Caring for the Patient on a Ventilator

The nurse must be able to do the following:

1. Identify the indications for mechanical ventilation.
2. List the steps in preparing a patient for intubation.
3. Determine the FIO2, tidal volume, rate and mode of ventilation on a given
ventilator.
4. Describe the various modes of ventilation and their implications.
5. Describe at least two complications associated with patients response to mechanical
ventilation and their signs and symptoms.
6. Describe the causes and nursing measures taken when trouble-shooting ventilator
alarms.
7. Describe preventative measures aimed at preventing selected other complications
related to endotracheal intubation.
8. Give rationale for selected nursing interventions in the plan of care for the ventilated
patient.
9. Complete the care of the ventilated patient checklist.
10. Complete the suctioning checklist.
1. To review indications for and basic modes of mechanical ventilation,
possible complications that can occur, and nursing observations and
procedures to detect and/or prevent such complications.
2. To provide a systematic nursing assessment procedure to ensure early
detection of complications associated with mechanical ventilation.
Indication for Intubation
1. Acute respiratory failure evidenced by the lungs inability to maintain arterial
oxygenation or eliminate carbon dioxide leading to tissue hypoxia in spite of low-flow or
high-flow oxygen delivery devices. (Impaired gas exchange, airway obstruction or
ventilation-perfusion abnormalities).
2. In a patient with previously normal ABGs, the ABG results will be as follows:
PaO2 > 50 mm Hg with pH < 7.25

PaO2 < 50 mm Hg on 60% FIO2 : restlessness, dyspnea, confusion, anxiety, tachypnea,

tachycardia, and diaphoresis
PaCO2 > 50 mm Hg : hypertension, irritability, somnolence (late), cyanosis (late), and
LOC (late)
3. Neuromuscular or neurogenic loss of respiratory regulation. (Impaired ventilation)
4. Usual reasons for intubation: Airway maintenance, Secretion control, Oxygenation and
Ventilation.
Types of intubation: Orotracheal, Nasotracheal, Tracheostomy
Preparing for Intubation
1. Recognize the need for intubation.
2. Notify physician and respiratory therapist. Ensure consent obtained if not emergency.
3. Gather all necessary equipment:
a. Suction canister with regulator and connecting tubing
b. Sterile 14 Fr. suction catheter or closed in-line suction catheter
c. Sterile gloves
d. Normal saline
e. Yankuer suction-tip catheter and nasogastric tube
f. Intubation equipment: Manual resuscitator bag (MRB), Laryngoscope and blade, Wire
guide, Water soluble lubricant, Cetacaine spray
g. Endotracheal attachment device (E-tad) or tape
h. Get order for initial ventilator settings
i. Sedation prn
j. Soft wrist restraints prn
k. Call for chest x-ray to confirm position of endotracheal tube
l. Provide emotional support as needed/ ensure family notified of change in condition.

Intubation
Types of Ventilators
Ventilator Settings
Modes of Mechanical Ventilation
Complications of Mechanical Ventilation
1. Associated with patients response to mechanical ventilation:
A. Decreased Cardiac Output
1. Cause - venous return to the right atrium impeded by the dramatically increased
intrathoracic pressures during inspiration from positive pressure ventilation. Also reduced
sympatho-adrenal stimulation leading to a decrease in peripheral vascular resistance and
reduced blood pressure.
2. Symptoms increased heart rate, decreased blood pressure and perfusion to vital
organs, decreased CVP, and cool clammy skin.
3. Treatment aimed at increasing preload (e.g. fluid administration) and decreasing the
airway pressures exerted during mechanical ventilation by decreasing inspiratory flow
rates and TV, or using other methods to decrease airway pressures (e.g. different modes
of ventilation).
B. Barotrauma
1. Cause damage to pulmonary system due to alveolar rupture from excessive airway
pressures and/or overdistention of alveoli.
2. Symptoms may result in pneumothorax, pneumomediastinum, pneumoperitoneum,
or subcutaneous emphysema.
3. Treatment - aimed at reducing TV, cautious use of PEEP, and avoidance of high airway
pressures resulting in development of auto-PEEP in high risk patients (patients with
obstructive lung diseases (asthma, bronchospasm), unevenly distributed lung diseases
(lobar pneumonia), or hyperinflated lungs (emphysema).
C. Nosocomial Pneumonia
1. Cause invasive device in critically ill patients becomes colonized with pathological
bacteria within 24 hours in almost all patients. 20-60% of these, develop nosocomial
pneumonia.

