SHORE HEALTH SYSTEM CRITICAL CARE POLICY I PROCEDURE

Transcription

1 SHORE HEALTH SYSTEM CRITICAL CARE Page 1 of 5 POLICY I PROCEDURE TITLE: NURSING CARE OF THE MECHANICALLY VENTI LA TED PATIENT DATE ESTABLISHED: 9/12 REVIEWED/REVISED: 1/13 CROSS REFERENCES: SHS Administrative Policy TX-72: Respiratory Care in ICU and ED SHS Administrative Policy TX-63: ICU Multidisciplinary Rounding Team Program Critical Care Agitation/Sedation Order Set ICU Hyperglycemia Protocol PURPOSE: To provide mechanical ventilation, while at the same time reducing the patient's risk of developing Ventilator Associated Pneumonia (VAP). SCOPE: ICU RN, RCP MONITORING: VAPNAC Rates, Ventilator Bundle Compliance, Hand Hygiene Compliance, MRSA Transmission Rates EQUIPMENT: Oral Care Kit Suction Canister Suction Connecting Tubing Chlorhexidine gluconate INFECTION CONTROL CATEGORY: ~ POLICY: 1.0 All adult patients requiring ongoing mechanical ventilation will be admitted to the I CU. 1.1 Patients who are on ventilator support at home will be placed on a hospital ventilator during their hospitalization This can be overwritten by an order from the lntensivist on call to maintain the patient's home ventilator. 2.0 Hand hygiene will occur per policy. 2.1 Additionally, hands will be cleansed before and after suctioning, touching respiratory equipment, and /or coming into contact with respiratory secretions.

2 Page 2 of Oral intubation is preferred over nasal intubation. 4.0 Oro-gastric tube is preferred over nasa-gastric tube when possible. 4.1 If nasa-gastric tube is in place, caregivers will jointly consider risks and benefits of replacing with oro-gastric tube. 5.0 All 4 elements of the ventilator bundle are to be applied to mechanically ventilated patients unless medically contraindicated: 5.1 Head of bed will be elevated at least 30 degrees 5.2 Peptic ulcer disease (PUD) prophylaxis 5.3 Deep venous thrombosis (DVT) prophylaxis 5.4 Sedation vacation & assessment of readiness to extubate 6.0 Ventilator bundle compliance will be monitored by the ICU personnel. 7.0 Endotracheal tube securement devices will be changed or repositioned a minimum of daily by a Respiratory Care Practitioner (RCP). 7.1 Assessment of underlying skin structures will be assessed at this time. 8.0 Endotracheal tube placement (depth of insertion) will be documented and checked a minimum of every eight hours. 9.0 Ventilator circuits and heat moisture exchangers (HMEs) will be changed by RCPs only when visibly soiled Mechanically ventilated patients will be placed on the ICU Hyperglycemia protocol unless otherwise ordered by physician Nutritional needs of the patient will be assessed, discussed, and addressed daily by the Multidisciplinary Rounding Team Weaning assessment will be performed daily by RCP unless the patient does not pass the Safety Screen ICU nursing staff will assist the RCP with the completion of the Safety Screen as required Sedation will be administered for mechanically ventilated patients according to the Critical Care Agitation/Sedation order set unless otherwise ordered by physician.

