OUTCOMES : While receiving ventilatory assistance, the patient will experience an adequate supply of oxygen and concurrently, adequate elimination of carbon dioxide at the cellular level.



EQUIPMENT : - Laerdal resuscitator (with mask and oxygen flow tubing)
- Suction equipment (refer to policy / procedure: Suctioning A Patient With A Endotracheal / Tracheostomy Tube ) including a Yankeur suction catheter - Mechanical ventilator - having passed Performance Check ( as detailed by manufacturer)
- Stethoscope
- High volume and low pressure cuff manometer - 12 g Dwellcath cannula.

PROCEDURE : Endotracheal Tube: Position:
- The correct position / length of the endotracheal tube, as verified by Chest X-Ray, should be documented in the patient's progress notes and upon the daily flow chart.
- The "responsible" nurse should verify, at the beginning and end of their shift, that the endotracheal tube position is at the documented level.

Endotracheal Tube: Securing: - At all times, the endotracheal tube should be securely taped, according to the policy / procedure: Care and Securing of an
Endotracheal / Tracheostomy Tube.
Endotracheal Tube: Cuff:
-At all times, the "responsible" nurse should listen for an air leak in the tube cuff, as evidenced by a gurgling sound.
- Hourly, the "responsible" nurse should document on the daily flow chart the actual cuff pressure measurement or the presence or absence of an audible air leak during the previous hour. - The cuff pressure should be maintained from 15 to 25 cm H2O. The cuff pressure should be verified, by use of a cuff pressure
manometer: at least every four hours; upon hearing an air leak or after repositioning the endotracheal tube.
- The cuff pressure of low volume / high pressure cuffed endotracheal tubes are not routinely measured. If an audible air leak presents, using a syringe instill sufficient air into the cuff to seal the leak - then, withdraw 0.5 ml of air.

Tracheal / Oropharyngeal Aspiration:
- Refer to the policy / procedure: Suctioning of an Endotracheal / Tracheostomy Tube.
- At least second-hourly, unless stipulated by the Director of ICU or his delegate, attend tracheal aspiration maintaining strict asepsis. Note the amount and nature of secretions on the daily flowchart.
- At least second-hourly, using a Yankeur sucker and a clean technique, aspirate oropharyngeal secretions.

Humidification:
Refer to the policy / procedure: Humidification.
- At the beginning of the shift: verify that the temperature of the inspiratory tubing is warm to touch.
- Hourly: check and document the temperature of humidified air ( as registered on the Fisher - Paykel humidifier base). Unless
otherwise ordered by the Director of the ICU, or his delegate, it should be functioning at 37o C. (that is: 39o C. at humidifier base and -2o C. at distal end of temperature probe).
- Hourly: check and verify that the level of sterile water in the humidifier is around indicated level. Replenish volume as required, ensuring minimal interruption to ventilation.

Ventilatory Assistance:
- Continuously: observe patient for signs of respiratory distress. ( These include: increased respiratory effort; increased difficulty in ventilation; agitation; a sudden decrease in SpO2; poor or unequal chest expansion and cyanosis.) If these signs occur, the
"responsible" nurse should be prepared to manually ventilate the patient, using a Laerdal silicone resuscitator, while investigating the cause of the ventilator emergency. Refer to the policy / procedure: Nursing Management: Ventilator Emergency.
- Continuously observe the patient's SpO2. Inform Director of ICU, or his delegate, if SpO2 deviates from the accepted parameters. The SpO2 alarm limits should be functioning at all times.
- Hourly: observe and document respiratory and ventilatory functioning. In particular:
- Ventilatory inspiratory modes and measurements;
- Ventilatory expiratory mode and measurement;
- Intermittent mandatory ventilation rate;
- Spontaneous breath rate;
- I.M.V. tidal volume;
- Spontaneous breath tidal volume;
- Peak inspiratory airway pressure;
- Peak inspiratory flow and flow pattern;
- Sensitivity;
- Fraction of inspired oxygen;
- Low airway pressure limit;
- High airway pressure limit;
- SpO2.
- At the beginning of the shift and every four hours: auscultate patient's lung fields. Document and report, whether air entry is equal to both lungs and the presence of adventitious breath sounds.

