Nursing Diagnosis in Critical Care for Mechanically Ventilated Patients

What is a Mechanical Ventilator?

A mechanical ventilator is a device that provides breathing support by delivering air into the lungs under positive or negative pressure. This machine is crucial for patients who cannot breathe adequately on their own, ensuring continuous ventilation and oxygen delivery. Typically, patients are intubated with an endotracheal tube or tracheostomy tube before being connected to the ventilator via oxygen tubing. Mechanical ventilation becomes necessary when a patient exhibits signs of respiratory failure or airway compromise, often confirmed by consistently low oxygen levels (PaO2), elevated carbon dioxide levels (PaCO2), and persistent acidosis (low pH).

Historically, mechanical ventilators were categorized by their ventilation support method, falling into two main types: negative-pressure and positive-pressure ventilators.

Positive-pressure Ventilators (PPVs)
Positive-pressure ventilators work by applying positive pressure to the airway, forcing air into the lungs and expanding the alveoli during inspiration. This method generally requires endotracheal intubation or tracheostomy.

Volume-cycled ventilators: These ventilators deliver a predetermined volume of air with each breath. Once this volume is administered, the ventilator cycles off, allowing passive exhalation. The delivered air volume remains relatively consistent.
Pressure-cycled ventilators: These ventilators deliver airflow until a preset pressure is reached, at which point they cycle off, and exhalation occurs.
High-frequency oscillatory support ventilators: These specialized ventilators deliver extremely rapid respiratory rates, ranging from 180 to 900 breaths per minute. These are accompanied by very small tidal volumes and high airway pressures, effectively moving oxygen-rich air through the airways while facilitating alveolar air expulsion.
Noninvasive positive-pressure ventilation (NIPPV): NIPPV provides positive-pressure ventilation through facemasks (covering the nose and mouth), nasal masks, or oral/nasal devices like nasal pillows. NIPPV avoids the need for intubation or tracheostomy, thus reducing the risk of hospital-acquired infections such as pneumonia. Pressure-controlled ventilation with pressure support is a common and comfortable mode, reducing breathing effort and improving gas exchange.

Negative-pressure Ventilators (NPVs)
Negative-pressure ventilators, applied externally to the thorax and abdomen, inflate the lungs by expanding the rib cage and abdomen. While less common than PPVs today, NPVs were historically significant, particularly during the Copenhagen polio epidemic in the 1950s.

Iron-lung or Tank ventilators: These large, cylindrical devices enclose the patient’s body, except for the head, in a sealed tank. By cyclically altering air pressure within the tank, these ventilators stimulate inhalation and exhalation through the patient’s natural airways.
Cuirass ventilator: A smaller, shell-like version of the iron lung, the cuirass ventilator encases only the patient’s torso, sealed at the neck and waist. An external pump or portable ventilator regulates pressure within the shell.
Exovent ventilator: A modern iteration of the cuirass ventilator, the Exovent NPV was developed in 2020 in response to the COVID-19 pandemic.
Jacket ventilator: Also known as poncho or raincoat ventilators, jacket ventilators are lighter versions of iron lungs or cuirass ventilators. They are made from airtight material with internal plastic or metal grids and utilize a suction pump and backplate, with pressure regulated by a portable ventilator.

Ventilator mode defines 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.

Nursing Care Plans & Management in Critical Care

For patients undergoing endotracheal intubation and/or tracheostomy and receiving mechanical ventilation in critical care, primary nursing goals include enhancing gas exchange, maintaining a clear airway, preventing trauma, facilitating communication, reducing anxiety, and preventing cardiac and pulmonary complications.

Nursing Problem Priorities in Critical Care

The critical nursing priorities for patients on mechanical ventilation are:

Ensuring a patent airway and correct endotracheal tube placement.
Monitoring and managing respiratory status, including lung sounds, oxygen saturation, and end-tidal carbon dioxide (EtCO2).
Managing sedation and pain for patient comfort and ventilator synchrony.
Identifying and addressing potential complications like tube dislodgement, pneumothorax, or airway obstruction, and implementing immediate interventions.
Preventing ventilation-associated complications, such as ventilator-associated pneumonia (VAP) and ventilator-induced lung injury (VILI).
Collaborating with the healthcare team to optimize ventilator settings, weaning protocols, and extubation readiness, alongside providing continuous patient and family education and support.

