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Intensive and Critical Care Nursing (2007) 23, 414

REVIEW

Nursing care of the mechanically ventilated


patient: What does the evidence say?
Part one
Bronwyn A. Couchman a,1, Sharon M. Wetzig b,2,
Fiona M. Coyer c,, Margaret K. Wheeler c,3
a

Department of Intensive Care Medicine, Royal Brisbane and Womens Hospital,


Butterfield St., Brisbane, Qld 4029, Australia
b Intensive Care Unit, Princess Alexandra Hospital, Ipswich Rd.,
Brisbane, Qld 4102, Australia
c Queensland University of Technology, Victoria Park Rd.,
Brisbane, Qld 4059, Australia
Accepted 8 August 2006

KEYWORDS
Nursing care;
Mechanical ventilation;
Patient assessment;
Patient safety;
Patient comfort

Summary The care of the mechanically ventilated patient is at the core of a


nurses clinical practice in the Intensive Care Unit (ICU). Published work relating to
the numerous nursing issues of the care of the mechanically ventilated patient in
the ICU is growing significantly. Literature focuses on patient assessment and management strategies for patient stressors, pain and sedation. Yet this literature is
fragmentary by nature. The purpose of this paper is to provide a single comprehensive examination of the evidence related to the care of the mechanically ventilated
patient.
In part one of this two-part paper, the evidence on nursing care of the mechanically
ventilated patient is explored with specific focus on patient safety: particularly
patient and equipment assessment. Part two of the paper examines the evidence
related to the mechanically ventilated patients comfort, the patient/family unit,
patient position, hygiene, management of stressors, pain management and sedation.
2006 Elsevier Ltd. All rights reserved.

Corresponding author. Tel.: +61 7 3864 3895; fax: +61 7 3863 3814.
E-mail addresses: Bronwyn Couchman@health.qld.gov.au (B.A. Couchman), Sharon Wetzig@health.qld.gov.au (S.M. Wetzig),
f.coyer@qut.edu.au (F.M. Coyer), mk.wheeler@qut.edu.au (M.K. Wheeler).
1 Tel.: +61 7 3636 8534; fax: +61 7 3636 1557.
2 Tel.: +61 7 3240 6268.
3 Tel.: +61 7 3864 9757; fax: +61 7 3864 3814.
0964-3397/$ see front matter 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.iccn.2006.08.005

Nursing care of the mechanically ventilated patient

Introduction
Mechanical ventilation is indicated for numerous
clinical and physiological reasons. The nursing
management of the mechanically ventilated
patient is challenging on many levels: from the
acquisition of highly technical skills; expert knowledge on invasive monitoring; and implementation
of interventions to care for the patient. Each
critically ill patient brings the clinical rationale for
mechanical ventilation and additional complexities
associated with their illness. It is recognised that
the reason for mechanical ventilation and patient
admission impacts on patient assessment and management. However, there are core evidence-based
collaborative principles which underpin the nursing
management of such patients in the intensive care
unit (ICU), those being patient safety: patient
and equipment assessment; and patient comfort:
patient position; hygiene; management of stressors
and; pain and sedation management.
To identify the evidence supporting practice a
thorough review of current literature was undertaken using the following steps: electronic search
conducted of MEDLINE, CINAHL, EMBASE and PsychReview databases for articles published between
1995 and 2006 and; key words used were mechanical ventilation, patient assessment, airway management, sedation and comfort.
Many confounding variables exist in the care of
the critically ill mechanically ventilated patient in
the ICU. Consequently not all practice may be supported by evidence. As evidence-based literature
addressing the overarching care of the mechanically ventilated patient is scant, for the purpose of
this paper common practice is supported by expert

Table 1

5
or anecdotal comment. This paper presents a summary of the important principles in the management of the mechanically ventilated patient. The
focus of this article, the first in a two-part series,
is the examination of literature addressing patient
assessment and safety.