2. Treatment aimed at prevention by the following:

Avoid cross-contamination by frequent handwashing
Decrease risk of aspiration (cuff occlusion of trachea, positioning, use of small-bore NG
tubes)
Suction only when clinically indicated, using sterile technique
Maintain closed system setup on ventilator circuitry and avoid pooling of condensation in
the tubing
Ensure adequate nutrition
Avoid neutralization of gastric contents with antacids and H2 blockers
D. Positive Water Balance
1. Syndrome of Inappropriate Antidiuretic Hormone (SIADH) due to vagal stretch
receptors in right atrium sensing a decrease in venous return and see it as hypovolemia,
leading to a release of ADH from the posterior pituitary gland and retention of sodium
and water. Treatment is aimed at decreasing fluid intake.
2. Decrease of normal insensible water loss due to closed ventilator circuit preventing
water loss from lungs. This fluid overload evidenced by decreased urine specific gravity,
dilutional hyponatremia, increased heart rate and BP.
E. Decreased Renal Perfusion can be treated with low dose dopamine therapy.
F. Increased Intracranial Pressure (ICP) reduce PEEP
G. Hepatic congestion reduce PEEP
H. Worsening of intracardiac shunts reduce PEEP

2. Associated with ventilator malfunction:

A. Alarms turned off or nonfunctional may lead to apnea and respiratory arrest
Troubleshooting Ventilator Alarms
Low exhaled volume: Cuff leak, Tubing disconnect, Patient disconnected

Evaluate cuff; reinflate prn; if ruptured, tube will need to be replaced. Evaluate
connections; tighten or replace as needed; check ETT placement, Reconnect to ventilator
High pressure: Secretions in airway, Patient biting tubing, Tube kinked, Cuff herniation,
Increased airway resistance/decreased lung compliance (caused by bronchospasm, right
mainstem bronchus intubation, pneumothorax, pneumonia), Patient coughing and/or
fighting the ventilator; anxiety; fear; pain.
Suction patient, Insert bite block, Reposition patients head/neck; check all tubing
lengths, Deflate and reinflate cuff, Auscultate breath sounds, Evaluate compliance and
tube position; stabilize tube, Explain all procedures to patient in calm, reassuring manner,
Sedate/medicate as necessar
Low oxygen pressure: Oxygen malfunction
Disconnect patient from ventilator; manually bag with ambu; call R.T

3. Other complications related to endotracheal intubation.

A. Sinusitis and nasal injury obstruction of paranasal sinus drainage; pressure necrosis
of nares
1. Prevention: avoid nasal intubations; cushion nares from tube and tape/ties.
2. Treatment: remove all tubes from nasal passages; administer antibiotics.
B. Tracheoesophageal fistula pressure necrosis of posterior tracheal wall resulting from
overinflated cuff and rigid nasogastric tube
1. Prevention: inflate cuff with minimal amount of air necessary; monitor cuff pressures
q. 8 h.
2. Treatment: position cuff of tube distal to fistula; place gastrostomy tube for enteral
feedings; place esophageal tube for secretion clearance proximal to fistula.
C. Mucosal lesions pressure at tube and mucosal interface
1. Prevention: Inflate cuff with minimal amount of air necessary; monitor cuff pressure q.
8 h.; use appropriate size tube.
2. Treatment: may resolve spontaneously; perform surgical interventions.
D. Laryngeal or tracheal stenosis injury to area from end of tube or cuff, resulting in
scar tissue formation and narrowing of airway

1. Prevention: inflate cuff with minimal amount of air necessary; monitor cuff pressure q.
8.h.; suction area above cuff frequently.
2. Treatment: perform tracheostomy; place laryngeal stint; perform surgical repair.
E. Cricoid abcess mucosal injury with bacterial invasion
1. Prevention: inflate cuff with minimal amount of air necessary; monitor cuff pressure q.
8 h.; suction area above cuff frequently.
2. Treatment: perform incision and drainage of area; administer antibiotics.
4. Other common potential problems related to mechanical ventilation:
Aspiration, GI bleeding, Inappropriate ventilation (respiratory acidosis or alkalosis, Thick
secretions, Patient discomfort due to pulling or jarring of ETT or tracheostomy, High
PaO2, Low PaO2, Anxiety and fear, Dysrhythmias or vagal reactions during or after
suctioning, Incorrect PEEP setting, Inability to tolerate ventilator mode.

PLAN OF CARE FOR THE VENTILATED PATIENT

Patient Goals:
1.
2.
3.
4.
5.
6.

Patient will have effective breathing pattern.