Nursing Assessment in Critical Care

Assess for the following subjective and objective data:

Adventitious breath sounds (wheezing, crackles, rhonchi)
Apnea or irregular breathing patterns
Apprehension and anxiety
Arterial pH less than 7.35 (acidosis)
Decreased tidal volume (reduced air exchange)
Decreased oxygen saturation (SpO2 < 92%)
Decreased PaO2 level (< 60 mm Hg – hypoxemia)
Diminished or absent lung sounds
Dyspnea (shortness of breath)
Forced vital capacity less than 10 mL/kg (reduced lung capacity)
Increased PaCO2 level (> 50 mm Hg – hypercapnia)
Increased or decreased respiratory rate (abnormal breathing frequency)
Inability to maintain airway (due to emesis, depressed gag or cough reflex)
Restlessness and agitation
Abnormal breath sounds
Excessive secretions in the airway
Increased peak airway pressure (indicating resistance to airflow)
Ineffective cough

Assess for factors related to mechanical ventilation:

Acute respiratory failure (underlying cause of ventilation)
Noncompliant lung tissue (e.g., ARDS, pulmonary fibrosis)
Respiratory muscle weakness or paralysis (neuromuscular disorders)
Altered ventilation-perfusion ratio (V/Q mismatch)
Decreased energy and fatigue
Endotracheal intubation (presence of artificial airway)
Stasis of secretions (impaired mucociliary clearance)

Nursing Diagnosis in Critical Care

Formulating a nursing diagnosis is crucial for patients in critical care undergoing mechanical ventilation. Based on comprehensive assessment, nursing diagnoses pinpoint specific health challenges. These diagnoses guide the development of individualized care plans, focusing on the patient’s unique needs and clinical condition. While standardized nursing diagnosis labels provide a valuable framework, clinical practice emphasizes the nurse’s expert judgment and adaptability in tailoring care. In critical care, prioritizing nursing diagnoses directly impacts patient outcomes and the effectiveness of interventions.

Common nursing diagnoses in critical care for patients on mechanical ventilation include:

Impaired Gas Exchange related to altered oxygen supply, alveolar-capillary membrane changes, or ventilation-perfusion mismatch.
Ineffective Airway Clearance related to presence of endotracheal tube, increased secretions, or decreased cough reflex.
Risk for Infection related to invasive procedures, presence of artificial airway, and suppressed immune response.
Risk for Injury related to ventilator malfunction, tube displacement, or adverse effects of mechanical ventilation.
Anxiety related to inability to communicate, dependence on ventilator, and critical care environment.
Impaired Verbal Communication related to endotracheal tube or tracheostomy.
Deficient Knowledge related to mechanical ventilation, treatment regimen, or discharge planning.
Imbalanced Nutrition: Less Than Body Requirements related to increased metabolic demands and inability to take oral intake.
Decreased Cardiac Output related to increased intrathoracic pressure and altered venous return.
Disturbed Sleep Pattern related to critical care environment and mechanical ventilation.

Nursing Goals in Critical Care

The primary nursing goals for mechanically ventilated patients in critical care are:

Achieve and maintain optimal gas exchange, indicated by reduced dyspnea, normal oxygen saturation (SpO2 > 92%), and arterial blood gases (ABGs) within patient-specific parameters.
Prevent complications associated with mechanical ventilation, including VAP, VILI, and barotrauma.
Facilitate patient participation in weaning efforts as appropriate to their condition and capabilities.
Ensure caregivers understand and can implement necessary behaviors to support the patient’s respiratory function.
Maintain clear and patent airways, evidenced by normal breath sounds post-suctioning.
Equip caregivers to identify potential complications and initiate appropriate actions.
Reduce patient anxiety, demonstrated by a calm demeanor and cooperative behavior.

Nursing Interventions and Actions in Critical Care

Nursing care for patients in critical care on mechanical ventilation demands both technical proficiency and effective communication. Continuous assessment, particularly pulmonary auscultation and arterial blood gas interpretation, is essential. Nurses play a vital role in early detection of changes and potential complications. A strong nurse-patient relationship, even in the context of critical illness, is crucial for optimal care.