Patient safety
A useful strategy for promoting the safety of the
mechanically ventilated patient is to utilise a health
assessment framework. The Emergency Care Cycle
is one health assessment framework that facilitates a systematic and comprehensive approach to
patient assessment. This framework has two components: the Primary survey (see Table 1) which
identifies immediate life-threatening events, and
the Secondary survey (see Table 2) which often
utilises a head-to-toe systems approach to assess
the functional status of each body system (Nettina,
2006). The safety considerations in the care of the
mechanically ventilated patient will be discussed
utilising this framework (Fig. 1).
Some overall patient safety considerations are
worth noting first. Patients receiving mechanical
ventilation in ICU require continuous observation
and monitoring. For this reason a nurse/patient
ratio of 1:1 is recommended (ACCCN, 2005). This
ensures that the patient can be closely monitored
and that response to any alarms can be rapid
(Winters and Munro, 2004). Promoting safety for
the ventilated patient also involves ensuring emergency equipment (see Table 3) is available in the
event of accidental extubation or ventilator failure
(Yeh et al., 2004). Routine safety measures utilised

Primary survey
Assessment parameters

Relevant numerical data

A: Airway

Is the airway patent and secure?


- Listen to air movement
- Observe rise and fall of chest
- Check tube is secure and length is correct

B: Breathing

Is the patient breathing?


- Observe chest rise and fall
- Observe patient colour

SpO2 , tidal volume, respiratory rate

C: Circulation

Does the patient have adequate circulation?


- Check for a pulse
- Assess strength of pulse
- Observe patient colour

Heart rate and rhythm, arterial blood pressure

D: Disability
E: Exposure

What is the patients level of consciousness?


What is the patients surrounding environment?
Is the patients dignity preserved?

B.A. Couchman et al.


Table 2 Secondary survey: systems approach for the
ventilated patient
System
Neurological

Respiratory

Assessment parameters
Glasgow Coma Score
Ability to communicate
Sedation score
Degree of neuromuscular
blockade
BIS monitoring

Artificial airway:
Tube placement
Tube security
Cuff status

Airway patency:
Assessment of lung secretions
(suctioning)
Adequacy of humidification

Cardiovascular

Gastrointestinal

Metabolic
Renal

Skin integrity

Breathing:
Respiratory rate, volume and
pressure
ABG analysis
Pulse oximetry
Capnometry
Heart rate and rhythm
Blood pressure
Central venous pressure
Peripheral perfusion
Chest X-ray interpretation
Measurement of cardiac
output
Observe for signs of DVT

Abdominal
discomfort/distension
Presence of bowel sounds
Amount and characteristics of
gastric aspirates
Frequency of bowel
movement
Physical strength and body
weight
Serum phosphate level
Liver function tests
Temperature
Blood glucose level

Urine output
Serum electrolytes, urea and
creatinine levels
Pressure ulcer risk
Observe for presence of
pressure ulcers

when caring for any critically ill patient should also


be applied. These include checking intravenous
infusions; checking patient equipment and alarm
settings; ensuring the correct attachment of

Figure 1 Patient assessment.

monitoring devices and appropriateness of alarm


settings.

Primary survey
The Primary survey (see Table 1) is concerned
with identifying life-threatening circumstances
that require immediate attention (Nettina, 2006).
The pneumonic A: Airway, B: Breathing, C: Circulation, D: Disability and E: Exposure is utilised.
The assessment is essentially unchanged regardTable 3

Emergency equipment and safety checks

Essential equipment required at the bedside


Self-inflating manual resuscitation bag with
appropriately sized face mask
High-flow suction unit with Yankeur sucker and
endotracheal suction catheters
Additional equipment readily accessible to the
bedside
Intubation equipment
Oxygenwall and portable supplies
Battery operated suction unit

Safety checks
All equipment is present, readily accessible and
in full working order
The ventilator is connected where possible to
an uninterrupted power supply
Intravenous infusions are being delivered
according to a current order with the correct
rate, composition, time of expiry, point of
administration, etc.
Patient equipment is functioning properly and
safe alarm limits are set
Monitoring devices are connected appropriately
and safe alarm limits are set

Nursing care of the mechanically ventilated patient


less of whether or not the patient is mechanically
ventilated. Particular attention should be given to
ensuring the artificial airway is secure to prevent
dislodgement, and to checking the insertion length
of the airway for correct placement. As a caution,
the availability of additional numerical data from
the mechanical ventilator and monitoring devices
should not substitute for physical assessment of the
patient. Used in conjunction with physical assessment, the numerics provide rapid and valuable
information, however their validity should be verified by direct patient observation to avoid inaccurate assessment.

Secondary survey
The Secondary survey assesses the function of
each body system individually and usually is completed in a head-to-toe format (Hillman and Bishop,
2004). Acute dysfunction in one or more body systems is the precursor to initiation of mechanical ventilation. The addition of artificial respiratory support further impairs physiological function
by altering physiological homeostasis (Hillman and
Bishop, 2004). Assessing all body systems thoroughly enables early identification of issues and
appropriate intervention to minimise or prevent
complications. The discussion focuses on the considerations specific to the mechanically ventilated
patient.

