TOPIC: MECHANICAL cardiac arrest of the anesthesia

or the insult of an arrest.

VENTILATION
CRITERIA FOR INSTITUTION OF
• Mechanical Ventilation is ventilation
VENTILATORY SUPPORT
Parameters Ventilation Normal
of the lungs by artificial means
usually by a ventilator. Indicated Range
A. Pulmonary function
• A ventilator delivers gas to the lungs studies:
with either negative or positive
pressure. • Respiratory rate > 35 10-20
(breaths/min).
PURPOSES • Tidal volume <5 5-7
• To maintain or improve ventilation, & (ml/kg body wt)
• Vital capacity < 15 65-75
tissue oxygenation.
(ml/kg body wt)
• Maximum <-20 75-100
• To decrease the work of breathing &
improve patient's comfort. Inspiratory Force
(cm HO2)
INDICATIONS:
B. Arterial blood
1. ACUTE RESPIRATORY FAILURE DUE TO: Gases
• Mechanical failure, includes
neuromuscular diseases as • PH < 7.25 7.35-7.45
Myasthenia Gravis, Guillain-Barré • PaO2(mmHg) < 60 75-100
Syndrome, and Poliomyelitis • PaCO2 (mmHg) > 50 35-45
(failure of the normal respiratory
neuromuscular system)
• Musculoskeletal abnormalities,
such as chest wall trauma (flail TYPES OF MECHANICAL VENTILATORS:
chest) • Negative-pressure ventilators
• Positive-pressure ventilators.
• Infectious diseases of the lung
such as pneumonia, tuberculosis. NEGATIVE-PRESSURE
VENTILATORS
2. ABNORMALITIES OF PULMONARY GAS
EXCHANGE AS IN:
• Early negative-pressure ventilators
were known as "iron lungs.
• Obstructive lung disease in the
form of asthma, chronic bronchitis
• The patient's body was encased in
or emphysema.
an iron cylinder and negative
pressure was generated
• Conditions such as pulmonary
edema, atelectasis, pulmonary
• The iron lung are still occasionally
fibrosis.
used today.
• Patients who has received
• Intermittent short-term negative-
general anesthesia as well as post
pressure ventilation is sometimes
 used in patients with chronic
diseases.
• The use of negative-pressure
ventilators is restricted in clinical
practice, however, because the limit
positioning and movement and they
lack adaptability to large or small
body torsos (chests)
• Our focus will be on the positive-
pressure ventilators.
POSITIVE-PRESSURE
VENTILATORS
• Positive-pressure ventilators deliver
gas to the patient under positive-
pressure, during the inspiratory
phase.
TYPES OF POSITIVE-PRESSURE VENTILATORS
1. Volume Ventilators.
2. Pressure Ventilators
3. High-Frequency Ventilators
1. VOLUME VENTILATORS
• The volume ventilator is commonly
used in critical care settings.
• The basic principle of this ventilator is
that a designated volume of air is
delivered with each breath.
• The amount of pressure required to
deliver the set volume depends on
• Patient's lung compliance
• Patient-ventilator resistance
factors.
• Therefore, peak inspiratory pressure
(PIP) must be monitored in volume
modes because it varies from breath
to breath.
• With this mode of ventilation, a
respiratory rate, inspiratory time, and
tidal volume are selected for the
mechanical breaths.
2. PRESSURE VENTILATORS
• The use of pressure ventilators is
increasing in critical care units.
• A typical pressure mode delivers a
selected gas pressure to the patient
early in inspiration, and sustains the
pressure throughout the inspiratory
phase.
• By meeting the patient's inspiratory
flow demand throughout inspiration,
patient effort is reduced and
comfort increased.
• Although pressure is consistent with
these modes, volume is not.
• Volume will change with changes in
resistance or compliance,
• Therefore, exhaled tidal volume is
the variable to monitor closely.
• With pressure modes, the pressure
level to be delivered is selected, and
with some time are preset as well.
3. HIGH-FREQUENCY
VENTILATORS
• High-frequency ventilators use small
tidal volumes (1 to 3 mL/kg) at
frequencies greater than 100
breaths/minute.