1. Managing Mechanical Ventilation in Critical Care

Managing mechanical ventilation effectively in critical care requires a deep understanding of ventilator settings and patient response. The goal is to support the patient’s respiratory needs while minimizing complications.

Prior to intubation assessment:

1. Investigate the etiology of respiratory failure.

Understanding the underlying cause is crucial for tailoring ventilation support and addressing the root problem.
2. Observe changes in the level of consciousness.
Early hypoxia signs include disorientation and restlessness; late signs include lethargy and stupor. Mechanical ventilation addresses both hypercapnic and hypoxemic respiratory failure.
3. Assess respiratory rate, depth, and pattern, including accessory muscle use.
Changes indicate respiratory distress. Mechanical ventilation is needed when spontaneous breathing is insufficient to sustain life.
4. Assess heart rate and blood pressure.
Tachycardia can be an early sign of hypoxia; blood pressure may initially increase then decrease with worsening hypoxia.
5. Auscultate lungs for normal or adventitious breath sounds.
Adventitious sounds indicate respiratory issues. Auscultation helps detect pulmonary edema, obstructive lung disease, or pleural effusion/pneumothorax.
6. Assess skin color and check lips and nailbeds for cyanosis.
Cyanosis indicates severe deoxygenation and ineffective breathing.
7. Monitor oxygen saturation using pulse oximetry.
Pulse oximetry detects early oxygen changes; normal SpO2 is 92-98% for adults without respiratory issues.
8. Monitor arterial blood gases (ABGs) as indicated.
ABGs show respiratory failure (increased PaCO2, decreased PaO2) and guide ventilator adjustments.

After intubation assessment:

9. Assess for correct endotracheal (ET) tube placement.

Verify placement via symmetrical chest rise, bilateral breath sounds, and X-ray. Correct placement is crucial for effective ventilation.
10. Assess patient comfort and cooperation with mechanical ventilation.
Discomfort may indicate incorrect ventilator settings or inadequate oxygenation. Patients should breathe comfortably, not “fight” the ventilator.
11. Assess ventilator settings and alarm system hourly.
Ensure settings are accurate and alarms are functional. Never disable alarms, even during suctioning.
12. Count patient respirations for one full minute and compare to ventilator settings.
Discrepancies may indicate patient-ventilator asynchrony or respiratory distress.
13. Maintain airway patency using oral or nasal airways as needed.
Artificial airways prevent tongue occlusion. Choose appropriate size for patient.
14. Maintain High-Fowler’s position as tolerated.
This position promotes oxygenation by maximizing chest expansion. Prevent sliding down to avoid diaphragmatic compression.

Preparation for endotracheal intubation:

15. Notify respiratory therapist to bring mechanical ventilator.

Prepare for immediate ventilation support.
16. Prepare intubation equipment: ET tubes (various sizes), laryngoscope, blades, stylet, syringe, benzoin, waterproof tape, local anesthetic agents.
Ensure all necessary equipment is readily available for rapid intubation.
17. Administer sedation as ordered.
Sedation promotes patient comfort and eases intubation. Pretreatment agents (LOAD: Lidocaine, Opioid, Atropine, Defasciculating agents) may be used.

Assisting with intubation:

18. Position patient supine, hyperextend neck (unless contraindicated), align airway axes.

Optimal positioning is crucial for visualizing vocal cords during intubation. Sniffing position is often used.
19. Apply cricoid pressure (Sellick maneuver) as directed.
May prevent regurgitation during rapid sequence intubation. Maintain pressure until ET tube placement is verified.
20. Preoxygenate patient as indicated.
Administer 100% oxygen for 3 minutes via nonrebreather mask to prevent desaturation during intubation.
21. Verify correct ET tube placement.
Use end-tidal CO2 detector (colorimetric or quantitative) to confirm placement within 1-2 breaths.
22. Continue manual Ambu-bag ventilation until ET tube is stabilized.
Stabilize patient before initiating mechanical ventilation. Use 100% oxygen BVM if desaturation occurs.
23. Document ET tube position, noting centimeter marking at lip.
Documentation provides a reference for detecting tube displacement. Typical depth is 21cm for women, 23cm for men.
24. Institute mechanical ventilation with prescribed settings.
Set ventilator mode (AC, SIMV), tidal volume, rate, FiO2, PEEP, pressure support as ordered. AC mode is often initial mode.
25. Anticipate need for nasogastric/oral gastric suction.
Suction prevents abdominal distention from gastric intubation or air entry during resuscitation.
26. Administer muscle-paralyzing agents, sedatives, and opioid analgesics as ordered.
Pharmacological support ensures patient comfort and ventilator synchrony.
27. Examine cuff volume and pressure.
Inflate cuff until no leak is detected. Respiratory therapist checks cuff pressure (20-30 mm Hg).
28. Position patient with head of bed elevated.
Elevate head to at least 30 degrees to reduce aspiration risk and improve oxygenation.
29. Inflate ET tube cuff properly and check inflation every 4-8 hours.
Proper inflation (20-30 cm water) ensures ventilation and reduces aspiration risk.
30. Note inspired humidity and temperature; use heat moisture exchanger (HME).
Maintain humidity and temperature to prevent dehydration of airway and thickened secretions.