Neurological system
Neurological assessment of the patient on mechanical ventilation involves a range of methods. The
Glasgow Coma Score (GCS) remains a widely used
tool for assessing conscious level in terms of arousal
and verbal/physical response in many patient populations (Fischer and Mathieson, 2001). Administration of sedative and/or muscle relaxant agents,
as well as the inability of the ventilated patient
to make a verbal response will impact on the
application and accuracy of the GCS. The limitations of using the GCS for intubated patients
have been overcome through use of communication scoring systems. These subjective tools assess
the patients ability to communicate via non-verbal
means, including mouthing words, using letter
boards, writing notes, etc. (Lindgren and Ames,
2005). It is also important to assess pupil size
and reaction as part of a focused neurological
assessment (Fischer and Mathieson, 2001). In the
sedated patient, early signs of neurological deterioration such as a decrease in level of consciousness
are masked leaving late signs, such as pupillary

7
changes, as one of the few indications of a change
in the patients neurological condition.
Many ventilated patients require some form of
sedation to enable them to tolerate this therapy. To reduce the significant risks associated with
oversedation (e.g. increased ventilation time and
increased length of stay, both ICU and hospital),
a number of tools have been developed to determine the patients level of sedation (Hogarth and
Hall, in press; Heffner, 2000). Some of these tools
assess degree of sedation as well as degree of agitation. When sedation orders include a target score
on the sedationagitation scale, this allows the ICU
nurse to titrate sedation doses accordingly (Ely et
al., 2003). This will be expanded further in part two
of this paper.
Neuromuscular blockade is occasionally required
for ventilated patients in order to allow greater
ease of ventilation. When this therapy is used, it
is important to ensure that the blockade remains
partial rather than complete as this is associated
with an increased risk of critical illness neuropathy (De Jonghe et al., 2004). The level of paralysis can be easily assessed using a peripheral nerve
stimulator, with administration of paralytic agents
titrated to achieve the required level. Bispectral
Index Score (BIS) monitoring, which analyses electroencephalography (EEG) waveforms and statistically estimates level of sedation, is becoming more
popular for monitoring sedation in the paralysed
patient (Riker and Fraser, 2001). While used commonly during administration of anaesthetics, a systematic review (LeBlanc et al., 2006) showed that
its application in the ICU setting requires further
investigation.
Assessment of the patients conscious state and
communication assists in determining the best
approach to use in this area, as will be discussed
further in part two of this paper.

Respiratory system
Effective respiratory assessment is pivotal to ensuring the safety of the mechanically ventilated
patient. A helpful way to gather the data is to divide
the assessment into three main areas the artificial airway, airway patency and breathing.
Artificial airway
All mechanically ventilated patients have an
artificial airway in situ to enable delivery of the
respiratory support. Regardless of whether this is
an endotracheal tube or a tracheostomy tube, the
aspects of tube placement, tube security and cuff
status must be addressed.

8
Incorrect tube placement places the patient at
significant risk. Absent or ineffective ventilation,
aspiration and injury to the airway can result from
oesophageal intubation or from placement that is
too high or low in the trachea (Winters and Munro,
2004). Tube placement at the time of insertion
may be assessed in various ways depending on the
available equipment. Subsequent displacement of
the tube however may result from head flexion,
tension during transport (DeBoer et al., 2003) and
swelling of surrounding tissues, thus ongoing assessment promotes patient safety.
Frequently used strategies to verify placement
include auscultation, end-tidal carbon dioxide monitoring and radiological examination (DeBoer et al.,
2003). Auscultation of breath sounds across the lung
fields is a commonly used technique. Stethoscopes
are readily accessible however referred sounds may
be transmitted even with incorrect tube placement (DeBoer et al., 2003; Grmec, 2002). Endtidal carbon dioxide monitoring using capnometry
and capnography was determined to be a reliable
method for assessing tube placement in two small
studies, although influenced by the clinical setting,
availability of equipment and experience of the
user (Knapp et al., 1999; Grmec, 2002). The numerical and waveform displays provide continuous data
on expired carbon dioxide levels, changes to which
may indicate tube dislodgement or obstruction. A
concern however is that subtle changes to tube
position such as movement into the larynx may not
be readily detected (Knapp et al., 1999). Chest
radiograph is often considered as the standard for
assessing tube placement however this technique
also has limitations. Of note is that the assessment
is at a single point in time and thus does not provide regular or continuous data, delays between the
time of imaging to viewing the film can be lengthy,
and anatomy or image quality can make assessment
of placement difficult (DeBoer et al., 2003). All
endotracheal tubes and some tracheostomy tubes
have distance markings along the length of the
tube. These assist in assessing placement if measured consistently in relation to a fixed structure
(for example, the teeth or gums). Given the lack
of evidence supporting one method as superior
and the limitations of any of the methods outlined
above, it would seem prudent to utilise two or more
techniques, one of which is able to be measured
regularly or continuously, to assess tube placement
in the mechanically ventilated patient.
Tube security supports maintenance of correct
tube placement and minimises injury to the airway
caused by excessive movement. Techniques to
secure artificial airways ideally will hold the tube
firmly in position independent of head and neck