• The high-frequency ventilation
accomplishes oxygenation by the
diffusion of oxygen and carbon
dioxide from high to low gradients of
concentration.
• This diffusion movement is increase if
the kinetic energy of the gas
molecules is increased. • A high-
frequency ventilator would be used
to achieve lower peak ventilator
pressures, thereby lowering the risk of
barotrauma.
CLASSIFICATION OF POSITIVE-
PRESSURE VENTILATORS
• Ventilators are classified according
to how the inspiratory phase ends.
The factor which terminates the
inspiratory cycle reflects the
machine type.
• They are classified as:
1. Pressure cycled ventilator
2. Volume cycled ventilator
3. Time cycled ventilator
1. VOLUME-CVCLED
VENTILATOR
• Inspiration is terminated after a
preset tidal volume has been
delivered by the ventilator.
• The ventilator delivers a preset tidal
volume (VT), and inspiration stops
when the preset tidal volume is
achieved.
2. PRESSURE-CYCLED
VENTILATOR
• In which inspiration is terminated
when a specific airway pressure has
been reached.
• The ventilator delivers a preset
pressure; once this pressure is
achieved, end inspiration occurs.
3. TIME-CYCLED VENTILATOR
• In which inspiration is terminated
when a preset inspiratory time, has
elapsed.
• Time cycled machines are not used
in adult critical care settings. They
are used in pediatric intensive care
areas.
VENTILATOR MODE
• The way the machine ventilates the
patient
• How much the patient will
participate in his own ventilatory
pattern.
• Each mode is different in
determining how much work of
breathing the patient has to do.
MODES OF MECHANICAL VENTILATION
A. Volume Modes
B. Pressure Modes
A. VOLUME MODES
1. Assist-control (A/C)
2. Synchronized intermittent mandatory
ventilation (SIMV)
1. ASSIST CONTROL MODE A/C
• The ventilator provides the patient
with a pre-set tidal volume at a pre-
set rate.
• The patient may initiate a breath on
his own, but the ventilator assists by
delivering a specified tidal volume to
the patient. Client can initiate
breaths that are delivered at the
preset tidal volume.
 • Client can breathe at a higher rate
than the preset number of
breaths/minute
• The total respiratory rate is
determined by the number of
spontaneous inspiration initiated by
the patient plus the number of
breaths set on the ventilator.
• In A/C mode, a mandatory (or
"control") rate is selected.
• If the patient wishes to breathe
faster, he or she can trigger the
ventilator and receive a full-volume
breath.
• Often used as initial mode of
ventilation
• When the patient is too weak to
perform the work of breathing (e.g.,
when emerging from anesthesia).
Disadvantages:
• Hyperventilation,
2. SYNCHRONIZED INTERMITTENT
MANDATORY VENTILATION (SIMV)
• The ventilator provides the patient
with a pre-set number of
breaths/minute at a specified tidal
volume and FiO2-
• In between the ventilator-delivered
breaths, the patient is able to
breathe spontaneously at his own
tidal volume and rate with no
assistance from the ventilator.
• However, unlike the A/C mode, any
breaths taken above the set rate are
spontaneous breaths taken through
the ventilator circuit.
• The tidal volume of these breaths
can vary drastically from the tidal
volume set on the ventilator,
because the tidal volume is
determined by the patient's
spontaneous effort.
• Adding pressure support during
spontaneous breaths can minimize
the risk of increased work of
breathing.
• Ventilators breaths are synchronized
with the patient spontaneous
breathe. (no fighting)
• Used to wean the patient from the
mechanical ventilator.
• Weaning is accomplished by
gradually lowering the set rate and
allowing the patient to assume more
work
B. PRESSURE MODES
1. Pressure-controlled ventilation (PCV)
2. Pressure-support ventilation (PSV)
3. Continuous positive airway pressure
(CPAP)
4. Positive end expiratory pressure
(PEEP)
5. Noninvasive bilevel positive airway
pressure ventilation (BiPAP)
1. CONTROL MODE (CM)
CONTINUOUS MANDATORY
VENTILATION (CMV)
• Ventilation is completely provided by
the mechanical ventilator with a
preset tidal volume, respiratory rate
and oxygen concentration
• Ventilator totally controls the
patient's ventilation i.e. the ventilator
initiates and controls both the
volume delivered and the frequency
of breath.