2. Promoting Patent Airway Clearance in Critical Care

Maintaining a patent airway is paramount for mechanically ventilated patients in critical care. Impaired mucociliary clearance and cough reflexes increase the risk of secretion accumulation.

1. Assess airway patency.

Obstruction can be caused by secretions, mucous plugs, hemorrhage, bronchospasm, or tube malposition.
2. Observe sputum color, odor, quantity, and consistency.
Thick, tenacious secretions increase airway resistance. Discolored, odorous sputum suggests infection.
3. Auscultate lungs for breath sounds.
Diminished or adventitious sounds may indicate obstruction or need for suctioning.
4. Monitor oxygen saturation before and after suctioning.
Evaluates suctioning effectiveness. SpO2 < 92% indicates hypoxia.
5. Assess arterial blood gases (ABGs).
Decreasing PaO2 and increasing PaCO2 indicate respiratory compromise.
6. Monitor peak airway pressures and airway resistance.
Increases signal secretion/fluid accumulation and potential ventilation issues.
7. Monitor ET tube placement.
Tube may slip into right main bronchus, obstructing left lung airflow.
8. Note excessive coughing, dyspnea, high-pressure alarm, visible secretions.
These indicate need for suctioning in patients with ineffective cough reflexes.
9. Explain suctioning procedure to patient; reassure throughout.
Reduce anxiety and fear associated with suctioning. Provide sedation and pain relief as needed.
10. Encourage deep breathing and coughing exercises; early ambulation when possible.
Expand alveoli and mobilize secretions. Ambulation is most effective.
11. Turn patient every two hours.
Mobilizes secretions and prevents VAP. Promotes drainage and ventilation to all lung segments.
12. Institute airway suctioning as indicated, based on breath sounds and ventilator pressure.
Suction based on clinical need, not routine. Over-suctioning can cause hypoxia.
13. Use closed in-line suction.
Reduces infection risk and hypoxia; often less expensive. Maintain sterile technique.
14. Hyperoxygenate as ordered before suctioning.
Preoxygenation with 100% oxygen prevents hypoxia during suctioning.
15. Instruct patient in coughing techniques during suctioning.
Enhances cough effectiveness. Step-cough technique for weak coughs.
16. Administer IV fluids and aerosol bronchodilators as indicated.
Hydration thins secretions. Bronchodilators relax smooth muscles and improve ventilation.
17. Administer humidified oxygen as prescribed.
Supplements oxygen and prevents drying of airways and secretions.
18. Consult respiratory therapist for chest physiotherapy as indicated.
Chest physiotherapy (postural drainage, percussion) loosens and mobilizes secretions.

3. Reducing Anxiety and Fear in Critical Care

Mechanical ventilation in the critical care setting can induce significant anxiety and fear in patients and families. Addressing psychological needs is as vital as physiological support.