B.A. Couchman et al.


movement, be easily applied and removed to
enable adjustment to tube position and attention
to hygiene and will minimise trauma to adjacent
tissues. Available options include cotton tape,
specifically designed tube holders and non-stretch
adhesive tapes. Although a number of studies
comparing methods of securing endotracheal
tubes exist, a systematic review by Gardner et al.
(2005) indicates that no conclusions regarding the
benefits of one method over another have been
determined. Assessment includes ensuring the
method used is properly applied and that the tube
is secured in the desired position.
The presence of an artificial airway places the
patient at risk of developing complications associated with the tube itself. Regular assessment of
the cuff enables effective management to minimise
the risk of aspiration from underinflation and tracheal mucosal injury from overinflation (Vyas et
al., 2002). Evidence to support a single management technique as superior is limited. Crimlisk et
al. (1996) performed a descriptive study which indicated two primary techniques which were utilised
in the clinical setting: measuring cuff pressures to
ensure they remain at 25 mmHg or below; inflating
the cuff with the minimum volume of air required
to ensure air leak on inspiration (minimal occlusive
volume); and inflating the cuff with the minimum
volume of air to allow a small leak on inspiration
(minimal leak technique). Consideration of inflation pressures, patient head movement and tube
diameter to airway diameter ratios should also be
considered if the desired seal is not achieved (Vyas
et al., 2002).
Airway patency
Assessment of airway patency encompasses the
assessment of lung secretions and strategies to
manage these. The normal respiratory function
of the mechanically ventilated patient is compromised placing them at risk of complications. Artificial airways bypass the humidification and filtering mechanisms of the upper airways (St John and
Malen, 2004), medical gas is cold and dry and disease processes and therapies can impair the cough
reflex (Jaber et al., 2004). Lung secretions should
be assessed for colour, consistency and volume
(Winters and Munro, 2004). Endotracheal suctioning provides opportunity to assess the secretions
but also to support the patient by removing secretions. Endotracheal suctioning in itself however is
potentially hazardous to the patient and should be
performed with care.
A review by Day et al. (2002) indicates that
the frequency of suctioning should be determined
by the patients need, rather than performed

Nursing care of the mechanically ventilated patient


routinely. Physical assessment of the patient including auscultation and palpation of the chest, and
review of the patients secretion production over
recent hours will indicate the need for suctioning.
Observation of airway pressures and trends in pulse
oximetry and end-tidal carbon dioxide readings are
also important (Winters and Munro, 2004). Suctioning only when needed limits exposure to potential
complications.
Hypoxaemia is the most common complication
noted with suctioning (Demir and Dramali, 2005).
Techniques for supplementing oxygenation during
the suctioning procedure include hyperoxygenation alone or in combination with hyperinflation.
A review by Day et al. (2002) and a meta-analysis
by Oh and Seo (2003) indicate that both techniques
are effective in preventing hypoxaemia, however
both are capable of causing respiratory damage or
haemodynamic instability. Perhaps due to variability in application of the interventions, the literature is inconclusive regarding the ideal method of
preventing hypoxaemia (Wynne et al., 2004; Day
et al., 2002; Oh and Seo, 2003). A randomised
controlled trial conducted in 2002 by Demir and
Dramali (2005) found that patients suctioned using
a closed technique without hyperoxygenation did
not demonstrate a significant difference in partial pressure of oxygen or oxygen saturation. The
majority of subjects however had an FiO2 of less 50%
or less, a positive end expiratory pressure (PEEP)
of 8 cm H2 O or less and a mean pre-suction PaO2
of 95.49 mmHg, suggesting they may not have been
at high risk of developing hypoxemia. Consideration
of the patients status prior to suctioning including:
PEEP; FiO2 ; PaO2 ; heart rate (HR); mean arterial
pressure (MAP); and observation of the patients
response to suctioning, provide useful data to
guide suctioning practices which promote patient
safety by minimising the adverse effects caused by
hypoxemia.
Instillation of normal saline via the endotracheal
tube prior to suctioning is a common practice in
some intensive care units. The theory behind this
practice is that the saline loosens and thins secretions and stimulates the cough reflex thus facilitating removal of secretions (Blackwood, 1999). While
the theory may seem plausible, two reviews of the
literature do not support the technique and suggests that it may actually be harmful to the patient
(Blackwood, 1999; Day et al., 2002).
Complications are also associated with the suctioning procedure itself for which general recommendations based on limited studies and accepted
practice have been made. The size of catheter used
should be less than one-half the diameter of the
artificial airway to minimise the risk of atelectasis