3 Page 3 of Sedation Vacation will occur daily according to the order set for mechanically ventilated patients unless contraindicated NSS lavage will not be performed unless clinically indicated or specifically ordered by physician Endotracheal suctioning will be performed only when necessary Subglottic suctioning will be performed a minimum of BID as described in the Critical Care Procedure: Oral Care for the Mechanically Ventilated Patient If EVAC tube is present, high intermittent or low continuous will be used The RCP will instill 5 ml of air into the EVAC tube every 4 hours Patients will be assessed to determine need for removal of oropharyngeal secretions every 4 hours, as needed, and before repositioning ETT or deflating ETT cuff Opening of suction lines will be limited as much as possible Oral and ETT/Tracheal suctioning will have separate suction tubing but may share a canister Ensure Yankauer is covered except when in use, and is changed every 24 hours The connection between the in-line ETT/tracheal suction catheter and its suction tubing should be interrupted only if absolutely necessary Oral care will be performed a minimum of every 4 hours as described in the Critical Care Procedure: Oral Care for the Mechanically Ventilated Patient. PROCEDURE: ORAL CARE FOR THE MECHANICALLY VENTILATED PATIENT 1.0 Obtain 24 hour oral care kit and label with patient's name and date/time of initiation. Hang in patient room on hanger provided. 2.0 Set up suction system and Yankauer per package instruction. Covered Yankauer may bifurcate with ETT/Tracheal suction tubing at canister. 3.0 Suction subglottic secretions with catheter provided twice per day (approximately every 12 hours). 3.1 Attach subglottic catheter to suction handle. 3.2 To suction secretions, slide switch to "on" while suctioning oropharynx subglottic region. When finished slide switch to "off."

4 Page 4 of5 3.3 Rinse tubing. Discard suction catheter and reattach covered Yankauer to handle. 4.0 Brush teeth twice a day (approximately every 12 hours) with provided brush attachment and oral cleansing solution, followed by the application of oral Chlorhexidine gluconate (CHG). 4.1 Before opening package, burst solution packet with thumbs. Attach toothbrush with solution to suction handle. 4.2 Brush teeth for approximately 1-2 minutes exerting gentle pressure while moving in short horizontal or circular strokes. Gently brush surface of tongue. Remove toothbrush attachment and reattach Yankauer. 4.3 Apply suction by turning the switch of the handle to the on position to remove debris. Turn switch to off position when suction is complete. 4.4 Using a sponge-tipped oral swab, apply CHG to all oral surfaces, avoiding implanted false teeth (to minimize potential for staining) 4.5 Apply suction by turning the switch of handle to the on position, to remove excess CHG from oral cavity. Turn switch to off position when suction is complete. 4.6 Clear tubing with water Place mouth moisturizer on applicator swab and apply to lips only 4.8 Refrain from rinsing or providing any other moisturizers to the oral cavity for at least 30 minutes to prevent deactivating CHG 5.0 Oral swab and mouth moisturizer will be completed every 4 hours except when brushing teeth. Individual oral swabs with moisturizer are also available and may be used as needed in addition to oral care kit. 5.1 Use thumbs to burst solution in packet before opening. Attach swab with solution to handle after removing covered Yankauer. 5.2 Use suction swab to clean teeth, tongue and gums. 5.3 Place perpendicular to gum line applying gentle mechanical action for 1-2 minutes. Turn swab in clockwise rotation to remove mucus and debris. 5.4 Apply suction by turning on the switch of handle, then off when suction complete. Clear tubing with water.

5 Page 5 of5 5.5 Place mouth moisturi?er on applicator swab and apply to lips and inside mouth. 6.0 Oropharyngeal suction with Yankauer will occur every 4 hours, as needed, and before deflation of cuff and/or ETT repositioning. References: AACN Procedure Manual for Critical Care. 6th Edition AACN Practice Alert: Ventilator Associated Pneumonia, January AACN Practice Alert: Oral Care in the Critically Ill, October Micromedex 2.0: Chlorhexidine gluconate, Sage Instructions for Oral Care Using Sage Q Care System, Approved by the Critical Care Committee at the 01/30/13 departmental meeting. APPROVED BY: ~ ~ Holly FraSe: RN ader of the Unit-based Council - MHE ICU f. 2:0. 13 Ryan. Fast, S, RN, CNML, NEA-BC Date Manager Critical Care & Multi-Specialty Care Units- DGH Cyn a Beemer, MSN; RN, CCRN, NEA-BC Nurse Manager, ICU/Tele- MHE I;M -1.3 Date Pe~ma Otmishi, MD Medical Director, ICU f/3o(r} Date H:\POL-PRO\CRIT CARE\MECHANICALL Y VENTI LA TED PT