1. Assess patient’s understanding of mechanical ventilation and perceived threat.

Accurate appraisal guides treatment strategies and addresses individual concerns.
2. Assess for signs of anxiety.
Anxiety affects respiratory rate and pattern, causing rapid, shallow breathing and ABG abnormalities.
3. Observe physical responses of anxiety.
Restlessness, repetitive movements, vital sign changes.
4. Assess previous coping strengths of patient and family.
Past coping mechanisms can be leveraged to increase sense of control.
5. Encourage expression of fears; acknowledge concerns.
Verbalization helps manage fears and clarify reality.
6. Reduce distracting stimuli; explain ventilator alarms.
Quiet environment enhances rest. Explain alarms to reduce alarm fatigue and anxiety.
7. Educate about safety precautions: backup power, oxygen, emergency equipment.
Reduces anxiety by addressing the unknown and preplanning for emergencies.
8. Display calm, confident manner; be available for support and explanations.
Trusted presence and clear explanations reduce anxiety.
9. Provide relaxation techniques.
Music therapy, guided imagery, and other techniques can reduce anxiety.
10. Encourage sedentary diversional activities.
Television, music, handicrafts, writing enhance quality of life and pass time.
11. Encourage visits from family and friends; promote optimism.
Social support reinforces security and well-being.
12. Promote spiritual care as appropriate.
Reiki therapy and other spiritual practices may reduce anxiety.
13. Reinforce education about cognitive behavioral therapy (CBT).
CBT can help manage anxiety during mechanical ventilation and weaning.
14. Refer to psychiatric liaison, psychiatrist, or chaplain as appropriate.
Specialty expertise provides wider treatment options for anxiety management.

4. Administering Medications and Pharmacological Support in Critical Care

Pharmacological support is crucial in critical care for mechanically ventilated patients to optimize respiratory function and ensure comfort.

1. Induction agents: Rapid loss of consciousness for intubation.

1.1. Etomidate: Rapid onset, short duration, cerebroprotective, hemodynamically stable.
1.2. Ketamine: Dissociative state, analgesic, bronchodilator, may decrease intracranial pressure.

2. Paralyzing agents: Neuromuscular blockade after induction.

2.1. Succinylcholine: Rapid onset (45-60 sec), shortest duration (8-10 min).
2.2. Rocuronium: Slightly longer onset (60-75 sec), longer duration (30-60 min).

3. Opioids: Pain relief and sedation.

3.1. Morphine: Potent opioid analgesic, reduces pain perception.
3.2. Fentanyl: Potent opioid, pain relief, sedation, reduces anxiety and agitation.

4. Diuretics: Manage fluid balance.

Loop diuretics (e.g., furosemide) for edema and volume overload.

5. Vasopressors and inotropes: Support cardiac output.

Vasopressors (e.g., norepinephrine) and inotropes (e.g., dobutamine) improve cardiac function.

6. Broad-spectrum antibiotics: Empiric treatment of potential infections.

Ceftriaxone, cefepime, piperacillin-tazobactam for wide coverage of bacteria.

7. Vancomycin and Linezolid: Treat MRSA infections.

Effective against MRSA-related respiratory infections.

8. Antifungal agents: Treat fungal infections.

Fluconazole, voriconazole for suspected or confirmed fungal pneumonia.

5. Preventing Respiratory Injury Risk in Critical Care

Ventilator-induced lung injury (VILI), including barotrauma and volutrauma, is a significant risk in critical care. Prevention requires careful ventilator management and monitoring.

1. Review ventilator settings hourly, especially tidal volume and plateau pressures.

Ensure correct settings and prevent barotrauma. Peak pressures > 45 cm H2O and plateau pressures > 30 cm H2O are risk factors.
2. Assess respiratory rate, rhythm, and work of breathing.
Synchronize patient with ventilator; avoid “bucking.” Adjust settings or sedate patient as needed.
3. Assess arterial blood gas results and monitor oxygen saturation.
Guide ventilator settings and interventions. ABGs assess acid-base status and oxygenation.
4. Assess for barotrauma signs: crepitus, subcutaneous emphysema, altered chest excursion, asymmetrical chest, abnormal ABGs, tracheal shift, restlessness, pneumothorax on chest X-ray.
Early detection is crucial as barotrauma can occur at any time, even in sedated patients.
5. Auscultate breath sounds.
Decreased breath sounds on one side may indicate pneumothorax.
6. Monitor chest X-ray reports daily; stat portable chest X-ray if barotrauma suspected.
Chest radiography is key for early detection of barotrauma.
7. Monitor plateau pressures with respiratory therapist.
Plateau pressure monitoring helps prevent barotrauma. Maintain below 30 cm H2O.
8. Ensure ventilator alarms are ON.
Alarms alert to ventilation problems. Joint Commission emphasizes alarm safety.
9. Listen for alarms; know alarm ranges and troubleshooting.
Prompt response to alarms is vital. Apnea, low exhale, low pressure, and high peak pressure alarms indicate different issues.
10. Suction patient only when necessary.
Avoid over-suctioning, which can worsen barotrauma. Suction may be used to evacuate pleural air in pneumothorax.
11. Lower ventilator tidal volume settings, as indicated.
Lower tidal volumes (8-10 mL/kg) reduce alveolar overdistention risk.
12. Provide early nutritional support, as appropriate.
Adequate nutrition, especially protein, is crucial for respiratory muscle strength.
13. Ensure proper sedation and pain management.
Minimize agitation and patient-ventilator dyssynchrony with adequate sedation.
14. Assist in tube thoracostomy, emergency needle thoracostomy, or large-bore thoracostomy.
Prompt evacuation of pleural air is needed for barotrauma. Needle thoracostomy for tension pneumothorax.
15. Observe for air leaks in water-seal chamber.
Detects persistent air leaks. Air leak with each inspiration in mechanically ventilated patient.
16. Clamp tubing to determine origin of air leak.
Differentiates between pleural air leak and system leak. Leak persists with clamped tube indicates system leak.

