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    Careplan

    Mechanical ventilation invasive adult

    Nov.08.2021

    Mechanical Ventilation Invasive (Adult Inpatient)

    Clinical Description

    • Care of the hospitalized patient experiencing the need for controlled or assisted breathing through an artificial airway.

    Key Information

    • Laryngeal mask airways may be used for short-term use to facilitate breathing; however, they do not offer aspiration protection and should be changed to an endotracheal tube if there is a need for a prolonged artificial airway.
    • Cuff (if present) must be deflated prior to using a speaking valve or capping a tracheostomy tube. Some speaking tracheostomies may have exceptions to this rule. Consider a cuffless tracheostomy, if speaking valve or cap use will be routine.
    • Enteral feeding is preferred over parenteral due to physiologic benefits, such as gut integrity and function, stress ulcer prophylaxis and reduction of infection risk.
    • Probiotic use may lower the incidence of ventilator-associated pneumonia. Probiotic strains, dosages and delivery methods vary among studies; therefore, larger population multicenter randomized controlled trials are needed to determine the most effective treatment.

    Clinical Goals

    By transition of care

    A. The patient will achieve the following goals:

    • Effective Communication

    • Optimal Device Function

    • Mechanical Ventilation Liberation

    • Optimal Nutrition Delivery

    • Absence of Device-Related Skin and Tissue Injury

    • Absence of Ventilator-Induced Lung Injury

    B. Patient, family or significant other will teach back or demonstrate education topics and points:
    • Education: Overview
    • Education: Self-Management
    • Education: When to Seek Medical Attention

    Correlate Health Status

    • Correlate health status to:

      • history, comorbidity
      • age, developmental level
      • sex, gender identity
      • baseline assessment data
      • physiologic status
      • response to medication and interventions
      • psychosocial status, social determinants of health
      • barriers to accessing care and services
      • health literacy
      • cultural and spiritual preferences
      • safety risks
      • family interaction
      • plan for transition of care

    Communication Impairment

    Signs/Symptoms/Presentation

    • agitation
    • anxiety
    • artificial airway present inhibiting vocalization
    • fear
    • frustration expressed
    • irritability
    • maladaptive communication behavior (e.g., facial expressions, hand or head movements)
    • powerlessness
    • social withdrawal

    Problem Intervention

    Ensure Effective Communication

    • Keep call system within reach; adapt to meet needs; respond to call light in person.
    • Acknowledge and validate intensity and complexity of voicelessness. Maintain eye contact when speaking and awaiting response.
    • Promote calming presence. Involve patient in decision-making and care to promote inclusion, self-efficacy, confidence and sense of control.
    • Establish a nonverbal communication method. Use augmentative techniques to preserve self-identity and self-esteem, such as writing tools, letter board, computer, flash cards or picture boards.
    • If tracheostomy, consider alternative communication method to facilitate sound or speech, such as speaking valve, occlusive cap or electrolarynx; deflate tracheostomy cuff, if present, when using devices to allow exhalation; monitor closely.
    • Assess and monitor for signs of biopsychosocial concerns that may affect ability to communicate, such as delirium, anxiety and depression.

    Associated Documentation

    • Communication Enhancement Strategies
    • Psychosocial Support

    Device-Related Complication Risk

    Signs/Symptoms/Presentation

    • air auscultated in stomach
    • airflow absent out of airway device
    • airflow out of mouth
    • breath sounds unequal
    • chest movement asymmetrical
    • difficulty passing suction catheter
    • excessive cough
    • gastric distension
    • gurgling sound from throat
    • inability to ventilate
    • mechanical ventilation with an artificial airway
    • restlessness
    • upper airway sounds increased
    • work of breathing increased

    Vital Signs

    • heart rate increased
    • respiratory rate increased
    • SpO2 (peripheral oxygen saturation) decreased
    • EtCO2 (end-tidal carbon dioxide) increased

    Laboratory Values

    • PaCO2 (arterial carbon dioxide) increased
    • PaO2 (partial pressure of arterial oxygen) decreased

    Diagnostic Results

    • CXR (chest x-ray) abnormal tube position
    • EtCO2 waveform abnormal
    • obstruction visualized with bronchoscopy
    • ultrasonography abnormal tube position

