Managing Mechanical Ventilation (MV)

• To maintain the patient's arterial blood gas, which is achieved through keeping the PaO₂, pH, and PaCO₂ as close to normal limits possible.
• Indicated for patients who cannot maintain adequate ventilation and/or unable to protect one's own airway.

• Ensure patient on a ventilator is carefully monitored and that the alarms are always on.
• Monitor the system at regular intervals to detect problems early.
• Anticipate problems and anticipate your response to the problems.
• Remember that machines fail and have a manual system in place, i.e., oxygen tank and Ambu bag.

  See Fig. 9.3A Ambu Bags, Infant to Adult Sizes

Special Considerations

• The psychosocial needs of the patient must be addressed.
• The nutritional needs of the patient who is on an MV are of utmost importance.
• Cardiac output may be decreased, which will affect end-organ perfusion.
• Patients on MV are at high risk for the development of pneumothorax.
• Repositioning of patient at least every 2 hours facilitates removal of pulmonary secretions and prevention of atelectasis.
• Age of patient.
• Coexistence of different pathologies.

Relevant Nursing Diagnoses

• Impaired spontaneous ventilation
• Ineffective breathing pattern

• Improved patient oxygenation status
• Able to maintain airway reflexes
• Absence of adventitious breath sounds
• Normal respiratory rate
• Negative inspiratory flow of greater than–20 cm
• Vital capacity greater than 10 mL/kg
• PaO₂ greater than 60 on FiO₂ of less than 50%
• Patient achieves target tidal volumes, promoting optimal lung expansion

• Oxygen and air source at 50 psi
• Spirometer
• Ventilator
• Humidifier
• Oxygen analyzer
• Distilled water
• Ambu bag
• Two endotracheal tubes and emergency equipment (sizes appropriate for patient). For women use 6.5 mm to 7.5 mm ETT and for men use 7.0 mm to 8.0 mm
• Connectors, adaptors, and ventilator circuit
• Monitors (blood pressure cuff, pulse oximetry, electrocardiogram)
• Stethoscope
• Suction equipment
• Communication device, i.e., magic slate, pen and paper
• Emergency airway equipment, such as oral airway, laryngoscope handle, and blades

• Wash hands.
• Reduces the transmission of microorganisms.
• Explain the rationale for therapy to patient and family.
• Establishes rapport, reduces anxiety, and promotes autonomy.
• Develop communication plan if time and condition permit.
• Enables patient to communicate needs.
• Address physical and psychological comfort measures.
• Reduces discomfort, and improves patient outcomes.
• Administer pain and anxiety medication as prescribed.
• Reduces discomfort and anxiety related to therapy.
• Adjust alarm setting.
• Provides early detection of potential problems. Mechanical alarms are useful but patient assessment is vital.
• Provide client opportunity for position changes and mouth and endotracheal tube care frequently.
• Promotes mobilization of secretions, and prevents oral cavity erosion.
• Preoxygenate by providing 100% oxygen and suction when indicated.
• Promotes removal of pulmonary secretions and improved pulmonary function.
• Continuously evaluate ventilator settings, arterial blood gases (ABGs), goals for therapy, and patient response.
• Improvement or deterioration in patient condition often requires changes in ventilator setting.
• Monitor patient's ventilator pressure readings and breath sounds for presence and quality.
• Barotrauma and pneumothorax associated with MV often present in an abrupt rise in peak inspiratory pressure or decreased breath sounds.
• Perform oral care and avoid triggers for gag reflex, such as deep oropharyngeal suctioning.
• Contaminated oral secretions are often associated with nosocomial pneumonia. Gagging causes discomfort and increases intrathoracic and intracranial pressure.
• Elevate head of bed at least 30 degrees.
• Reduces the risk for aspiration and promotes lung expansion.
• Change ventilator tubing according to hospital policy to prevent colonization of microorganisms.
• Warm, moist nature of ventilator equipment is a medium for bacterial growth, which makes patient prone to nosocomial infections.
• Make appropriate ventilator changes such as increasing or decreasing rate and/or tidal volume and monitor for patient's ability to be weaned from ventilator.
• Changes in ventilator setting facilitate spontaneous ventilation and self-sustained ventilation.
• Make referrals to dietitian to provide optimal nutrition.
• Provides holistic care to meet the individual needs of the patient.
• Wash hands.
• Reduces the transmission of microorganisms.

Evaluation and Follow-Up Activities

• Assess the initial reason for MV, and evaluate goals for therapy
• Anticipate duration of MV
• Know successful criteria for achievement of goals
• Detect patient problems early
• Evaluate arterial blood gas analysis
• Patient's tolerance to treatment

Key Points for Reporting and Recording

• Size and depth of endotracheal tube used.
• Date of MV initiation.
• Ventilator settings at time of report.
• Patient's response to ventilatory changes.
• Arterial blood gas analysis for the shift.
• Vital signs.
• Frequency of additional therapy, i.e., nebulizer treatments, chest postural treatment, suctioning.
• Amount, color, and consistency of secretions.
• Alarm limits.
• Ventilator settings
• Vital signs.
• Last treatments and suctioning.
• Patient's tolerance.
• Neurological status of patient.
• Breath sounds.