Nursing care of the ventilated patient (SWAHS) - Intensive

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.