MedSurg II - Mech Ventilation

olanjones's version from 2017-04-03 01:23


Question Answer
Most common artificial airway in critical careEndotracheal tube (can be placed either orally or nasally) Indications for placement - upper airway obstruction, apnea, high aspiration risk, ineffective secretion clearance, respiratory distress
ET insertion PrepExplain procedure to pt - they won’t be able to talk while they are intubated, You will need a bag valve mask available & attached to oxygen, Est. IV access, Keep suctioning equipment at bedside
Rapid sequence intubationRapid, concurrent administration of both a sedative and paralytic agent during emergency airway management, ↓ risk of aspiration
Sedative/hypnotics usedmidazolam for sedation, fentanyl blunts pain; succinylcholine or pancuronium produce skeletal muscle paralysis
Assisting w/ ET PlacementPt’s head in sniffing position
Oral placement: tube is placed btwn vocal cords to bifurcation of the bronchi
Once placement is verified, the patient will be attached to ventilator
Verifying ET Placement-End-tidal CO2 monitor (presence of CO2 verifies placement; if no CO2 tube is in esophagus & will need to be repositioned)
-Watch for symmetric chest movement & auscultate lungs for b/l breath sounds
-GOLD STANDARD: Obtain a CXR to verify placement
Assessments for ET pts-Monitor ABG’s, SP02
-Assess for signs of hypoxemia (change in mental status, anxiety, dusky skin, dysrhythmia)
-Assess pt’s RR, rhythm, use of accessory muscles
-Oral secretions ↑when intubated -require frequent mouth suctioning using a Yankaeur (allow pt to hold if able–gives them some control)
-Need for oral care
Indications for SuctionVisible secretions in ET, sudden onset of respiratory distress, suspected aspiration of secretions, ↑peak airway pressures, auscultation of adventitious breath sounds, ↑RR/sustained coughing, sudden or gradual ↓PaO2 or SPO2
Oral Care (Very important - their mouth is always open)-Use soft toothbrush 2x day to remove plaque, Use 0.12% chlorhexidine oral rinse 2x day, Oral swabs with a 1.5% hydrogen peroxide solution every 2-4 hr
-Lips, gums, tongue should be kept moist w/ saline/water swabs to prevent drying
-Monitor for skin breakdown because of pressure from ET tube (may cause necrosis); Tape/velcro needs to be changed & tube repositioned every 24 hours/prn
What should you do if someone extubates themselvesStay w/ pt & call for help; Manually ventilate w/ a bag valve mask & 100% oxygen (pt may need to be re-intubated or may do okay w/ O2 mask/NC - re-intubation may be difficult d/t edema from the trauma of extubation)
PPVDuring inspiration the ventilator pushes air into the lungs under positive pressure
Volume ventilationDelivers a determined tidal volume w/ each inspiration
What is used to determine vent settingsPt lung compliance/resistance, ABGs, ideal body weight, level of consciousness, muscle strength
What may cause alarm to go offmechanical malfunction, apnea, unplanned extubation, or patient asynchrony with a ventilator
A high pressure alarm could mean pt needs to be suctioned or is biting the tube


Question Answer
Controlled mandatory ventilation (CMV)Pt’s respirations are completely controlled by the ventilator (used in Sx/PACU)
Assist-control ventilation (ACV)Ventilator delivers a preset tidal volume at a preset frequency; Patient can breathe faster than the preset rate but not slower (allows pt some control over ventilation)
Synchronized intermittent mandatory ventilation (SIMV)Ventilator provides a preset tidal volume at a preset frequency & synchrony w/ pt's respirations (between ventilator breaths, pt is able to breathe spontaneously but still receives a preset FIO2)
Pressure support ventilation-Positive pressure is applied to the airway only during inspiration in conjunction w/ pts breathing (must be able to initiate own breathing, may deliver a set FIO2)
-Mode used most frequently for weaning pts from ventilator – do they have the muscle strength to breathe on their own
Positive end-expiratory pressure (PEEP)Deliverers positive pressure during exhalation - keeps alveoli open, improving oxygenation using less O2 * usual setting: 5cm H2O
-↑levels may cause barotrauma & ↓CO
Benefits of PEEPImproves gas exchange, vital capacity, inspiratory force
Contraindications for PEEPPts w/ highly compliant lungs (COPD), hypovolemia, or low cardiac output


Question Answer
DefinitionPneumonia that occurs 48 hrs or more after intubation
RFintubation & ventilation, poor nutritional status, immobility, underlying disease process
Clinical evidence of VAPFever, ↑WBC, purulent/odorous sputum, crackles/rhonchi on auscultation, pulmonary infiltrates CXR
PreventionHOB elevation at a minimum of 30 - 45° unless contraindicated, No routine changes of ventilator circuit tubing, Subglottal suctioning