• Client does not breathe
spontaneously.
• Client cannot initiate breathe

2. PRESSURE-CONTROLLED
VENTILATION (PCV) MODE
• The PCV mode is used ( PCV) - If
compliance is decreased and the
risk of barotrauma is high.
• It is used when the patient has
persistent oxygenation problems
despite a high FiOg and high levels
of PEEP.
• The inspiratory pressure level,
respiratory rate, and inspiratory-
expiratory (I:E) ratio must be
selected.
• In pressure controlled ventilation the
breathing gas flows under constant
pressure into the lungs during the
selected inspiratory time.
• The flow is highest at the beginning
of inspiration( i.e when the volume is
lowest in the lungs).
• As the pressure is constant the flow is
initially high and then decreases with
increasing filling of the lungs.
• Like volume controlled ventilation
PCV is time controlled.
• Advantages of pressure limitations
are:
1. Reduction of peak pressure and
therefore the risk of barotruma
and tracheal injury.
2. Effective ventilation.
3. Improve gas exchange
• Tidal volume varies with compliance
and airway resistance and must be
closely monitored.
• Sedation and the use of
neuromuscular blocking agents are
frequently indicated, because any
patient-ventilator asynchrony usually
results in profound drops in the SaO2
• This is especially true when inverse
ratios are used. The "unnatural"
feeling of this mode often requires
muscle relaxants to ensure patient-
ventilator synchrony.
• Inverse ratio ventilation (IRV) mode
reverses this ratio so that inspiratory
time is equal to, or longer than,
expiratory time (1:1 to 4:1).
• Inverse I:E ratios are used in
conjunction with pressure control to
improve oxygenation by expanding
stiff alveoli by using longer distending
times, thereby providing more
opportunity for gas exchange and
preventing alveolar collapse.
• As expiratory time is decreased, one
must monitor for the development of
hyperinflation auto:PEE: Regional
barotrauma may occur owing to
excessive total PEEP.
• When the PCV mode is used, the
mean airway, and intrathoracic
pressures rise, potentially resulting in
a decrease in cardiac output and
oxygen delivery. Therefore, the
patient's hemodynamic status must
be monitored closely.
• Used to limit plateau pressure that
can cause barotrauma and Severe
ARDS
3. PRESSURE SUPPORT VENTILATION
(PSV)
• The patient breathes spontaneously
while the ventilator applies à pre-
determined amount of positive
pressure to the airways upon
inspiration.
 • Pressure support ventilation
augments patients spontaneous
breaths with positive pressure boost
during inspiration i.e. assisting each
spontaneous inspiration.
• Helps to overcome airway resistance
and reducing the work of breathing.
Indicated for patients with small
• Indicated for patients with small
spontaneous tidal volume and
difficult to wean patients
• Patient must initiate all pressure
support breaths.
• Pressure support ventilation may be
combined with other modes such as
SIMV or used alone for a
spontaneously breathing patient.
• The patient's effort determines the
rate, inspiratory flow, and tidal
volume.
• In PSV mode, the inspired tidal
volume and respiratory rate must be
monitored closely to detect changes
in lung compliance.
• It is a mode used primarily for
weaning from mechanical
ventilation.
4. CONTINUOUS POSITIVE AIRWAY
PRESSURE (CPAP)
• Constant positive airway pressure
during spontaneous breathing
• CPAP allows the nurse to observe the
ability of the patient to breathe
spontaneously while still on the
ventilator.
• CPAP can be used for intubated
and non-intubated patients.
• It may be used as a weaning mode
and for nocturnal ventilation (nasal
or mask CPAP)
5. POSITIVE END EXPIRATORV
PRESSURE (PEEP)
• Positive pressure applied at the end
of expiration during
mandatory/ventilator breath
• Positive end-expiratory pressure with
positive-pressure (machine) breaths.
