Management of Mechanical Ventilators (Nursing)

00:01 In this section, we're going to talk about what you'll be doing as a nurse to make sure that you keep your patients safe as possible, and minimize some of the risks that come along with being on a ventilator.

00:12 So, we call these a ventilator bundle.

00:14 I thought that was such a funny word, the first time I heard about it.

00:17 So, I had this vision in my mind that it was a group of ventilators all brought together and that's not it at all.

00:25 What a ventilator bundle is, is a package of evidence-based interventions.

00:29 That means we did as a society, a lot of research trying to figure out why do patients develop these things? And what are simple strategies that we could use to help minimize or prevent these problems.

00:43 So, first step, you'll notice it most patients on a ventilator unless there is some unusual reason why not.

00:49 They will have the head of their bed elevated 30 to 45 degrees.

00:53 That's kind of an across the board type of order that comes along with ventilator bundles.

00:58 You're going to do the regular infection control measures, those may vary a little bit by hospital.

01:04 But obviously, you're going to do your very best like you do with every patient to follow infection control procedures.

01:10 We're going to try to make sure they don't get an ulcer.

01:12 We talked about that with the medications that you can give.

01:15 So we don't wait for the patient to develop a sign of an ulcer.

01:19 We know that a patient who's on a ventilator in the hospital that critically ill is at an increased risk for an ulcer, which is why we do prophylaxis.

01:27 We give them the medication already, because we know they're at high risk to try to minimize the risk of that.

01:33 They're also at risk because they're immobilized for the most part when they're on a ventilator, that they develop a deep venous thrombosis. So that's a DVT.

01:43 So we know they're at risk for it.

01:45 We definitely don't want that DVT developing or worse yet, breaking off and traveling up to the lungs to cause a PE.

01:51 So we prophylactically also treat that with medication.

01:55 In addition to these daily spontaneous breathing trials, you'll also do spontaneous awakening trials.

02:01 Remember, you'll do this in collaboration with your registered respiratory therapist.

02:05 Now, that cuff that we talked about earlier, at the end of the endotracheal tube that's down here.

02:11 Remember, its job is to keep that tube in place.

02:14 But you want to be very careful that you have the appropriate pressure level in that pillow, that little cuff that you filled up.

02:20 So it shouldn't be between 20 and 30.

02:23 Have it too high, your risk tissue damage, too low and your risk that cuff being deflated too much to keep the tube in place and they could excavate themselves.

02:34 Now, this other problem is dealing with subglottic suctioning that's necessary.

02:40 Really uncomfortable for your patient.

02:43 No patient enjoys the process of sectioning.

02:45 So why would we do this to someone? Remember, this is a Ventilator Bundle.

02:51 A group of orders that are based in research that are meant to keep a patient safer and minimize the risk of VAPP.

02:58 You have all that gunk gathering around in there.

03:00 If the patient should aspirate that into their lungs, that's most likely going to cause a pneumonia.

03:06 So the oral care is another cool thing. So simple.

03:09 Every two hours you do oral care, and you do it with a very specific substance chlorhexidine gluconate.

03:16 Now another things kind of have to do with mobility.

03:19 Since a patient on a ventilator is not mobile, you watch them very closely for pressure care for wound prevention.

03:25 You don't want to cause skin breakdown.

03:28 And that can happen rapidly.

03:30 So you want to get them mobilized as early as possible.

03:33 Move as much as you can keep the patient as independent as possible as what is safe for the patient. And that's it.

03:40 That's a Ventilator Bundle of research based interventions we know will minimize the risks and complications for a patient who's on a mechanical ventilator.

03:50 Well, we've gone through what you do before, during, and after a patient has been intubated.

03:56 We've talked about the risks, the complications.

03:58 Now we're going to talk about the great stuff.

04:00 This is when you get to help the patient wean off the ventilator.

04:05 We do it in steps. We have consistent policies that we follow, but sometimes it's a little bit different for each patient, depending on how they respond.

04:13 So first question, I want you to ask yourself, has the underlying issue been addressed and improved? So whatever put the patient at risk, where they need to be placed on a ventilator, have we at least improved it? Or has it been resolved? Next question. Has the patient headed towards hemodynamic stability? Are their vitals stable? Do things seem much closer to homeostasis than they were when you intubated the patient? Now, all of these answers need to be yes to these questions.

04:42 So we want the underlying issue to be well improved or completely addressed.

04:47 We want them to be heading towards hemodynamic stability.

04:51 We're gonna look at their oxygen saturations and make sure they are consistently improving, and they're within a safe range.

04:57 Now, the last part, and it's the biggest one.

05:01 If you want to take a look and see is the patient able to breathe comfortably on minimal ventilator settings? It's kind of like a trial run to see how that patient would do if they were no longer on the ventilator.

05:13 And that's it. Those are four really big questions.

05:17 Now, when you're in practice, you'll be working with the respiratory therapists and with the physicians and the health care providers.

05:23 And you'll have multiple conversations about this.

05:26 And they'll do special tests and observe the patient and assess them and give them trial. So, it can be a complicated process to wean some patients off the ventilator.

05:35 But now that you're equipped, you know what the pressures mean, you know what to watch for, you know what to do if you recognize cues that are a problem for the patient, and you will be equipped to know how to care for a ventilator patient.