Care_of_mechanically_ventilated patient (RPA) - Intensive Care ...

INTENSIVE CARE SERVICE 

NURSING POLICY & PROCEDURES 

NAME OF POLICY: CARE OF THE MECHANICALLY VENTILATED 

PATIENT 

GOAL: TO PROVIDE PATIENT SAFETY AND COMFORT WHILE 

MECHANICALLY VENTILATED 

Introduction: 

Mechanical ventilation is initiated for various reasons such as: 

� Acute lung injury 

� Airway management, and 

� Surgical intervention. 

The ETT (nasal or oral) may be left insitu for up to 10 days after which, the patient will be 

considered for a tracheostomy, if mechanical ventilation is to be continued (see care of the 

tracheostomy) 

Nursing Responsibilities: 

� Check ventilator setting, they should correspond to Medical Officer’s orders on “Carevue” 

� Ensure patient is not left unattended (if assisting with another patient, ensure patient is 

observed) and alarm parameters are set appropriately on the ventilator 

� Check emergency equipment is present and in working order: 

� Air-viva 

� Black bag and mask 

� Oxygen tubing attached to oxygen outlet 

� Full portable oxygen cylinder 

� 20ml syringe and dwellcath on top of the ventilator 

� Yanker sucker attached to suction apparatus 

� PEEP valve on appropriate Air-viva/black bag (if patient is on PEEP 

> 5cmH2O) 

� Assess baseline respiratory status and record under “Initial Assessment”: 

� Rate and depth of breathing 

� Osculate chest wall for breath sounds 

� Assess chest wall for asymmetry 

� Assess saturation levels 

� Review last ABG 

� Assess ETT position: 

� Check black numerical markings on the ETT, should correspond to initial 

documented tube position. If upward or downward migration has occurred 

inform Medical Officer prior to any adjustment 

©ROYAL PRINCE ALFRED HOSPITAL INTENSIVE CARE SERVICE

� Ensure ETT is secured using the ‘bow’ method demonstrated on ETT Tying 

poster 

� Portable Chest X-ray: 

� Inform the patient of the procedure and support where necessary 

� Assist and direct the radiographers 

� Where possible and applicable sit patient up for a chest X-ray 

� When X-rays are taken ensure all indwelling tubes and lines are 

moved off the chest wall 

� When moving patients for procedures ensure ETT is protected at all 

times 

� Protect reproductive organs on females and males of child bearing 

years 

� Protect yourself by standing at least 7 feet away from X-ray 

� Ensure all immediate staff in the vicinity are aware of X-rays being 

taken (usually the responsibility of the radiographer) 

� Assess pulmonary lung fields in comparison with previous X-ray and 

position of ETT 

� General Care: 

� Patient to be nursed, unless contraindicated e.g. acute haemodynamic 

instability, with the head of the bed elevated at least 30 o to minimise 

risk of nosocomial pneumonias (ruler to be used to ensure accuracy). 

In the event of IABP and spinal cord injury, patients can be nursed 

with the bed tilted to 30 o as tolerated. 

� Titrate patient ventilation in response to ABG in conjunction with 

Medical Officer’s parameter (eg. maintain saturation >95%, Arterial 

oxygen >65mmHg, Carbon dioxide no greater than 50mmHg) and/or 

in consultation with Intensivist 

� Obtain an ABG as clinically indicated, SaO2 monitoring should be 

used as first line indicator of ventilation and ABG’s used to assess 

CO2 and pH when required. ABG sampling is not necessary after 

changing ventilation settings if saturation levels are unchanged. 

� Check cuff pressure is at appropriate pressure to maintain seal (see 

separate policy) 

� Assess water humidification level and the set temperature is 

maintained 

� Provide adequate sedation as prescribed 

� Change inline suction catheter every 72hrs, ensuring to keep catheter 

clear of secretions with regular flushes post suctioning. 

� Maintain oral hygiene 

� Ensure lips are moist (apply Vaseline) 

� Avoid pressure from ETT on the lips (change ETT position form one 

side of the mouth to the other during daily/PRN tape changes if 

necessary) 

� Ensure adequate pulmonary toileting (suction 4-6/24hr & PRN) 

� Observe patient for Respiratory/haemodynamic compromise during 

physiotherapy treatment 

� Aspirate NG tube 4-6/24hr until entral feeding is successfully 

established (see separate policy) 


� Positioning an Intubated Patient: 

� ICU patients must be repositioned every 2-3/24 to observe pressure 

areas and relieve pressure on the pressure points, turning is also 

essential for chest physiotherapy (even when using pressure relieving 

mattress’s) 

� Prior to turning a patient ensure that the ETT is secure, the ties may 

need to be retied if they are loose. 

� Turning is always performed with at least two staff members. Ideally 

one person should be specifically responsible for the ETT and IV 

lines. 

� When performing a turn ensure the task of protecting the airway is 

delegated and the person knows that they must be able to visualise the 

ETT at all times 

� On completion of the turn adjust the ventilator tubing so that there 

isn’t tension pulling down on the ETT 

� Barotrauma: 

� Be alert to changes in peak inspiratory pressure (PIP) 

� Observe for signs of a Pneumothorax 

� subcutaneous emphysema 

� decrease tidal volume (leak) 

� decrease in oxygen saturation percentage 

� distress patient 

Ventilation tube change: 

If the patient is to unstable haemodynamically and/or respiratory, check with Intensivist before 

this procedure 

� All tubing from the ventilator up to the “blue” connector of the ETT is to be changed, 

every 7 days 

� When tubing is change a ventilation “safety check” is also initiated 

� Air-viva, black bag, oxygen tubing and PEEP valve and water humidification (if 

applicable) is changed every 7 days 

� Record change on careplan 

ETT placement Portable chest X-ray 


REFERENCES: 

Bucher, L & Melander, S. (1999). Critical Care Nursing. W. B. Saunders Company, Philadelphia 

Marino, P.L (1991) The ICU book. Lea & Febiger, Philadelphia 

Occupational Health and Safety: Universal precautions taken in the preparation, administration of drug and 

disposal of equipment and sharps. 

Cross Referenced: RPAH Occ. Health & Safety Manual and Infection Control Manual 

NSW Infection Control Policy 98/99 

Revised by: Frankie Hopkins (ACNC) & Chanelle Innes (CNC) April 2002 

Reviewed by: Marjorie Kinghan (CNE) 

Authorised by: Dr. Paul Phipps (Intensivist) 

Revision March 2004 

With the introduction of Powerchart online ordering, a clinical agreement has been set up with the Director 

of ICS and other Staff Specialists. Nursing Management, with the agreement of the hospital executive, have 

made arrangement that allows all permanently employed RPAH Nursing Staff to place orders for a variety of 

tests on their behalf. It is a Health Insurance Commission (HIC) directive that all orders placed by nursing 

staff are countersigned by the responsible MO within 14 days.

Care_of_mechanically_ventilated patient (RPA) - Intensive Care ...

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