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
• The ETT and other lines should be safeguarded during turning and care should be
taken to ensure that there are no lines or other equipment under the patient turned.
• The skin should be kept dry and should be inspected with each change of position,
including under restraints. (Refer to Restraints Guideline)
• The head of the bed should be elevated if the patient’s condition allows to help
prevent aspiration and improve oxygenation.
• If the patient has any signs of developing pressure areas he/she should be nursed on
an air mattress. (Refer to Pressure Area Care Guideline).
• The ETT should be repositioned at alternate sides of the mouth to prevent pressure
areas developing.
• The NG tube should be secured in such a way as to minimize pressure on the nares
and changed at least daily.
• If the patient has a hard collar it should be changed to an Aspen collar as soon as
possible and the back of the head and neck checked once a shift for the presence of
pressure areas.
References:
1. Anonymous. (2002) ‘Eye care for intensive care patients‘, Best Practice Vol 6 (1)
ISSN 1329-1874.
2. Ashurst,S. (1997) ‘Nursing care of the mechanically ventilated patient in ITU: 1,
British Journal of Nursing Vol 6 (9) Nov, 447-454.
3. Blackwood, B. (1998) ‘The practice and perception of intensive care staff using the closed suction system’,
Journal of Advanced Nursing Vol 28 (5) Nov,1020-1029.
4. Greifzu, S. (2002) ‘Caring for the chronically critically ill’, RN Vol 65 (7) July, 42-44, 46, 48-49.
5. Hickson,S, Sole,M.L, King,T. (98) ‘Nursing Strategies to prevent Ventilator-Associated Pneumonia, AACN
Clinical Issues Vol 9 (1) Feb, 76-90.
6. Schwenker,D, Ferrin,M, Gift,A. (1998) ‘A survey of Endotracheal suctioning with instillation of NaCl’, American
Journal of Critical Care Vol 7 (4) 256.
7.Stamm,A.M. (1998) ‘Ventilator- associated pneumonia and frequency of circuit changes’, American Journal of
Infection Control Vol 26 (1) Feb, 71-73.
8. Tan,I.K.S, Oh,T.E.(1997) Intensive Care Manual, 4 th ed, p.246, Bath, Butterworth & Heinemann.
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