9
(Day et al., 2002). The suction catheter should
be inserted to the depth of the carina and then
withdrawn by 1 cm prior to commencing suctioning
(Day et al., 2002). Care should be taken however
as persistent contact with the carina can result
in ulceration and induce haemodynamic changes
associated with coughing and vagal stimulation.
Limiting the duration of the suctioning procedure
to less than 1015 s reduces the risk of hypoxaemia
and atelectasis (Day et al., 2002; Subirana et al.,
2003). Restricting the number of passes in a suction
episode to three or less also assists in minimising
complications. A further consideration is the degree
of negative pressure applied during the procedure.
Evidence is lacking to suggest an exact maximum
pressure to be applied, however pressures of
200 mmHg or greater have been associated with
tracheal damage (Day et al., 2002; Donald et al.,
2000). Recommendations for acceptable suction
pressures given in the literature range from 80 to
170 mmHg (Day et al., 2002; Donald et al., 2000).
Of importance also is the use of open versus
closed suction systems. The latter are reported to
have the advantages of minimising hypoxaemia,
maintaining PEEP and reducing contamination
(Subirana et al., 2003). Two prospective randomised controlled trials found that a closed
system presented no additional complications for
the patient although it may not decrease complications associated with suctioning (Zeitoun et al.,
2003; Lorente et al., 2005). In particular, a literature review by Grap and Munro (2004) indicates
that closed suction systems offer no advantage in
the prevention of ventilator associated pneumonia
(VAP). However, the closed nature of the systems
and ability to leave the system in situ greater
than 24 h, reduces breaks to the ventilation circuit
and thus the possibility of contamination from the
environment (Kollef, 1999).
A further consideration when assessing the physical airway is evaluating the adequacy and function
of humidification devices. Inadequate humidification can lead to partial or complete airway obstruction and damage to respiratory tissue (Jaber et al.,
2004). Two humidification systems are available:
heated humidifiers (HH); and heat and moisture
exchangers (HME). In a discussion of the literature by Kelly et al. (2004), it is suggested that
both systems are effective; however both also have
potential adverse effects including bacterial contamination and over-hydration (HH), or thick sputum and increased work of breathing (HME). The
humidification system used should take into consideration factors such as the anticipated duration
of mechanical ventilation, the degree of spontaneous effort by the patient and the amount and