USES OF CPAP & PEEP
• Prevent atelactasis or collapse of
alveoli
• Treat atelactasis or collapse of
alveoli
• Improve gas exchange &
oxygenation
• Treat hypoxemia refractory to
oxygen therapy.(prevent oxygen
toxicity
6. NONINVASIVE BILATERAL POSITIVE
AIRWAY PRESSURE VENTILATION
(BIPAP)
• BiPAP is a noninvasive form of
mechanical ventilation provided by
means of a nasal mask or nasal
prongs, or a full-face mask.
• The system allows the clinician to
select two levels of positive-pressure
support:
1. An inspiratory pressure support
level (referred to as IPAP)
2. An expiratory pressure called EPAP
(PEEP/CPAP level)
COMMON VENTILATOR SETTINGS
PARAMETERS/ CONTROLS
• Fraction of inspired oxygen (FIO2)
• Tidal Volume (VT)
• Peak Flow/ Flow Rate
 • Respiratory Rate/ Breath Rate /
Frequency (F)
• Minute Volume (VE)
• I:E Ratio (Inspiration to Expiration
Ratio)
• Sigh
FRACTION OF INSPIRED OXVGEN (FIO2)
• The percent of oxygen
concentration that the patient is
receiving from the ventilator.
(Between 21% & 100%) (room air has
21% oxygen content
• Initially a patient is placed on a high
level of FIO2 (60% or higher)
• Subsequent changes in FIO, are
based on ABGs and the SaO2
• In adult patients the initial FiO, may
be set at 100% until arterial blood
gases can document adequate
oxygenation.
• An FiO, of 100% for an extended
period of time can
• be dangerous (oxygen toxicity) but it
can protect against hypoxemia
• For infants, and especially in
premature infants, high levels of FiO2
(>60%) should be avoided.
• Usually the FIO, is adjusted to
maintain an SaO2 of greater than
90% (roughly equivalent to a PaŎ2
>60 mm Hg).
• Oxygen toxicity is a concern when
an FIO, of greater than 60% is
required for more than 25 hours
SIGNS AND SYMPTOMS OF OXYGEN
TOXICITY
1. Flushed face
2. Dry cough
3. Dyspnea
4. Chest pain
5. Tightness of chest
6. Sore throat
TIDAL VOLUME (VT)
• The volume of air delivered to a
patient during a ventilator breath.
• The amount of air inspired and
expired with each breath.
• Usual volume selected is between 5
to 15 ml/kg body weight)
• In the volume ventilator, Tidal
volumes of 10 to 15 mL/kg of body
weight were traditionally used.
• The large tidal volumes may lead to
(volutrauma) aggravate the
damage inflicted on the lungs
• For this reason, lower tidal volume
targets (6 to 8 mL/kg) are now
recommended
PEAK FLOW / FLOW RATE
• The speed of delivering air per unit of
time, and is expressed in liters per
minute Usual volume selected is
between 5 to 15 ml/ kg body weight)
• The higher the flow rate, the faster
peak airway pressure is reached and
the shorter the inspiration.
• The lower the flow rate, the longer
the inspiration.
RESPIRATORY RATE/ BREATH
RATE / FREQUENCY (F)
• The number of breaths the ventilator
will deliver/minute (10-16 b/m).
• Total respiratory rate equals patient
rate plus ventilator rate

• The nurse double-checks the
functioning of the ventilator by
observing the patient's respiratory
rate
FOR ADULT PATIENTS AND OLDER CHILDREN:
WITH COPD
• A reduced tidal volume
• A reduced respiratory rate
FOR INFANTS AND YOUNGER CHILDREN:
• A small tidal volume
• Higher respiratory rate
MINUTE VOLUME (VE)
• The volume of expired air in one
minute.
• Respiratory rate times tidal volume
equals minute ventilation
• VE = (VT x F)
• In special cases, hypoventilation or
hyperventilation is desired
IN A PATIENT WITH HEAD INJURY
• Respiratory alkalosis may be required
to promote cerebral
vasoconstriction, with a resultant
decrease in ICP.