    Problem Intervention

    Optimize Device Care and Function

    • Maintain head of bed elevation with regular position changes to minimize ventilation-perfusion mismatch and breathlessness.
    • Provide oral care regularly with antimicrobial solution and subglottic suction to reduce the risk of infection; perform prior to cuff deflation or tube manipulation.
    • Assess tube size, depth, location and securement frequently to minimize the risk of tube displacement; confirm placement with radiography or ultrasonography.
    • Facilitate regular mechanical ventilator and humidification equipment checks to ensure proper function; monitor and manage ventilator and alarm settings.
    • Provide humidification and evaluate need for suctioning to minimize risk of airway obstruction; regularly replace closed suction equipment.
    • Perform ongoing device and stoma care to prevent infection; minimize excessive moisture around device; ensure tracheostomy inner cannula or single lumen device is cleaned or replaced regularly to prevent obstruction from secretions.
    • Monitor and manage cuff pressure routinely, if present; deflate cuff when not clinically indicated.
    • Maintain readily available emergency equipment that includes appropriate-sized manual resuscitation bag, mask, suction equipment, cleaning supplies and replacement airway devices.
    • If displacement occurs, provide oxygen to the nose, mouth and stoma. Notify provider.

    Associated Documentation

    • Airway Safety Measures
    • Airway/Ventilation Management
    • Oral Care

    Inability to Wean

    Signs/Symptoms/Presentation

    • confusion
    • continued need for mechanical ventilation
    • disconnected from reality
    • fear
    • inability to decrease ventilator settings
    • increase in oxygenation or ventilation requirements
    • level of consciousness decreased
    • lung compliance decreased
    • muscle weakness
    • positive fluid balance
    • respiratory effort absent
    • unable to follow commands

    Vital Signs

    • heart rate increased
    • respiratory rate increased
    • blood pressure increased or decreased
    • SpO2 (peripheral oxygen saturation) decreased
    • EtCO2 (end-tidal carbon dioxide) increased

    Laboratory Values

    • ABG (arterial blood gas) abnormal

    Problem Intervention

    Promote Extubation and Mechanical Ventilation Liberation

    • Assess for pain, agitation and delirium regularly, utilizing a validated tool; minimize medication effects that may contribute to agitation, delirium or delay extubation.
    • Encourage early rehabilitation using therapeutic intervention and functional mobility training to minimize deconditioning, weakness, functional dependence and delirium.
    • Assess readiness to wake up, breathe, wean and extubate; consider protocol approach to reduce ventilator and intensive care days.
    • Perform spontaneous awakening trial; adjust medication to minimize effects that may contribute to extubation failure.
    • Perform SBT (spontaneous breathing trial); consider low inspiratory-pressure support.
    • Facilitate clustered care and uninterrupted sleep/rest pattern that supports home sleep routine; promote calm environment.
    • Acknowledge fear and anxiety related to the patient’s and support system’s experience of prolonged mechanical ventilation; encourage complementary therapies, such as music therapy.
    • Perform a cuff leak test to predict postextubation risk for swelling or stridor; consider intravenous or inhaled steroids for high-risk patients.
    • Consider prophylactic noninvasive ventilation after extubation for high-risk patients [e.g., COPD (chronic obstructive pulmonary disease), heart failure, older adults].
    • Consider the need for a longer-term airway.

    Associated Documentation

    • Environmental Support
    • Medication Review/Management
    • Sleep/Rest Enhancement

    Nutrition Impaired

    Signs/Symptoms/Presentation

    • inability to intake nutrition via oral route

    Problem Intervention

    Optimize Nutrition Delivery

    • Perform a nutritional assessment; include a nutrition-focused physical exam.
    • Determine calorie, protein, vitamin, mineral and fluid requirements.
    • Assess for micronutrient deficiencies; supplement if depleted.
    • Initiate early enteral nutrition support; consider another form of stress ulcer prophylaxis, if enteral feeding is contraindicated.
    • Optimize protein intake, unless contraindicated.
    • Consider postpyloric versus gastric tube feeding for patient at increased risk of aspiration.
    • Advocate for, and adjust, infusion rate, formulation or volume based on feeding tolerance and clinical status (e.g., hemodynamic stability); minimize unnecessary interruptions.
    • Anticipate the need for a promotility agent, if reduced gastric emptying or delayed bowel motility is suspected.
    • Monitor nutrition delivery to ensure safe practices (e.g., confirmation of tube placement, tube patency, medication delivery, head of bed elevation, oral care).