10
consistency of sputum. Whichever system is in use,
assessment of the patient is essential (Kelly et al.,
2004). Excessively thick or thin secretions, crusting in the artificial airway, water in the circuit or
changes in airway pressures may suggest inappropriate humidification. A holistic approach involving
adequate systemic hydration is also important.
Breathing
A comprehensive understanding of the adequacy
of ventilation and oxygenation in the mechanically
ventilated patient is essential as some if not all of
the respiratory effort is coordinated by the ventilator. Necessary information is gathered from performing a physical assessment and from analysis of
laboratory and patient monitoring data.
Physical assessment provides invaluable information concerning the patients interaction with
the ventilator. The presence of dyspnoea, dyssynchronous chest and abdominal movement, the use
of accessory muscles and agitation may suggest
the ventilation settings are inappropriate for the
patients requirements (Hillman and Bishop, 2004).
Physical assessment of the patient may also alert
the clinician to subtle changes in the patients respiratory status which otherwise may have gone
unnoticed. Altered breath sounds and asymmetrical chest movement, for example, may indicate the
development of a pneumothorax when other signs
such as dyspnoea and rapid, shallow breathing are
masked by sedation and full mandatory ventilation.
Monitoring data from the ventilator also aids in
understanding the patients respiratory status and
the appropriateness of the ventilator settings. Respiratory rate, tidal volume, minute volume and airway pressures as absolute values reflect the current
delivery of ventilatory support. When analysed as
trends over time, such data can provide information
about the status of lung function and the patients
respiratory effort (Jubran and Tobin, 1996).
Monitoring of gas exchange is a routine aspect of
caring for a mechanically ventilated patient. Arterial blood gas (ABG) analysis is the gold standard
for determining arterial carbon dioxide and oxygen
levels. The complications and costs associated
with repeated ABG analysis however support the
use of non-invasive monitoring techniques. Pulse
oximetry and capnometry are relatively simple
and effective tools for monitoring gas exchange. A
meta-analysis indicated that pulse oximeters are
accurate to 2% for oxygen saturations greater
than 70% (Jensen et al., 1998). Capnometers
provide a numerical reading of end-tidal carbon
dioxide levels. Reviews by Capovilla et al. (2000)
and Frakes (2001) suggest that in the context of
stable ventilation/perfusion dynamics and cardiac

B.A. Couchman et al.


output, capnometry trends provide an excellent
indication of arterial carbon dioxide levels. Even
in less stable states, the variation between the
end-tidal and arterial carbon dioxide levels provides information on dead space and perfusion
changes (Soubani, 2001; Frakes, 2001). As with
any technology however, a sound understanding
of how the data are obtained and the factors that
influence the measurements is essential to avoid
inappropriate interpretation (Martin and Wilson,
2002). Regardless, if used appropriately, noninvasive monitoring devices provide a continuous
and safe method for assessing gas exchange.

Cardiovascular system
The patient receiving mechanical ventilation may
experience a marked alteration in cardiovascular
function. The increase in intrathoracic pressure
that occurs results in a reduction in preload as
venous return decreases. This is exacerbated in
patients who have high PEEP settings or who are
on inverse ratio ventilation. The extent of impairment depends on the baseline cardiovascular state
of the patient (Pinsky, 2005). It is important that
the ICU nurse undertakes comprehensive cardiovascular assessment of the patient to determine
adequacy of cardiac output and to observe for complications associated with poor cardiac output. This
involves assessment of heart rate and rhythm, blood
pressure, central venous pressure, peripheral perfusion, urine output and chest X-ray, as well as
serum electrolytes (McGrath and Cox, 1998). Regular assessment of haemoglobin is also important
in this group due to the significant impact that
anaemia can have on the patients oxygen-carrying
capacity. Measures to conserve blood should be considered to prevent and/or treat anaemia (Fowler
and Berensen, 2003). Patients receiving mechanical ventilation should have continuous multi-lead
electrocardiography monitoring to enable timely
assessment and treatment of cardiac arrhythmias
or myocardial ischaemia (Robb, 1997).
A relatively new technique called Pulse Pressure
Variation assesses the variation in pulse pressure
(via an arterial catheter or plethysmograph) with
respiration, which provides an estimate of fluid
status the higher the variation, the drier the
patient is. This method is yet to be substantially
validated, but a prospective clinical investigation
(Cannesson et al., 2005) shows that it could provide a simple, accurate measurement of fluid status
using existing monitoring equipment.
It is well recognised that accurate determination of cardiac output in the most critically ill
patients using these basic assessment parameters

Nursing care of the mechanically ventilated patient


is difficult. Techniques that endeavour to provide an accurate measurement of cardiac output
are numerous (Adams, 2004). The so-called goldstandard is the bolus thermodilution method using
a pulmonary artery catheter (Zink et al., 2004).
Other techniques have sought to provide the same
accuracy in measurement while providing continuous data and/or reducing invasiveness and cost.
These include continuous thermodilution method,
transthoracic/transoesophageal echocardiography,
pulse contour analysis, and oesophageal Doppler
(Adams, 2004).
The reduction in preload experienced by ventilated patients can be best managed by maintaining
an adequate fluid volume status. It is reported that
maintaining adequate filling pressures (e.g. CVP
of 1012 mmHg) optimises preload and therefore
reduces the risk of a reduction in cardiac output
(Pinsky, 2005).
The risk of developing deep vein thrombosis
(DVT) is greatly increased in the ventilated patient
as a result of venous stasis related chiefly to immobility, but also to the decrease in venous return
described above (Pinsky, 2005). It is important to
assess the patient for signs of DVT and to initiate preventative measures early (Yang, 2005).
Current practice in DVT prophylaxis involves use
of thrombo-embolic deterrent (TED) stockings,
sequential compression devices, passive movement
exercises and administration of either unfractionated heparin or low-molecular weight heparin. A
review paper (Yang, 2005) indicates that of these
therapies the mechanical options are not associated with a decreased risk when used alone, so the
combination of mechanical and pharmacological is
recommended.

