Nursing Care of Patients on Mechanical Ventilation

 

Nursing Care of Patients on Mechanical Ventilation

Nursing care of mechanically ventilated patients is a crucial and demanding task. Patient safety is the primary concern, requiring nurses to be knowledgeable about ventilation modes, perform thorough assessments, manage ventilation effectively, and be skilled in weaning techniques. Mechanical ventilation is used for conditions like acute respiratory failure, COPD exacerbations, coma, neurological diseases, and postoperative support. Its goals include improving gas exchange, reducing the work of breathing, increasing lung volume, alleviating respiratory muscle fatigue, reversing respiratory distress and failure, enhancing hypoxemia, and promoting lung healing.

Systematic Approach to Care

1. Primary Survey (ABCDE Approach):

   • Airway: Verify the security of artificial airways and ensure air movement and chest rise to prevent hypoxia.
   • Breathing: Monitor chest rise, color, respiratory rate, tidal volume, pulse oximetry, and ABG to detect issues.
   • Circulation: Assess pulse, heart rate, rhythm, blood pressure, and capillary refill. Watch for indicators of poor cardiac output.
   • Disability: Recognize changes in consciousness linked to airway, breathing, or circulation issues.
   • Exposure: Evaluate the patient’s environment, including temperature and pain management.

2. Secondary Survey:

   • Conduct a head-to-toe assessment to detect complications early.
   • Use the Glasgow Coma Scale for neurological assessment.
   • Ensure artificial airway placement and manage lung secretions through proper suctioning techniques.
   • Maintain airway humidification to prevent obstruction.

Respiratory System Reassessment:

• Confirm airway placement and securement.
• Regularly check and manage the cuff to avoid aspiration or mucosal damage.
• Ensure effective suctioning and humidification to prevent hypoxia and tissue damage.

Cardiovascular System Assessment:

• Monitor the effects of positive pressure ventilation on cardiac output.
• Use methods like thermodilution or echocardiography for cardiac output measurement.
• Maintain an adequate volume status and monitor cardiovascular indicators like mean arterial pressure, blood pressure, heart rate, and urine output.

Nutritional Support

Proper nutrition is critical for mechanically ventilated patients. Recommended caloric intake is 25 to 30 kcal/kg/day, with 1 to 2 gm/kg/day of protein. Avoid overfeeding to prevent complications such as hyperglycemia and respiratory distress. 

Gastrointestinal and Infection Prevention

Use established feeding protocols for oral or nasogastric tubes. Assess bowel function and implement aseptic techniques to prevent infections. Regularly check temperature and white blood cell counts to detect infections early. Maintaining skin integrity reduces the risk of pressure injury and ventilator-associated pneumonia, thereby decreasing hospital and ventilation times.

Patient Safety

A comprehensive framework for ICU patient assessment and monitoring is crucial for promoting safety. Nurses should ensure emergency equipment is available and functional, including resuscitation bags, suction equipment, and oxygen and intubation supplies. Safety checks involve setting alarm limits, attaching monitoring devices correctly, and ensuring the ventilator has an emergency power supply.

Patient Comfort

Maintaining patient comfort in the ICU is challenging. Nurses should create a calm environment for patients and families, focusing on positioning, hygiene, and managing stressors like pain and invasive tubes. Positions such as semi recumbent, supine, prone, and lateral decubitus help improve comfort and oxygenation. Hygiene involves eye and oral care and bathing, which also provide opportunities for patient assessment.

Pain and Sedation

Effective pain management and sedation are crucial for mechanically ventilated patients. Pain is assessed using scales and behavioral and physiological indicators. IV opioids like morphine and fentanyl are commonly used for pain relief. Sedation levels are monitored using various scales, and continuous sedation should be managed carefully to avoid prolonging ventilation. Sedatives like midazolam, diazepam, lorazepam, and propofol are used based on patient needs. Daily sedation interruptions and readiness-to-wean assessments can reduce ventilator-associated pneumonia and intubation time.

Weaning

Weaning from mechanical ventilation involves gradually reducing ventilatory support. This process should begin shortly after initiating ventilation and requires careful clinical judgment. Key criteria for extubation include the patient's alertness, adequate spontaneous ventilation, normal ABG levels, stable blood pressure, minimal inotropic support, and controlled pain. Extubation should be performed during normal working hours for optimal support, and post-extubation monitoring should focus on respiratory and cardiovascular status.

Conclusion

Caring for mechanically ventilated patients involves ensuring patient safety, maintaining comfort, managing pain and sedation effectively, and safely weaning patients from ventilation. Nurses must develop appropriate assessment and management skills to provide excellent care and facilitate optimal patient outcomes.

References:

Hickey SM, Sankari A, Giwa AO. Mechanical Ventilation. [Updated 2024 Mar 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539742/

Mora Carpio AL, Mora JI. Ventilator Management. [Updated 2023 Mar 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448186/