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 Eye Care: • The unconscious, sedated or paralyzed patient is at risk of developing eye problems ranging from mild conjunctivitis to serious corneal injury and ulceration. Permanent eye damage may result from ulceration, perforation, vascularization and scarring of the cornea. • Sedation and muscle relaxants can lead to inadequate closure of the eye, lack of random eye movements and a loss of the blink reflex, all of which can lead to complications. • Fluid imbalances and increased permeability can promote conjunctival oedema. • Constrictive securing tapes can compromise venous return from the head leading to venous congestion and maybe an increase in interocular pressure and therefore an increase in conjunctival oedema. • 2 nd hourly eye care using saline soaked gauze to clean the eye and the application of lactrilube regularly in the ventilated patient is recommended to help reduce the risk of complications. G.I.T: • Intubated patients must have a nasogastric tube for gastric decompression or nutritional support. • The presence of bowel sounds and the turgor of the abdomen should be assessed during the initial assessment. • Nutrition and hydration are essential to build respiratory muscle strength necessary when a patient is being weaned from a ventilator. Patients who have inadequate nutritional stores are prone to infection, fluid and electrolyte imbalance, intestinal fluid retention, weight loss, pressure areas and poor wound healing. • Patients with a functioning GI tract should be fed enterally. TPN may be used if there are contraindications to enteral feeding. • The enterally fed patient should be monitored for diarrhoea, dehydration, fluid overload, constipation or abdominal cramping. These observations can be a guide in determining the strength and rate of increase of the feeds. • NG tubes should be flushed with 20-30 mls of water before and after administering medications. • Fine bore tubes can not be aspirated but should be flushed 4 hourly with water.
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 • If the patient is not being fed enterally the NG tube should be on free drainage and aspirated and flushed 6 hourly with water. • If the enterally fed patient has large aspirates (>200mls or > 4 hours feed) consult with medical staff regarding reducing the feed and/or discarding the aspirate. Otherwise the aspirate is generally returned if less that 200 mls or < 4 hours feed. • Elevating the head of the bed to 30 - 45 degrees (unless contraindicated) is effective in reducing the risk of aspiration. • Elimination should be recorded and aperients given if necessary. Genital/Urinary Tract: • IDCs predisposes urinary tract infections. • Routine urinalysis should be twice a day • Regular penil/perineum catheter care should be done. • The catheter should be secured to the leg carefully and repositioned as necessary to prevent pressure areas. • Hourly urine monitoring is carried out and medical staff informed of abnormally high or low measurements. Aim for a urine output of 0.5ml/kg. Repositioning And Pressure Area Care: • Attending to the patient’s hygiene protects the skin and ensures dignity and comfort • Ventilated patients are at a higher risk of developing nosocomial infections and pressure areas due to their immobility, their underlying disease process and the presence of invasive monitoring lines and equipment. • Repositioning the patient regularly has a number of positive effects: � routine turning and positioning assists in the mobilization of secretions � prevents the development of pressure areas, joint stiffness and deformities � improves oxygenation and can encourage weaning from the ventilator. � provides a different view on the environment for the patient � the patient should be repositioned 2 nd hourly if possible, taking care to position the limbs in proper alignment and supporting them to prevent dependant oedema. • If the patient has leg splints on they should be on for 2 hours and off for 2 hours. They should not be bandaged and the skin integrity should be checked with each turn. •
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Nursing care of the ventilated patient (SWAHS) - Intensive

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