• In this case, the tidal volume and
respiratory rate are increased
(hyperventilation) to achieve the
desired alkalotic pH by manipulating
the PaCO2
INCA PATIENT WITH COPD
• Baseline ABGs reflect an elevated
PaCO2 should not hyperventilated.
Instead, the goal should be
restoration of the baseline PaCO2.
• These patients usually have a large
carbonic acid load, and lowering
their carbon dioxide levels rapidly
may result in seizures.
I:E RATIO (INSPIRATION TO
EXPIRATION RATIO)
• The ratio of inspiratory time to
expiratory time during a breath
(Usually = 1:2)
SIGH
• A deep breath.
• A breath that has a greater volume
than the tidal volume.
• It provides hyperinflation and
prevents atelectasis.
• Sign Volume: Usual volume is 1.5 – 2
times tidal volume.
• Sigh rate/ frequency: Usual rate is 4
to 8 times an hour.
PEAK AIRWAY PRESSURE
• In adults if the peak airway pressure
is persistently above 45 cmH2O, the
risk of barotrauma is increased and
efforts should be made to try to
reduce the peak airway pressure.
• In infants and children it is unclear
what level of peak pressure may
cause damage. In general, keeping
peak pressures below 30 is desirable,
PRESSURE LIMIT
• On volume-cycled ventilators, the
pressure limit dial limits the highest
 pressure allowed in the ventilator
circuit.
• Once the high pressure limit is
reached, inspiration is terminated.
• Therefore, if the pressure limit is being
constantly reached, the designated
tidal volume is not being delivered to
the patient.
SENSITIVITY (TRIGGER
SENSITIVITY)
• The sensitivity function controls the
amount of patient effort needed to
initiate an inspiration
• Increasing the sensitivity (requiring
less negative force) decreases the
amount of work the patient must do
to initiate a ventilator breath.
• Decreasing the sensitivity increases
the amount of negative pressure
that the patient needs to initiate
inspiration and increases the work of
breathing.
• The most common setting for
pressure sensitivity are -1 to -2 cm
H20
• The more negative the number the
harder it to breath.
ENSURING HUMIDIFICATION
AND THERMOREGULATION
• All air delivered by the ventilator
passes through the water in the
humidifier, where it is warmed and
saturated.
• Humidifier temperatures should be
kept close to body temperature 35
°C- 37°C.
• In some rare instances (severe
hypothermia), the air temperatures
can be increased.
• The humidifier should be checked for
adequate water levels
• An empty humidifier contributes to
drying the airway, often with
resultant dried secretions, mucus
plugging and less ability to suction
out secretions.
• Humidifier should not be overfilled as
this may increase circuit resistance
and interfere with spontaneous
breathing,
• As air passes through the ventilator
to the patient, water condenses in
the drained into a receptacle and
not back into the sterile humidifier.
• If the water is allowed to build up,
resistance is developed in the circuit
and PEEP is generated. In addition, if
moisture accumulates near the
endotracheal tube, the patient can
aspirate the water.
• The nurse and respiratory therapist
jointly are responsible for preventing
this condensation buildup. The
humidifier is an ideal medium for
bacterial growth.
VENTILATOR ALARMS
• Mechanical ventilators comprise
audible and visual alarm systems,
which act as immediate warning
signals to altered ventilation.
• Alarm systems can be categorized
according to volume and pressure
(high and low).
• High-pressure alarms warn of rising
pressures.

• Low-pressure alarms warn of
disconnection of the patient from
the ventilator or circuit leaks.
COMPLICATIONS OF
MECHANICAL VENTILATION
IV- ARTIFICIAL AIRWAY COMPLICATIONS
I. Airway Complications,
II. Mechanical complications,
III. Physiological Complications,
IV. Artificial Airway Complications.
I. AIRWAY COMPLICATIONS
1. Aspiration
2. Decreased clearance of secretions
3. Nosocomial or ventilator-acquired
pneumonia
II. MECHANICAL COMPLICATIONS
1. Hypoventilation with atelectasis with
respiratory acidosis or hypoxemia.