    Associated Documentation

    • Nutrition Support Management

    Skin and Tissue Injury

    Signs/Symptoms/Presentation

    • bleeding
    • laceration
    • localized swelling
    • redness
    • skin blanching
    • skin integrity disrupted
    • stoma granulation
    • stridor
    • voice hoarse

    Problem Intervention

    Maintain Skin and Tissue Health

    • Reposition and resecure endotracheal tube regularly; ensure proper tube location.
    • Monitor depth of suction catheter advancement to minimize the risk of internal tracheobronchial tissue injury.
    • Assess skin and mucosal areas around the device frequently.
    • Monitor tightness of securement device regularly; consider skin barrier protection.
    • Minimize pressure points and prevent traction on device, using careful positioning, flexible extenders and props.
    • Assess and monitor for the presence of bleeding that may indicate injury to tracheobronchial tissue. Notify provider for persistent bleeding.
    • Anticipate adjunct therapy, such as cool mist, racemic epinephrine, corticosteroid or heliox, for symptoms related to airway swelling or stridor after removal of tube.

    Associated Documentation

    • Device Skin Pressure Protection

    Ventilator-Induced Lung Injury

    Signs/Symptoms/Presentation

    • lung compliance decreasing
    • oxygenation requirements increasing (e.g., FiO2 or positive end expiratory pressure needs)
    • ventilatory requirements increasing (e.g., minute volume, respiratory rate)

    Vital Signs

    • heart rate increased or decreased
    • respiratory rate increased
    • SpO2 (peripheral oxygen saturation) decreased
    • EtCO2 (end-tidal carbon dioxide) increased

    Laboratory Values

    • oxygen index increased
    • PaO2 (partial pressure of arterial oxygen) decreased
    • PaO2/FiO2 ratio decreased

    Diagnostic Results

    • bronchoscopy abnormal
    • CXR (chest x-ray) abnormal

    Problem Intervention

    Facilitate Lung-Protection Measures

    • Provide oxygen therapy judiciously to maintain oxygenation goals; adjust to avoid hyperoxia.
    • Monitor and limit ventilator tidal volumes to minimize volutrauma; initiate low tidal-volume strategy (e.g., less than 8 mL/kg for ideal body weight).
    • Monitor and limit ventilator pressure to reduce risk of barotrauma; maintain less than 30cm H2O (e.g., plateau, inspiratory pressure delta).
    • Apply PEEP (positive end expiratory pressure) to minimize atelectasis; adjust for changes in lung compliance and oxygenation.
    • Monitor fluid balance closely to minimize the risk of fluid overload.
    • Monitor ventilator waveforms and promote patient-ventilator synchrony; adjust ventilator settings and sedation.

    Associated Documentation

    • Lung Protection Measures

    Problem Intervention

    Prevent Ventilator-Associated Pneumonia

    • Assess readiness to extubate; perform sedation interruption and spontaneous breathing trial.
    • Maintain semirecumbent position to minimize aspiration risk.
    • Provide ongoing oral care to reduce pathogens in oral cavity; anticipate antiseptic oral decontamination.
    • Consider the use of antiseptic (e.g., chlorhexidine gluconate) cloths for daily bathing.
    • Minimize ventilator circuit breaks; consider use of closed suction device.
    • Minimize microaspiration risk; consider the use of ultrathin polyurethane tapered endotracheal tubes with subglottic secretion drainage, as well as cuff pressure monitoring.
    • Assess need for stress ulcer and venous thromboembolism prophylaxis due to increased risk during mechanical ventilation.

    Associated Documentation

    • Head of Bed (HOB) Positioning
    • Oral Care
    • VAP Prevention Measures

    Education

    CPG-Specific Education Topics

    Overview

    • description

    • indications

    Self-Management

    • CPR education

    • VAP prevention

    • VTE prevention

    When to Seek Medical Attention

    • unresolved/worsening symptoms

    General Education Topics

    General Education

    • admission, transition of care

    • orientation to care setting, routine

    • advance care planning

    • diagnostic tests/procedures

    • diet modification

    • opioid medication management

    • oral health

    • medication management

    • pain assessment process

    • safe medication disposal

    • tobacco use, smoke exposure

    • treatment plan

    Safety Education

    • call light use

    • equipment/home supplies

    • fall prevention

    • harm prevention

    • infection prevention

    • MDRO (multidrug-resistant organism) care

    • personal health information

    • resources for support

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    Clinical Practice Guidelines represent a consistent/standardized approach to the care of patients with specific diagnoses. Care should always be individualized by adding patient specific information to the Plan of Care.

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