6. Optimizing Cardiac Function in Critical Care

Mechanical ventilation in critical care can impact cardiac function due to increased intrathoracic pressures. Optimizing cardiac function is essential for overall patient stability.

1. Assess level of consciousness, blood pressure, heart rate, hemodynamic parameters.

Mechanical ventilation can decrease venous return, reducing BP, increasing HR, and decreasing cardiac output.
2. Assess capillary refill, skin temperature, and peripheral pulses.
Weak pulses, slow capillary refill, and cool skin indicate reduced cardiac output.
3. Monitor for dysrhythmias.
Dysrhythmias can result from low perfusion, acidosis, or hypoxia.
4. Auscultate heart sounds.
Diminished heart sounds may indicate decreased cardiac output.
5. Monitor fluid balance and urine output.
Positive pressure ventilation can reduce blood flow to kidneys and urine output. Monitor for fluid retention.
6. Assess response to activity and promote rest.
Overexertion increases oxygen demand and can compromise myocardial function.
7. Monitor liver function test results.
Decreased cardiac output can adversely affect liver function.
8. Maintain optimal fluid balance.
Volume therapy may be needed, but fluid restriction may be necessary if pulmonary pressures increase.
9. Provide small, easily digested meals; limit caffeine.
Large meals increase myocardial workload. Caffeine is a cardiac stimulant.
10. Measure cardiac output parameters and other functional parameters as appropriate.
Thoracic electrical bioimpedance (TEB) can noninvasively measure cardiac output.
11. Notify healthcare provider of signs of decreased cardiac output; anticipate ventilator changes.
Hypotension and decreased cardiac output may be ventilator-related. Respiratory variation on arterial pressure waveform is a clue.
12. Assist in Swan-Ganz catheter insertion and PEEP studies in ICU.
PEEP studies optimize PEEP settings while monitoring oxygenation and cardiac output.
13. Administer medications as ordered (diuretics, inotropic agents).
Diuretics manage fluid overload; inotropes improve cardiac contractility.

7. Facilitating Weaning Process in Critical Care

Weaning from mechanical ventilation in critical care is a staged process requiring careful assessment and patient support.

1. Assess vital signs.

Stable vital signs and improvement in underlying condition are needed before weaning. Defer weaning if tachycardia, crackles, or hypertension present.
2. Assess nutritional status and muscle strength.
Adequate nutrition and muscle strength are crucial for weaning success.
3. Determine psychological readiness for weaning.
Address patient anxiety about breathing independently. Reassurance is key.
4. Note restlessness, vital sign changes, accessory muscle use, discoordinated breathing, inability to cooperate, skin color changes.
These indicate need for slower weaning or program termination.
5. Monitor cardiopulmonary response to activity.
Excessive oxygen consumption indicates potential weaning failure. Rapid shallow breathing index < 105 is favorable.
5. Monitor laboratory tests as indicated.
CBC, albumin, prealbumin, transferrin, electrolytes assess nutritional adequacy for weaning.
6. Review chest radiograph results and ABGs.
Clear lungs or improvement and satisfactory oxygenation on FiO2 ≤ 40% are needed.
7. Clarify weaning techniques for patient and family.
Explain SIMV, PSV, SBT. SBT is preferred method. Reduce fear of unknown and promote cooperation.
8. Schedule undisturbed rest and sleep periods.
Maximize energy for weaning. Reestablishing spontaneous breathing is exhausting.
9. Provide encouragement and recognition of efforts.
Positive feedback and responsiveness to patient wishes enhance weaning success.
10. Collaborate with dietitian for diet adjustments.
Adequate protein is essential; avoid excessive carbohydrate intake before weaning.
11. Terminate weaning process if adverse reactions occur.
Adverse reactions include increased HR, BP, decreased SpO2, abnormal RR, arrhythmias, fatigue, panic, cyanosis, erratic breathing.