Observation of Vital Signs:
- At the beginning of the shift: ascertain desired parameters of heart rate; blood pressure and central venous pressure. Record parameters on daily flow chart.
- Continuously: observe patient's heart rate and rhythm. Verify that heart rate alarm are set at all times.
- Hourly: document heart rate and rhythm on the daily flow chart. Document and report any cardiac arrhythmias.
- Frequency of blood and central venous pressure measurements are determined by the haemodynamic stability of the patient.
- Continuously: observe the patient's level of consciousness; sedation and co-operation. Document and report behaviour trends.
- At all times: maintain an accurate fluid balance record.
- Hourly: document urine output on the daily flow chart (if applicable). Notify the Director of ICU, or his delegate, if output
falls outside desired urine output parameters, or when output is less than 0.5 ml/ kg/ hour for longer than 3 hours.

Physiotherapy:
- At the beginning of the shift, in liaison with the Director of ICU and attending physiotherapist, the "responsible" nurse
Should ascertain the physiotherapy requirements of the patient.
- Unless contraindicated: the physiotherapy regime for the ventilated patient will include:
- Hourly to second-hourly tracheal aspiration. Refer to the policy / procedure: Suctioning of an Endotracheal
Tracheal Tube.
- Second-hourly: hyperinflation and hyperoxygenation of lungs using Laerdal Silicone Resuscitator.
- Second to fourth-hourly: postural drainage; gentle percussion and vibrations (alternating lung fields).
- Each shift, if the patient is unable to move their limbs fully and independently, attend full range of motion exercises.

Elimination:
- Daily: attend and document urinalysis. Report abnormalities to the Director of ICU, or his delegate,
- Each shift: document bowel motions. If bowels have not been opened in the previous 24 hours, attend a rectal examination.
- Each shift, if flatus has not been passed, auscultate and document the nature of bowel sounds.
- If enteral feeding is not in progress, connect nasogastric tube to drainage bag. Manually aspirate nasogastric tube every four hours. Note amount and nature of drainage.

Maintenance of Mucous Membrane Integrity (Hygiene Needs):
- Every two hours, unless contraindicated, reposition patient. Maintain correct body alignment at all times. Unless the patient
conscious and co-operative, three staff are required for each position change. One for either side of the patient and the third person to control the patient's head and neck and maintain the security of the endotracheal tube.
- Each shift all pressure-prone areas are to be inspected and sufficient action taken to prevent further deterioration in skin integrity.
- Every two hours, following oropharyngeal suctioning, attend oral cavity care. Apply emollient cream to the patient's lips. - Every two hours, attend patient's eye toilet. If the patient is unconscious or has inflamed conjunctiva, apply liberal amounts
of lubricant ung to the lower conjunctival sacs. In the unconscious patient, if the eyelids will not stay closed independently,
they should be taped shut with 1 cm wide hypoallergenic tape. If the patient is conscious, lubricant drops should be used rather than ung, to prevent corneal ulceration.
- Every four hours, attend nasal toilet.
- Every four hours, attend perineal / meatal hygiene.
- Daily and as required: attend full sponge.
- Weekly and as required, attend hair wash.
- Document changes in condition of skin and mucous membranes and subsequent nursing actions in progress notes.

ALERT
At beginning of the shift: the "responsible" nurse is to verify that:
* The endotracheal, or tracheostomy, tube is adequately secured and is patent.
* There is a functioning suction source and equipment in close proximity to the patient.
* There is a functioning oxygen cylinder under the patient's bed.
* All alarms on the ventilator are correctly functioning.
* The ventilator is attached to an uninterrupted power source. (Refer to the policy / procedure: Electricity in ICU ).

No change should be made in ventilatory management without prior consultation with the Director of ICU, or his delegate.

Review Date