Gastrointestinal system
Nutritional status is a vital part of assessment and
care for the mechanically ventilated patient. The
capacity for oral intake is limited in this situation
due to the presence of the ETT and the patients
level of sedation, though it is possible for patients
ventilated via tracheostomy. In most critically ill
patients requiring ventilation, early enteral feeding via an oro/nasogastric tube is a well established
practice (Lindgren and Ames, 2005). Use of an
established feeding protocol, where feed absorption is closely monitored, feeding rate increased
gradually and prokinetic agents given as required
has been shown to provide the best outcomes,
when implemented in a pilot study (Bowman et al.,
2005). Accurate assessment of caloric requirements
in the critically ill patient remains a topic of some
debate. According to a multi-centre study (Krishnan

11
et al., 2003), best outcomes were found in patients
receiving moderate rather than high caloric intake,
around 918 kcal/kg/day.
It is important to note that effective functioning of the gastrointestinal tract (GIT) can be
impaired during mechanical ventilation as a result
of a reduction in splanchnic blood flow secondary
to decreased cardiac output (Aneman et al., 1999).
The reduction in GIT motility caused by use of sedative and narcotic agents further impairs functioning. Mechanically ventilated patients need to be
regularly assessed for abdominal discomfort and/or
distension, presence of bowel sounds, amount and
characteristics of gastric aspirates and frequency of
bowel movement (Bowman et al., 2005).
Adequacy of nutrition is particularly important
in the weaning phase of mechanical ventilation,
where patients are required to breathe with less
support from the ventilator (Lindgren and Ames,
2005). Assessment of the patients muscle mass
or degree of muscle wasting, physical strength
and body weight will provide an indication of the
need for increased nutritional support (Sabol, 2004;
Flancbaum et al., 1999). Assessment of serum electrolytes, particularly phosphate which is important in energy production, and supplementation if
required is also important to promote muscle functioning (McClave et al., 2002).
Hepatic blood flow via the portal vein may also
be compromised as a result of decreased cardiac output associated with mechanical ventilation
(Aneman et al., 1999). It is important to regularly measure liver function tests as well as clotting times to observe for any hepatic impairment
(Winters and Munro, 2004).

Metabolic system
Assessment of temperature is a basic yet important
parameter to monitor as an elevated temperature
can signal the patients response to infection
(Winters and Munro, 2004). Ventilated patients
have a significant risk of developing nosocomial
infections as a result of suppressed immune function and the presence of artificial tubes (e.g.
ETT, urinary catheter, central venous catheters)
(Lindgren and Ames, 2005). Other methods that are
commonly used to detect response to infection are
measurement of white blood cell count, C-reactive
protein (CRP), IL-6 and procalcitonin (PCT) levels.
A prospective study (Gaini et al., 2006) has recently
shown that CRP and IL-6 are more sensitive markers
of infection than PCT, while PCT is a better indicator
of severity. Some ICUs also utilise routine surveillance of high risk patients (e.g. patients ventilated
for 48 h or more) to assist in the early detection of

12
infection and identification of potential infection
control problems (Tablan et al., 2003).
Coupled with the assessment and early detection of infective processes are measures to minimize the risk of ventilated patients developing
nosocomial infections. The Centre for Disease Control and Prevention and a group representing the
Canadian Critical Care Trials Group and the Canadian Critical Care Society have published guidelines outlining best practice for the prevention
of ventilator-associated pneumonia. The guidelines
suggest a multi-faceted approach to prevention
which includes oral versus nasal intubation, limited interruptions to ventilator circuitry, elevation of the head of the bed, strategies for the
management of respiratory equipment, minimising
the duration of mechanical ventilation, and effective hand hygiene (Tablan et al., 2003; Dodek et
al., 2004). Such strategies along with strict application of Standard Precautions should constitute
standard practice for the nursing management of
the mechanically ventilated patient to prevent the
development of nosocomial infections.
Blood glucose monitoring and control is not a
new concept, but one which has certainly been the
focus of much research in the critically ill patient
population recently. Evidence from a randomisedcontrolled trial (van den Berghe et al., 2006) suggests that maintenance of blood glucose within
tight limits (4.46.1 mmol/L) is associated with a
reduction in mortality. This is of particular significance in patients who are ventilated as they frequently have an elevated blood glucose level as a
result of initiation of the bodys stress response that
occurs in critical illness (Winters and Munro, 2004).
The Surviving Sepsis Guidelines recommend that
patients with severe sepsis have a blood glucose
level maintained less than 8.3 mmol/L (Dellinger
et al., 2004).