8. Promoting Communication & Alternative Communication Methods in Critical Care

Communication is severely impaired by mechanical ventilation in critical care. Establishing effective alternative methods is critical to reduce patient distress.

1. Assess patient’s ability to communicate by alternative means.

Consider patient’s alertness, motor skills, and cognitive function when selecting communication methods.
2. Evaluate need for talking tracheostomy tube.
For cognitively and physically capable patients, talking trach tubes allow verbal communication.
3. Assess communication barriers in invasively mechanically ventilated (IMV) patients.
Recognize uncertainty among nurses caring for awake IMV patients.
4. Establish a means of communication.
Use eye contact, yes/no questions, gestures, letter boards, picture boards. Family can assist.
5. Educate patient and family about available communication systems.
Augmentative and alternative communication (AAC) systems: aided (electronic/non-electronic) and unaided (gestures).
6. Plan form of communication before IV line placement.
Avoid placing IV line in dominant hand to facilitate writing.
7. Place call light within reach; answer immediately.
Ensures patient can signal needs and feel secure.
8. Inform staff of patient’s inability to speak.
Alert staff to respond at bedside instead of intercom.
9. Encourage family to talk to patient.
One-sided conversation helps maintain reality and family connection.
10. Consult speech therapist for appropriate communication method.
Speech-language pathologists are experts in communication disorders and AAC.

9. Initiating Measures for Infection Control & Management in Critical Care

Ventilator-associated pneumonia (VAP) is a major risk in critical care for mechanically ventilated patients. Strict infection control is essential.

1. Identify infection risk factors.

Intubation bypasses normal airway defenses; ET tubes impair mucociliary transport.
2. Assess sputum characteristics.
Purulent, odorous sputum indicates infection; thick sputum suggests dehydration.
3. Auscultate breath sounds.
Rhonchi and wheezes suggest retained secretions and potential infection.
4. Assess for pulmonary infection signs: increased temperature, purulent secretions, elevated WBC, positive cultures, chest X-ray evidence.
VAP is a serious complication with high mortality. Diagnostic triad: pulmonary infection, bacteriologic evidence, radiologic suggestion.
5. Obtain sputum culture as indicated.
Identifies pathogens and guides antibiotic selection. Bronchoscopy or non-bronchoscopic techniques may be used.
6. Encourage hand hygiene among staff, family, and patient.
Hand washing and alcohol-based rubs are key to preventing hospital-acquired infections. Use PPE.
7. Encourage deep breathing and coughing exercises.
Maximize lung expansion and mobilize secretions, preventing atelectasis and secretion accumulation.
8. Provide oral hygiene every two hours, including antibiotic rinse. Instruct on secretion disposal.
Oral hygiene reduces oral bacterial flora. Chlorhexidine mouthwash, tooth brushing, proper tissue disposal.
9. Limit visitors and avoid contact with persons with respiratory infections.
Reduce exposure to pathogens in immunocompromised patients.
10. Elevate head of bed to 30-45 degrees or perform subglottic suctioning unless contraindicated.
Reduces gastric reflux and aspiration, preventing pneumonia. Semi-recumbent position reduces VAP risk.
11. Use continuous subglottic suction ET tube for intubation > 24 hours.
Prevents secretion accumulation and aspiration of oropharyngeal secretions.
12. Use sterile suctioning procedures and minimize opening of ventilator tubes.
Reduces microorganism introduction. Change tubing no more than every 48 hours.
13. Promote humidifiers or heat moisture exchangers.
Passive humidifiers preferred to reduce circuit colonization. Prevent condensation from entering ET tube.
14. Attempt spontaneous awakening trial as indicated.
Early extubation and reduced sedation minimize VAP risk. Spontaneous awakening and breathing trials.
15. Administer antibiotics or antifungals as prescribed.
Empiric antibiotics for early-onset VAP. Early administration of appropriate antibiotics improves outcomes.

