A nurse is caring for a client who is receiving mechanical ventilation and has an ideal weight

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When caring for a patient who is receiving mechanical ventilation The nurse hears the high pressure alarm?
Which of the following actions should the nurse take to reduce the risk of ventilator associated pneumonia?
Which range of h2o pressures would the nurse utilize to maintain the patient's endotracheal ET tube cuff inflation stabilize the tube and ensure adequate tracheal perfusion?

Nursing Interventions	Rationale
Review the ventilator settings every hour. Notify the respiratory unit of any discrepancy in the ventilator settings immediately:	Frequent assessment guarantees that the client is receiving correct mode, rate, tidal volume, FIo2, positive end-respiratory pressure (PEEP) and pressure support. Important attention to details can prevent problems.
Rate of mechanical breaths	The usual rate is between 10 to 14 breaths per minute.
Pressure support (PS)	Pressure support (PS) produces positive airway pressure during the inspiratory cycle of a spontaneous inspiratory effort.
Tidal volume (TV)	Typical ranges for TV are 6 to 8 mL/kg of ideal body weight. Research supports lower standard TVs to reduce barotrauma.
PEEP	PEEP serves to improve gas exchange and prevent atelectasis.
FIO2	The amount of oxygen prescribed depends on the client’s condition and ABG results.
Mode:
Assist control (AC)	Assist control (AC) delivers full ventilatory support by providing a preset tidal volume for each client-initiated breath.
Controlled mandatory ventilation (CMV)	CMV ensures a preset rate with no sensitivity to the client’s respiratory effort. The client cannot initiate breaths or alter the pattern.
Synchronized intermittent mandatory ventilation (SIMV)	SIMV ensures a preset rate in synchronization with the client’s own spontaneous breathing.
Make sure that the ventilator alarms are on.	The alarm alert the caregiver in cases of ventilation problems. A quick response to alarm ensures the correction of problems and maintenance of adequate ventilation.
Assess respiratory rate and rhythm including the work of breathing.	It is important to maintain the client in synchrony with the ventilator and not permit “bucking” it.
Assess arterial blood gases results and monitor oxygen saturation.	Objective data guide the ventilator settings and appropriate interventions.
Assess for the signs of pulmonary infection including increased temperature, purulent secretions, elevated white blood cell count, positive bacterial cultures, and evidence of pulmonary infection on chest X-ray studies.	VAPs occur in up to 28% of clients on ventilators. Mortality rates of 40% to 50% have been reported for these clients. Most ventilator-associated infections are caused by bacterial pathogens, with gram-negative bacilli being common.
Assess for the signs of barotrauma: the client with crepitus, subcutaneous emphysema, altered chest excursion, asymmetrical chest, abnormal ABGs, a shift in trachea, restlessness, evidence of pneumothorax on chest x-ray studies.	Barotrauma is damage to the lungs from positive pressure as seen in clients with an acute respiratory disease when high pressures are needed to ventilate stiff lungs or when PEEP is used. Frequent assessments are needed because barotrauma can occur at any time and the client will not show signs of dyspnea, shortness of breath, or tachypnea if heavily sedated to maintain ventilation.
Monitor chest x-ray reports daily and obtain a stat portable chest x-ray film if barotrauma is suspected.	Vigilant monitoring helps to reduce complications.
Monitor plateau pressures with the respiratory therapist.	Monitoring for barotrauma can involve measuring plateau pressure, which is the pressure after delivery of the tidal volume but before the client is allowed to exhale. The ventilator is programmed so that after delivery of the tidal volume the client is not allowed to exhale for a half second. Therefore pressure must be maintained to prevent exhalation. Elevation of plateau pressures increases both the risk and incidence of barotrauma when the client is on mechanical ventilation. There has been less occurrence of barotrauma since guidelines have recommended lower standard tidal volumes.
Listen for alarms. Know the range in which the ventilator will set off the alarm and how to troubleshoot:	The ventilator is a life-sustaining treatment that requires prompt response to alarms:
Apnea alarm	The apnea alarm is indicative of disconnection or absence of spontaneous respirations.
Low exhale volume	The low exhale alarm indicates that the client is not returning delivered TV (through disconnection or leak).
Low-pressure alarm	The low-pressure alarm indicates a possible disconnection or mechanical ventilator malfunction.
High peak pressure alarm	The high peak pressure alarm indicates bronchospasm, retained secretions, obstruction of ET tube, atelectasis, acute respiratory distress syndrome (ARDS), or pneumothorax, among others.
Institute measures to reduce VAP.	Nosocomial infections are a leading cause of mortality.
Keep the head of bed elevated to 30 to 45 degrees or perform subglottic suctioning unless it is medically contraindicated.	Elevation promotes better lung expansion. It also reduces gastric reflux and aspiration.
Wash hands before and after suctioning, touching ventilator equipment, and/or coming into contact with respiratory secretions.	An artificial airway bypasses the normal protective mechanisms of the upper airways. Handwashing reduces germ transmission.
Brush teeth two to three times per day with a soft toothbrush. Chlorhexidine-based rinses may also be incorporated into oral care protocols.	Oral care reduces colonization of the oropharynx with respiratory pathogens that can be aspirated into the lungs.
Use a continuous subglottic suction endotracheal (ET) tube for intubation that is expected to be longer than 24 hours.	This intervention prevents the accumulation of secretions that can be aspirated.
Use sterile suctioning procedures.	This technique decreases the introduction of microorganisms into the airway.
Notify the physician of signs of barotrauma immediately; anticipate the need for chest tube placement, and prepare the client as needed.	If barotrauma is suspected, intervention must follow immediately to prevent tension pneumothorax.

When caring for a patient who is receiving mechanical ventilation The nurse hears the high pressure alarm?

"Look to see if a tube is dislodged, or if a ventilator is disconnected from the endotracheal tube," he suggests. High-pressure alarms usually mean one of two things, says Campbell. "Either a patient is coughing, or they're bucking the ventilator, in which case they either need to be suctioned or sedated," he says.

Which of the following actions should the nurse take to reduce the risk of ventilator associated pneumonia?

Rationale: Research indicates that nursing actions such as maintaining the head of the bed at 30 to 45 degrees decrease the incidence of VAP. These actions are part of the standard of care for patients who require mechanical ventilation.

Which range of h2o pressures would the nurse utilize to maintain the patient's endotracheal ET tube cuff inflation stabilize the tube and ensure adequate tracheal perfusion?

Endotracheal tube cuff pressure is regularly measured in critically ill patients to ensure that the pressure is within a narrow therapeutic range of approximately 20 to 30 cm H₂O. The pressure must be high enough to ensure adequate ventilation and prevent aspiration of secretions that accumulate above the ET tube cuff.

A nurse is caring for a client who is receiving mechanical ventilation and has an ideal weight

When caring for a patient who is receiving mechanical ventilation The nurse hears the high pressure alarm?

Which of the following actions should the nurse take to reduce the risk of ventilator associated pneumonia?

Which range of h2o pressures would the nurse utilize to maintain the patient's endotracheal ET tube cuff inflation stabilize the tube and ensure adequate tracheal perfusion?

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