2. Hyperventilation with hypocapnia
and respiratory alkalosis
3. Barotrauma
a. Closed pneumothorax
b. Tension pneumothorax
c. Pneumomediastinum,
d. Subcutaneous emphysema.
4. Alarm "turned off"
5. Failure of alarms or ventilator
6. Inadequate nebulization or
humidification
7. Overheated inspired air, resulting in
hyperthermia
III. PHYSIOLOGICAL COMPLICATIONS
1. Fluid overload with humidified air
and sodium chloride (NaCI)
retention
2. Depressed cardiac function and
hypotension
3. Stress ulcer
4. Paralytic ileus
5. Gastric distension
6. Starvation
7. Dyssynchronous breathing pattern
A. Complications related to
Endotracheal Tube:
1. Tube kinked or plugged
2. Rupture of piriform sinus
3. Tracheal stenosis or
tracheomalacia
4. Mainstem intubation with
contralateral (located on or
affecting the opposite side of the
lung) lung atelectasis
5. Cuff failure
6. Sinusitis
7. Otitis media
8. Laryngeal edema
B. Complications related to
Tracheostomy tube:
1. Acute hemorrhage at the site
2. Air embolism
3. Aspiration
4. Tracheal stenosis
5. Erosion into the innominate artery
with exsanguination
6. Failure of the tracheostomy cuff
7. Laryngeal nerve damage
8. Obstruction of tracheostomy tube
9. Pneumothorax
10. Subcutaneous and mediastinal
emphysema
11. Swallowing dysfunction
12. Tracheoesophageal fistula
13. Infection
14. Accidental decannulation with
loss or airway
NURSING CARE OF PATIENTS
ON MECHANICAL VENTILATION
ASSESSMENT:
1. Assess the patient
2. Assess the artificial airway
(tracheostomy or endotracheal
tube)
3. Assess the ventilator Nursing
INTERVENTIONS
1. Maintain airway patency &
oxygenation
2. Promote comfort
3. Maintain fluid & electrolytes balance
4. Maintain nutritional state
5. Maintain urinary & bowel elimination
6. Maintain eye, mouth and cleanliness
integrity
7. Maintain mobility/ musculoskeletal
function
8. Maintain safety
9. Provide psychological support
10. Facilitate communication
11. Provide psychological support &
information to family
12. Responding to ventilator alarms
ventilator alarms
13. Prevent nosocomial infection
14. Documentation
RESPONDING TO ALARMS
• If an alarm sounds, respond
immediately because the problem
could be serious.
• Assess the patient first, while you
silence the alarm.
• If you can not quickly identify the
problem, take the patient off the
ventilator and ventilate him with a
resuscitation bag connected to
oxygen source until the physician
arrives.
• A nurse or respiratory therapist must
respond to every ventilator alarm.
• Alarms must never be ignored or
disarmed.
• Ventilator malfunction is a potentially
serious problem. Nursing or
respiratory therapists perform
ventilator checks every 2 to 4 hours,
and recurrent alarms may alert the
clinician to the possibility of an
equipment- related issue.
• When device malfunction is
suspected, a second person while a
the ventilates the patient while nurse
or therapist looks for the cause.
• If a problem cannot be promptly
corrected ventilator adjustment, a
different machine is procured so the
ventilator in question can be taken
out of service for analysis and repair
by technical staff.
CAUSES OF VENTILATOR
ALARMS
High pressure alarm
• Increased secretions
• Kinked ventilator tubing or
endotracheal tube (ETT)
• Patient biting the ETT
• Water in the ventilator tubing.
• ET advanced into right mainstem
bronchus.
Low pressure alarm
• Disconnected tubing
• A cuff leak
• A hole in the tubing (ETT or ventilator
tubing)
• A leak in the humidifier
Oxygen alarm
• The oxygen supply is insufficient or is
not properly connected.
High respiratory rate alarm
• Episodes of tachypnea,
 • Anxiety,
• Pain,
• Hypoxia,
• Fever
Apnea alarm
• During weaning, indicates that the
patient has a slow Respiratory rate
and a period of apnea.
Temperature alarm
• Overheating due to too low or no
gas flow.
