Nursing care of the ventilated patient (SWAHS) - Intensive

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W e s t e r n S y d n e y A re a H e a lth S e rv ic e H E A L T H Nursing Care Of The Ventilated Patient Intensive Care Evidence Based Practice Guidelines 2003 Ventilation: • Ensure the ventilation tubing is not kinked and that it is adequately supported so as not drag on the ETT/trachi. Take care of the tube while turning or moving the patient. • Check the ventilator and document the settings. Look at the alarm parameters and reset if necessary. • Ensure the ventilator and the cardiac monitor are plugged into emergency power supply in case of power failure. • Ensure that you have enough room to access the head of the bed in an emergency. • Check the type of humidification, and when the filters and ventilation tubing were last changed. • HME filters and end expiratory filters are changed routinely (and marked with the date and time) every 24 hours or more frequently if there is condensation visible. • Ventilator circuits are changed weekly. • Indications for an actively humidified circuit (Westmead ICU): � minute volume greater than 10 litres � chest trauma with pulmonary contusion � airway burns � severe asthma � hypothermia (
W e s t e r n S y d n e y A re a H e a lth S e rv ic e H E A L T H Nursing Care Of The Ventilated Patient Intensive Care Evidence Based Practice Guidelines 2003 • Closed suction catheters should be rinsed post suctioning to remove mucous and to reduce the likelihood of bacterial growth. • Tracheal suctioning should be attended 2 - 3 hourly, more often if necessary (See Suctioning an Artificial Airway Guideline). • Suction the oropharynx to remove potentially infected secretions. Monitors: • Check the level of any invasive monitoring transducers and zero them. (Haemodynamic Monitoring Guideline). • Check the alarm parameters and reset if necessary • Document the patient’s vital signs hourly and when there is a deviation from the usual. • Check and document a manual blood pressure to assess the accuracy of the arterial trace once a shift. Oral Care: • The aim of oral care and assessment is to promote normal hygiene while preventing infection and trauma. • The presence of an ETT can cause hyper salivation in some patients and an uncomfortably dry mouth in others. • A soft toothbrush can be used for oral hygiene and a small amount of toothpaste can help the cleansing action. Using large amounts of toothpaste may leave a residual coating and produce a burning sensation if it is not rinsed away properly. • Properly diluted sodium bicarbonate may be used to remove resistant coating on the tongue, debris or tenacious secretions but again overuse may cause superficial burns. • The lips should be kept moisturized to stop them becoming sore and cracked. • 2 nd hourly oral care is recommended, using water, not saline, and oral swabs and thorough suctioning of oral secretions, a toothbrush & paste should be used at least once a shift and more often if indicated.
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Nursing care of the ventilated patient (SWAHS) - Intensive

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