10. Promoting Optimal Nutrition Balance in Critical Care

Nutritional support is challenging but crucial for mechanically ventilated patients in critical care.

1. Weigh patient regularly.

Significant weight loss indicates catabolism and poor nutritional status, impacting ventilatory drive.
2. Evaluate ability to eat.
Patients with ET tubes need tube feeding or parenteral nutrition.
3. Observe for muscle wasting and loss of subcutaneous fat.
Indicates depletion of muscle energy and reduced respiratory muscle function.
4. Auscultate bowel sounds and measure abdominal girth. Observe for diarrhea and constipation.
GI function essential for enteral feeding. Monitor for distention, ileus, and gastric bleeding.
5. Monitor gastric residual volumes.
Prevent gastric distention and aspiration risk with enteral feedings.
6. Offer food patient desires and document oral intake resumption.
Poor appetite is common. Favorite foods may enhance intake.
7. Provide small, frequent meals of soft, easily digested foods.
Prevents fatigue, enhances intake, reduces gastric distress. Adequate protein is crucial for healing.
8. Encourage increased oral intake (at least 2500 mL/day) within cardiac limits.
Prevent dehydration and constipation.
9. Provide diet meeting respiratory needs.
High carbohydrate, protein, and calorie intake may be needed initially; reduce carbohydrates before weaning.
10. Administer early enteral feedings as needed.
Start within 24-48 hours of ICU admission to maintain immune function. ASPEN guidelines.
11. Provide parenteral feedings if enteral feedings not tolerated.
Parenteral nutrition for severely malnourished patients when enteral route is not feasible. Monitor for complications.

11. Providing Patient Education & Health Teachings for Critical Care Discharge

Education for patients and families is crucial for successful transition from critical care to home, especially for long-term mechanical ventilation.

1. Assess patient and caregiver perception and understanding of mechanical ventilation.

Starting point for education. Address knowledge gaps and misconceptions.
2. Assess readiness and ability to learn.
Tailor education to learning limitations, motivation, and needs. Consider fatigue, pain, sensory overload.
3. Encourage questions and expression of feelings.
Open communication and address misconceptions. HCP behavior impacts family understanding.
4. Schedule teaching sessions during quiet times; pace information.
Ensure rest to enhance learning. Logical sequence, simple to complex information.
5. Provide materials in multiple formats: books, pamphlets, audiovisuals, demonstrations, handouts.
Multisensory learning and resources for review post-discharge. Consider video-based education.
6. Encourage evaluation of ventilator dependence impact on lifestyle.
Home ventilation is 24/7 job. Address long-term health changes and caregiver roles.
7. Explain importance of vital sign assessment, breath sound auscultation, ventilation checks.
Reduces anxiety by providing actionable knowledge. Suctioning PRN, not routinely.
8. Explain inability to talk while intubated; alternative communication methods.
Endotracheal tube passes vocal cords. Teach alternative communication: paper, pen, pictures.
9. Explain inability to eat/drink while intubated; alternative nourishment (IV fluids, tube feeds).
Aspiration risk is high. Swallow evaluation may allow oral intake in long-term care.
10. Explain ventilator alarms; staff proximity.
Reduce anxiety about alarms. Explain normal alarms and staff responsiveness.
11. Explain need for suctioning as needed.
Reduce anxiety about suctioning procedure. Ensure home suction equipment for discharge.
12. Explain weaning process; extubation as sign of improvement.
Help patient maintain control and understand process. Weaning stages: ventilator, tube, oxygen.
13. Discuss long-term ventilation care management and referrals (facilities/home care).
Continuity of care with specialized resources. Community nurse for home resources. Vendor follow-up for equipment.
14. Recommend CPR training for caregivers.
Sense of security in emergencies. Mouth-to-tracheostomy breathing for CPR education.
15. Ensure safety concerns addressed; equipment in place pre-discharge.
Ease transfer process. Plan for power failures, manual self-inflation bag use.