire family. Prepare patient and family for long-term care needs and potential lifestyle changes. Provide anticipatory guidance and support for well-being.
7. Explain Vital Sign Assessment, Breath Sounds, and Ventilation Checks: Knowledge empowers patients and families and reduces anxiety. Teach tracheal suctioning when adventitious sounds or secretions are present. Avoid unnecessary suctioning.
8. Explain Communication Limitations: Intubation prevents speech. Explain alternative communication methods. Address frustration and hopelessness related to communication difficulties.
9. Explain NPO Status and Nutrition: Explain why oral intake is restricted during intubation and assure alternative nutrition (IV fluids, tube feeding, parenteral nutrition) will be provided. Swallow evaluation may be needed before oral intake is resumed.
10. Explain Ventilator Alarms: Explain that alarms are normal and staff are nearby. Reduce alarm anxiety. Address alarm fatigue issues and ensure alarms are properly set and responded to.
11. Explain Suctioning Needs: Explain why suctioning is needed and the procedure. If discharging home with tracheostomy, ensure suction equipment is in place and caregiver is trained.
12. Explain Weaning Process: Describe weaning stages (ventilator, tube, oxygen). Patient needs to understand what to expect during weaning.
13. Discuss Long-Term Ventilation Management: If long-term ventilation is anticipated, discuss long-term care options (facilities or home care). Provide referrals and resources. Community nurses can assist with home care resources.
14. Recommend CPR Training for Caregivers: CPR training enhances caregiver confidence in handling emergencies. Teach mouth-to-tracheostomy CPR.
15. Address Safety Concerns and Equipment: Ensure all safety concerns are addressed and equipment is in place before discharge. Plan for power failures and teach manual ventilation with Ambu bag. Predischarge planning eases transition.
Recommended Resources
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
Evidence-based nursing diagnosis handbook for care planning.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Comprehensive nursing care plan guide with evidence-based guidelines.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick reference for nursing diagnoses, interventions, and rationales.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Manual for planning, individualizing, and documenting nursing care.
Comprehensive care planning resource across nursing specialties.
See Also
Other resources related to respiratory nursing care plans:
