Prior intubation assessment: | |
Observe for changes in the level of consciousness. | Early signs of hypoxia include disorientation, irritability, and restlessness. While lethargy, stupor, and somnolence are considered as late signs. |
Assess the client’s respiratory rate, depth, and pattern, including the use of accessory muscles. | Changes in the respiratory rate and rhythm are early signs of possible respiratory distress. As moving air in and out of the lungs becomes more difficult, the breathing pattern changes to include the use of accessory muscles to increase chest excursions. |
Assess the client’s heart rate and blood pressure. | Tachycardia may result from hypoxia; Increased in blood pressure happen in the initial phases then followed by lowered blood pressure as the condition progresses. |
Auscultate the lung for normal or adventitious breath sounds. | Adventitious breath sounds such as wheezes and crackles are an indication of respiratory difficulties. Quick assessment allows for early detection of deterioration or improvement. |
Assess the skin color, examine the lips and nailbeds for cyanosis. | Bluish discoloration of the skin (cyanosis) indicates an excessive concentration of deoxygenated blood and that breathing pattern is ineffective to maintain adequate tissue oxygenation. |
Monitor oxygen saturation using pulse oximetry. | Pulse oximetry is useful in detecting early changes in oxygen. Oxygen saturation levels should be between 92% and 98% for an adult without any respiratory difficulties. |
Monitor arterial blood gases (ABGs) as indicated. | Increasing Paco2 and decreasing PaO2 indicates respiratory failure. If the client’s condition begins to fail, the respiratory rate and depth decreases and Paco2 begin to rise. |
After intubation assessment: | |
| Correct ET tube placement is important for effective mechanical ventilation. |
| Client discomfort may be secondary to incorrect ventilator settings that result in insufficient oxygenation. Once intubated and breathing on the mechanical ventilator, the client should be breathing easily and not “fighting or bucking” the ventilator. |
| Assessment ensures that settings are accurate and alarms are functional. |
Therapeutic interventions prior to intubation: | |
| An artificial airway is used to prevent the tongue from occluding the oropharynx. |
| This position promotes oxygenation via maximum chest expansion and is implemented during events of respiratory distress. Do not let the client slide down; this causes the abdomen to compress the diaphragm, which could cause respiratory change. |
| Deep breathing facilitates oxygenation. A deep cough is effective in clearing mucus out of the lungs. |
| Suctioning is needed to clients who are unable to remove secretions from the airway by coughing. |
Preparation for endotracheal intubation: | |
| Mechanical ventilators are classified according to the method by which they support ventilation. The two types are negative-pressure and positive-pressure ventilators (used most frequently). |
| Preparatory information can decrease anxiety and promote cooperation with intubation. |
Prepare the following equipment: | |
| Endotracheal tubes come in various sizes and shapes. Adult sizes range from 7 to 9 mm. Selection is based on the client’s size. |
| Blades and scopes facilitate the opening of the upper airway and visualization of the vocal cords for placement of oral ET tubes. A stylet makes the ET tube firmer and gives additional support to direction during intubation. |
| A syringe is used to inflate the balloon (cuff) after the ET tube is in position. Tape and benzoin are used to secure the ET tube. |
| These anesthetic agents suppress the gag reflex and promote general comfort. |
Administer sedation as ordered. | Sedation facilitates comfort and ease of intubation. |
Assist with intubation: | |
| This position is necessary to promote visualization of landmarks for accurate tube insertion. |
| Use of cricoid pressure to prevent passive regurgitation during rapid sequence intubation. It may also prevent passive regurgitation of gastric and oesophageal contents. |
| This provides assisted ventilation with 100% oxygen before intubation. Increasing oxygen tension in the alveoli may result in more oxygen diffusion into the capillaries. |
Therapeutic interventions after intubation: | |
| Correct placement is needed for effective mechanical ventilation and to prevent complications associated with malpositioning such as vomiting, hypoxia, gastric distention, lung trauma. The carbon dioxide detector is attached to the ET tube immediately after intubation to verify tracheal intubation. Other capnography devices that provide numerical measurements of end-tidal carbon dioxide (normal value is 35 to 45 mm Hg) and capnograms may also be used. |
| Stabilization is necessary before initiating mechanical ventilation. |
| Documentation provides a reference for determining possible tube displacement, usually 21 cm for the women and 23 cm at the lips for men. |
| An oral airway and/or block prevents the client from biting down on the ET tube. |
| These restraints may prevent self-extubation of the ET tube. Although all clients do not require restraints to prevent extubation, many do. |
| Modes for ventilating (assist/control, synchronized intermittent mandatory ventilation), tidal volume, rate per minute, fraction of oxygen in inspired gas (FIO2), pressure support, positive end-expiratory pressure, and the like must be preset and carefully evaluated for response. |
| Suction helps remove secretions. A Yankaeur suction device should be available. Suctioning procedures should not be done frequently but as needed only in order to lessen the risk for infection and airway trauma. |
| Abdominal distention may indicate gastric intubation and can also occur after cardiopulmonary resuscitation when the air is inadvertently blown or bagged into the esophagus, as well as the trachea. Suction prevents abdominal distention. Oral gastric suctioning may also reduce the risk for sinusitis. |
| These medications decrease the client’s work of breathing, decrease myocardial work, and may facilitate effective gas exchange. |
| Cuff pressure should be maintained at 20 to 30 mm Hg. Maintenance of low-pressure cuffs prevents many tracheal complications formerly associated with ET tubes. Notify the physician if the leak persists. The ET tube cuff may be defective, requiring the physician to change the tube. |
| The key is that the client receives oxygenation support at all times until mechanical ventilation is no longer required. |
What interventions can be implemented specifically to prevent the development of ventilator acquired pneumonia VAP )?
Several measures are generally accepted and widely applied to prevent VAP: avoiding intubation or re-intubation when possible; head of bed elevation; hand hygiene; and shortening ventilation through sedation interruptions, spontaneous breathing trials, or thromboembolic prophylaxis.
Which intervention would the nurse implement to prevent development of ventilator
To reduce risk for VAP, the following nurse-led evidence-based practices are recommended: reduce exposure to mechanical ventilation, provide excellent oral care and subglottic suctioning, promote early mobility, and advocate for adequate nurse staffing and a healthy work environment.
Which intervention would the nurse implement to prevent development of ventilator
The nurse should use an endotracheal tube with dorsal lumen above the cuff because it allows continuous suctioning of secretions in the subglottic area. Histamine-receptor blockers should be administered as a part of peptic ulcer prophylaxis to decrease the risk of ventilator-associated pneumonia (VAP).
How can we prevent ventilator
Q: What strategies reduce VAE?.
Using noninvasive positive pressure ventilation (NIPPV) whenever appropriate..
Interrupting sedation daily/spontaneous awakening trials for patients when possible..
Assess readiness for extubation daily/spontaneous breathing trials for patients when possible..