Renal system
The reduction in cardiac output associated with
positive pressure ventilation may result in reduced
urine output through neural and hormonal mechanisms (i.e. antidiuretic hormone secretion and
activation of the renninangiotensinaldosterone
system) (Pinsky, 2005). It is important to closely
monitor the urine output of a ventilated patient
as well as serum levels of urea and creatinine to
detect any renal impairment. Ensuring urine output
is greater than or equal to 0.5 mL/kg/h is one way
of assessing adequate renal function, according
to a recent evidence-based review (Rhodes and
Bennet, 2004). It is also important to maintain
adequate cardiac output, mean arterial pressure

B.A. Couchman et al.


and renal perfusion pressure to prevent acute renal
failure (Leblanc et al., 2005).

Skin integrity and mobility


Ventilated patients are at increased risk of impairment in skin integrity chiefly through immobility
associated with sedation and ventilation (Lindgren
and Ames, 2005). Effective pressure ulcer prevention is essential in reducing the patients length
of ventilation and hospital stay (Wolverton et al.,
2005). Although the Braden and Norton scales
have been tested for validity and reliability in a
prospective multi-centre study (Schoonhoven et
al., 2002), assessment of pressure ulcer risk using
the Waterlow scoring system best describes the risk
for critically ill patients. It includes administration
of inotropic agents, cytotoxics and high-dose
steroids in its risk assessment, and also has strategies for pressure relief/reduction depending on
the level of risk (Boyle and Green, 2001).
Semi-recumbent positioning rather than supine
positioning has been recommended as a measure to
reduce the risk of ventilator associated pneumonia,
according to a randomised trial (Drakulovic et al.,
1999). Mobility can be enhanced in the longer-term
ventilated patient through sitting him/her in a chair
for periods of time through the day. This improves
lung expansion and can reduce the risk of ventilator
associated pneumonia (Safdar et al., 2005).

Summary
The mechanically ventilated patient presents many
challenges for the intensive care nurse. Nursing care and management of the critically ill
mechanically ventilated patient is demanding and
necessitates an expert understanding of technological issues underpinned with a patient focused
approach. From the discussion above it is clear that
while mechanical ventilation is a necessary therapeutic intervention for many patients, it brings
with it an array of potential or actual complications
which present further challenges for the critically
ill patient. Nursing care based on evidence is pivotal to ensuring quality health outcomes for the
mechanically ventilated patient.
To support the use of evidence in the practice,
the concept of a Ventilator Care Bundle had been
utilised in the United States and the United Kingdom. The bundle includes four interventions which
have sound evidence to support their effectiveness
in improving outcomes for the mechanically ventilated patient: elevation of the head of the bed;
management of sedation including daily sedation

Nursing care of the mechanically ventilated patient


vacations; peptic ulcer prophylaxis; deep vein
thrombosis prophylaxis (Institute for Healthcare,
in press). The concept of Care Bundles provides
a mechanism for highlighting best practice in
a particular area to clinicians. If implemented
effectively, Care Bundles support the provision of
minimum standards of care for all patients in a subgroup (Resar et al., 2005; Crunden et al., 2005) and
provide indicators to measure the quality of care
provided (Provonost et al., 2003). As highlighted
throughout this paper however, much of our nursing
practice lacks definitive evidence to support one
approach to care over another. The use of evidencebased protocols/guidelines where available, in
conjunction with systematic and comprehensive
patient assessment promotes best practice in the
care of the mechanically ventilated patient.
This article has presented an overview of the
initial management of the mechanically ventilated
patient, covering key patient safety issues. Future
research to address deficits in evidence which supports nursing practice needs to focus on general
nursing assessment of the mechanically ventilated
patient and specifically issues related to ETT security, closed system suctioning and humidification.
The second paper in this series will address management issues related to patient comfort: specifically the patient/family unit, patient position and
hygiene, management of stressors, pain management and sedation.

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