Patient will have adequate gas exchange.
Patients nutritional status will be maintained to meet body needs.
Patient will not develop a pulmonary infection.
Patient will not develop problems related to immobility.
Patient and/or family will indicate understanding of the purpose for mechanical
ventilation.

Nursing Diagnosis

Nursing Interventions

Rationale

Ineffective breathing pattern r/t

____________________________.

Observe changes in respiratory rate and

depth; observe for SOB and use of accessory
muscles.

An increase in the work of breathing will add

to fatigue; may indicate patient fighting
ventilator.

Observe for tube misplacement- note and

post cm. Marking at lip/teeth/nares after xray confirmation and q. 2 h.

Indicates correct position to provide adequate

ventilation.

Prevent accidental extubation by taping tube

securely, checking q.2h.; restraining/sedating
as needed.

Avoid trauma from accidental extubation,

prevent inadequate ventilation and potential
respiratory arrest.

Inspect thorax for symmetry of movement.

Determines adequacy of breathing pattern;

asymmetry may indicate hemothorax or
pneumothorax.

Measure tidal volume and vital capacity.

Indicates volume of air moving in and out of

lungs.

Asses for pain

Pain may prevent patient from coughing and

deep breathing.

Monitor chest x-rays

Shows extent and location of fluid or

infiltrates in lungs.

Maintain ventilator settings as ordered.

Ventilator provides adequate ventilator

pattern for the patient.

This position moves the abdominal contents

away from the diaphragm, which facilitates
its contraction.

Elevate head of bed 60-90 degrees.

Impaired gas exchange r/t alveolar-capillary

membrane changes

Monitor ABGs.

Determines acid-base balance and need for

oxygen.

Assess LOC, listlessness, and irritability.

These signs may indicate hypoxia.

Observe skin color and capillary refill.

Determine adequacy of blood flow needed to

carry oxygen to tissues.

Monitor CBC.

Indicates the oxygen carrying capacity

available.

Administer oxygen as ordered.

Decreases work of breathing and supplies

supplemental oxygen.

Observe for tube obstruction; suction prn;

ensure adequate humidification.

May result in inadequate ventilation or

mucous plug.

Reposition patient q. 1-2 h.

Repositioning helps all lobes of the lung to be

adequately perfused and ventilated.

Potential altered nutritional status: less than

body requirements r/t NPO status

Monitor lymphocytes and albumin.

Indicates adequate visceral protein.

Provide nutrition as ordered, e.g. TPN, lipids

or enteral feedings.

Calories, minerals, vitamins, and protein are

needed for energy and tissue repair.

Obtain nutrition consult.

Provides guidance and continued

surveillance.

Potential for pulmonary infection r/t

compromised tissue integrity.

Secure airway and support ventialtor tubing.

Prevent mucosal damage.

Provide good oral care q. 4 h.; suction when

need indicated using sterile technique;
handwashing with antimicrobial for 30
seconds before and after patient contact; do
not empty condensation in tubing back into
cascade.

Measures aimed at prevention of nosocomial

infections.

Use disposable saline irrigation units to rinse

in-line suction; ensure ventilator tubing
changed q. 7 days, in-line suction changed q.
24 h.; ambu bags changes between patients
and whenever become soiled.

IAW Infection Control Policy and

Respiratory Therapy Standards of Care for
CCNS.

Potential for complications r/t immobility.

Assess for psychosocial alterations.

Dependency on ventilator with increased

anxiety when weaning; decreased ability to
communicate; social isolation/alteration in
family dynamics.

Assess for GI problems. Preventative

measures include relieving anxiety, antacids
or H2 receptor antagonist therapy, adequate
sleep cycles, adequate communication
system.

Most serious is stress ulcer. May develop

constipation.

Observe skin integrity for pressure ulcers;

preventative measures include turning
patient at least q. 2 h.; keep HOB < 30
degrees with a 30 degree side-lying position;
use pressure relief mattress or turning bed if
indicated; follow prevention of pressure
ulcers plan of care; maintain nutritional
needs.

Patient is at high risk for developing pressure

ulcers due to immobility and decreased tissue
perfusion.

Maintain muscle strength with active/activeassistive/passive ROM and prevent

contractures with use of span-aids or splints.

Patient is at risk for developing contractures

due to immobility, use of paralytics and
ventilator related deficiencies.

Knowledge deficit r/t intubation and

mechanical ventilation

Explain purpose/mode/and all treatments;

encourage patient to relax and breath with
the ventilator; explain alarms; teach
importance of deep breathing; provide
alternate method of communication; keep
call bell within reach; keep informed of
results of studies/progress; demonstrate
confidence.

Reduce anxiety, gain cooperation and

participation in plan of care.