Question Answer
Spontaneous breathing trialSpontaneous breathing trial (pressure support) or a T-tube that fits on the ET tube
S/S pt is not tolerating trialTachypnea, dyspnea, arrhythmias, tachycardia, agitation, anxiety, sustained saturation <91%
Prior to extubationHyper-oxygenat & suction pt. Dr/RT will have pt take a deep breath, then will deflate the cuff & pull the tube in one motion
After extubation-Instruct pt to take deep breaths & cough; supplemental O2 admin
-Monitor VS, respiratory status, oxygenation immediately after extubation, within one hour, and per institution policy


Question Answer
RNAuscultate breath sounds & respiratory effort, assess for ↓ventilation or adventitious sounds
RNMonitor ventilator settings and alarms; Maintain appropriate cuff inflation on ET tube
RNDevelop plan for communication w/ pt who has a trach/ET tube; Teach pt & caregiver about mechanical ventilation & weaning procedures
RNDetermine need for ET tube suctioning. Implement suctioning for unstable patients; Reposition and secure ET tube (may delegate to respiratory therapist, depending on agency policy).
RNAdmin sedatives, analgesics, paralytic medications prn; Monitor oxygenation level and signs of respiratory fatigue during weaning procedure
LPNSuction trach/ET tube for stable patients as directed by RN (after being educated and evaluated in this procedure)
LPNAssist RN or RT w/ repositioning/securing ET tube
LPNAdminister routinely scheduled medications; Administer enteral nutrition to stable patients
UAPObtain VS, measure I&O & report these to RN; Perform bedside glucose testing
UAPProvide personal hygiene and skin care/oral care; Perform passive or assisted range-of-motion exercises
UAPAssist with frequent position changes, including ambulation

Settings of Mech Vent

Question Answer
Respiratory rate (f)Number of breaths the ventilator delivers per minute *Usual setting: 6-20 breaths/min
Tidal volume (VT)Volume of gas delivered to patient during each ventilator breath *Usual volume: 6-10 mL/kg
FIO2Fraction of inspired O2 delivered to pt, May be set btwn 21%-100% *Usually adjusted to maintain PaO2 >60 mm Hg / SpO2 >90%
PEEPPositive pressure applied at the end of expiration of ventilator breaths *Usual setting: 5 cm H2O
Pressure supportPositive pressure used to augment patient’s inspiratory pressure *Usual setting: 6-18 cm H2O
I:E ratioDuration of inspiration to duration of expiration *Usual setting: 1:2 to 1:1.5 unless IRV is desired
Inspiratory flow rate & timeSpeed w/ which the VT is delivered *Usual setting: 40-80 L/min and time is 0.8-1.2 sec
SensitivityDetermines amount of effort pt must generate to initiate a ventilator breath; It may be set for pressure triggering or flow triggering *Usual setting: A pressure trigger is set 0.5-1.5 cm H2O below baseline pressure and a flow trigger is set 1-3 L/min below baseline flow
High-pressure limitRegulates the maximal pressure the ventilator can generate to deliver the VT; When pressure limit is reached, the ventilator terminates the breath & spills undelivered volume into the atmosphere *Usual setting: 10-20 cm H2O above peak inspiration

O2 Admin

Question Answer
NC/prongs23-42% at 1-6 L/min; Assess nostril patency, Apply water-soluble jelly to nares q 3-4 hrs, Mouth care
Face mask40-60% at 6-8 L/min (min flow 5 L); Remove q 1-2 hrs, Skin care, Emotional support (claustrophobia)
Partial rebreather mask50-75% at 8-11 L/min; Adjust flow to keep reservoir bag 2/3 full during inspiration
Nonrebreather mask80-100% at 12 L/min; Adjust flow to keep reservoir bag 2/3 full
Venturi mask24-40% at 4-8 L/min; Provides high-humidity & fixed concentration, Keep free of kinks
Trach collar/T-piece30-100% at 8-10 L/min; Assess for fine mist, Empty condensation from tubing, Keep water container full
Oxygen hood30-100% at 8-10 L/min; Used for infants/children, Cooled humid air
-Check O2 concentrations w/ O2 analyzer q 4 hrs, Uses sterile, distilled water
-Clean humidity jar daily, Change linens frequently
-Cover client w/ light blanket & towel/cap for head, Monitor pt temp frequently

O2 Hazards

Question Answer
InfectionChange masks, tubing, mouthpieces daily
Drying/irritation of mucosaAdmin humidified O2
Respiratory depression
(CO2 narcosis)
*Monitor RR frequently, Alt breathing room air/O2 at prescribed intervals
*Admin mixed O2/air, rather than pure O2, Use minimal concentration necessary
*Periodically inflate lungs fully
O2 toxicity-Premature infants may develop retinopathy/irreversible blindness d/t vasoconstriction of retinal vessels
-Clients on respirators are most susceptible to pulmonary damage
-Pulm damage = atelectasis, exudation of protein fluid into alveoli, damage/proliferation of pulm capillaries, interstitial hemorrhage
-S/S: cough, nasal congestion, sore throat, reduced vital capacity, substernal discomfort
-Can occur in any patient who breathes O2 concentrations >50% for >24 hours
CombustionBe sure electrical plugs/equipment are grounded, NO SMOKING, No oils on client or equipment

Recent badges