NURSING SERVICES DEPARTMENT

Transcription

1 NURSING SERVICES DEPARTMENT TITLE: Mechanical Ventilation PATIENT CARE PLAN DIAGNOSIS: DISCHARGE CRITERIA: 1 The patient will: Maintain adequate mechanics of PERTINENT INFORMATION:. ventilation as demonstrated by ABGs within normal limits 2 Indwelling or attached medical devices will remain intact until discontinued 3 Patient will be extubated following Weaning Procedure 1. Potential for injury related to external factors: Unfamiliar environment Ventilator support Patient & family will understand the need for intubation Endotube will remain patent until extubated by medical staff Reorient and increase observation Sedation per protocol to obtain RASS score of ( ) Explain extubation goals and potential time frames to patient and family 2. Alteration in Cognitive or Perceptual function related to: Altered mental status Effects of medication Patient will return to previous level of mental awareness and function Maintain quiet work environment Explain all inventions prior to starting Allow long sleep intervals and schedule patient care accordingly Follow: ( ) Lorazepam Protocol ( ) Midazolam Protocol Document sedation level hourly and prn with vital signs using Richmond Agitation-Sedation Scale (RASS)

2 Page 2 of 4 3. Alteration in respiratory function related to: Pain Noxious stimuli Secretions Respiratory status and disease pathophysiology Patient will exhibit adequate ventilation as exhibited by ABG values within normal limits Decrease or remove sources of discomfort, noxious stimuli. Medicate with narcotic as ordered, observe for desired effect and possible side effects Suction patient with in-line suction setup. Oxygenate with 100% FIO2 before and after suctioning Adjust ventilator alarms to match patient s mechanics Assess patient s chest x-ray, ABGs and mechanics 4. Potential or actual risk of injury related to medical devices: Dislodging Endotracheal tube Mechanical ventilation support Endotracheal tube will remain patent SpO2 will remain greater or equal to 90% Ventilator settings appropriate for patient condition Ventilator alarms will function appropriately Patient will maintain adequate respiratory status post extubation Assess the following: Lung sounds Endotube position Security of endotube holder Continuous SpO2 monitoring Ventilation adequacy Airway suctioning Sedation level Patient s level of understanding Vent settings and alarm function assessed every hour Wean and extubate per protocol when criteria met

3 Page 3 of 5 5. Potential or actual risk for ventilatorassociated complications Aspiration pneumonia Deep vein thrombosis formation Peptic ulcer disease X-ray reports will remain or return to normal Patient will remain free of deep vein thrombosis Gastric mucosa will remain intact Maintain head of bed degrees Oral care q 4hrs with 0.12 % chlorhexidine solution and brush teeth q 12 hrs Daily reduction of sedation levels to evaluate readiness to wean and extubate Evaluate for positive Homan s q 4 hrs Ted stocking as ordered Sequential compression devices as ordered DVT prophylactic anticoagulation as ordered H2 receptor inhibitor administered as ordered

4 Page 4 of 5 WEANING PROCEDURE: Prior to and during trial: Obtain and document baseline mechanical & spontaneous measurements Evaluate baseline vital signs & changes with each vent change Titrate sedation to optimal level Explain procedure to patient and family Document mechanical and spontaneous efforts along with response Sedation levels must be closely observed during the period. Decreases in mechanical ventilation may result in hypoventilation if the patient is too sedate or is medicated with narcotics. Patients may need to be occasionally stimulated during but if excessive stimulation is needed to maintain adequate rate, the patient is not ready to wean. Slow Wean (Patient sleepy but ready to wean) 1) Decrease respiratory rate to 6/min, PSV 15 for 30 minutes 2) Decrease respiratory rate to 4/min for 30 minutes (Do not change PSV pressures) 3) Decrease respiratory rate to 0/min for 30 minutes, patient in PSV Mode. (Do not change PSV pressures) 4) Decrease PSV to 10 for 30 minutes 5) Continue to wean to PSV 5 unless endotube size is less than 7.5 mm. (If less than 7.5mm keep PSV at 10) 6) Obtain and spontaneous parameters and document. Evaluate patient readiness for extubation using Burn s Wean Assessment Program 7) Obtain ABG and spontaneous parameters and report results to physician for extubation and oxygen orders 8) Provide supplemental nasal cannula oxygen after extubation Moderate Wean (Patient awake but occasionally needs stimulation) 1) Decrease respiratory rate to 4/min, PSV 15 for 30 minutes 2) Decrease respiratory rate to 0/min for 30 minutes, patient in PSV Mode. (Do not change PSV pressures) 3) Decrease PSV to 10 or 5 for 30 minutes 4) Continue to wean to PSV 5 unless endotube size is less than 7.5 mm. (If less than 7.5mm keep PSV at 10) 5) Obtain and spontaneous parameters and document. Evaluate patient readiness for extubation using Burn s Wean Assessment Program) 6) Obtain ABG and spontaneous parameters and report results to physician for extubation and oxygen orders 7) Provide supplemental nasal cannula oxygen after extubation Quick Wean (Patient very awake and cooperative) 1) Decrease respiratory rate to 4/min, PSV 10 for 30 minutes. (If endotube is less than 7.5mm keep PSV at 10) 2) Decrease respiratory rate to 0/min PSV 5 for 30 minutes, patient in PSV Mode (If endotube is less than 7.5mm keep PSV at 10) 3) Obtain and spontaneous parameters and document. Evaluate patient readiness for extubation using Burn s Wean Assessment Program 4) Obtain ABG and spontaneous parameters and report results to physician for extubation and oxygen orders 5) Provide supplemental nasal cannula oxygen after extubation

5 Page 5 of 5 Patient Care Plan Reviewed Date Signature APPROVAL: Vice President, Nursing President, Medical Staff ISSUED: REVIEWED: REVISED: FILE NAME: Mechanical Ventilator Care Plan