• Improper water levels
METHODS OF WEANING
1. T-piece trial,
2. Continuous Positive Airway Pressure
(CPAP) weaning,
3. Synchronized Intermittent Mandatory
Ventilation (SIMV) weaning,
4. Pressure Support Ventilation (PSV)
weaning.
1. T-PIECE TRIAL
• It consists of removing the patient
from the ventilator and having
him / her breathe spontaneously
on a T-tube connected to oxygen
source.
• During T-piece weaning, periods
of ventilator support are
alternated with spontaneous
breathing.
• The goal is to progressively
increase the time spent off the
ventilator.
2. SYNCHRONIZED INTERMITTENT
MANDATORY VENTILATION (SIMV)
WEANING
• SIMV is the most common method of
weaning.
• It consists of gradually decreasing
the number of breaths delivered by
the ventilator to allow the patient to
increase number of spontaneous
breaths
3. CONTINUOUS POSITIVE AIRWAV
PRESSURE (CPAP) WEANING
• When placed on CPAP, the patient
does all the work of breathing
without the aid of a back up rate or
tidal volume.
• No mandatory (ventilator-initiated)
breaths are delivered in this mode
i.e. all ventilation is spontaneously
initiated by the patient.
• Weaning by gradual decrease in
pressure value
4. PRESSURE SUPPORT VENTILATION
(PSV) YVEANING
• The patient must initiate all pressure
support breaths. Weaning readiness
Criteria
• During weaning using the PSV mode
the level of pressure support is
gradually decreased based on the
patient maintaining an adequate
tidal volume (8 to 12 mL/kg) and a
respiratory rate of less than 25
breaths/minute.
• PSV weaning is indicated for
• Difficult to wean patients
• Small spontaneous tidal volume.
WEANING READINESS CRITERIA
• Awake and alert
• Hemodynamically stable,
adequately resuscitated, and not
requiring vasoactive support
 • Arterial blood gases (ABGs)
normalized or at patient's baseline
• PaCO2 acceptable
• PH of 7.35-7.45
• PaO2 > 60 mm Hg,
• SaO2 >92%
• FIO₂ ≤40%
• Positive end-expiratory pressure
(PEEP) ≤5 cm H20
• F < 25 / minute
• Vt 5 ml / kg
• VE 5-10 L/m (f x Vt)
• VC > 10- 15 ml / kg
• PEP (positive expiratory pressure)
• 20 cm H20 (indicates patient's
ability to take a deep breath &
cough),
• Chest ×-ray reviewed for correctable
factors; treated as indicated
• Major electrolytes within normal
range,
• Hematocrit >25%,
• Core temperature >36°C and <39°C,
• Adequate management of
pain/anxiety/agitation,
• Adequate analgesia/ sedation
(record scores on flow sheet),
• No residual neuromuscular
blockade,
Role of nurse before weaning
1. Ensure that indications for the
implementation of Mechanical
ventilation have improved
2. Ensure that all factors that may
interfere with successful weaning are
corrected.
• Acid-base abnormalities
• Fluid imbalance
• Electrolyte abnormalities
• Infection
• Fever
• Anemia
• Hyperglycemia
• Protein
• Sleep deprivation
3. Assess readiness for weaning
4. Ensure that the weaning criteria /
parameters are met.
5. Explain the process of weaning to
the patient and offer reassurance to
the patient.
6. Initiate weaning in the morning when
the patient is rested.
7. Elevate the head of the bed & Place
the patient upright
8. Ensure a patent airway and suction if
necessary before a weaning trial,
9. Provide for rest period on ventilator
for 15 - 20 minutes after suctioning.
10. Ensure patient's comfort & administer
pharmacological agents for
comfort, such as bronchodilators or
sedatives as indicated.
11. Help the patient through some of the
discomfort and apprehension.
12. Support and reassurance help the
patient through the discomfort and
apprehension as remains with the
patient after initiation of the
weaning process.
13. Evaluate and document the
patient's response to weaning.
Role of nurse during weaning
 1. Wean only during the day.
2. Remain with the patient during
initiation of weaning.
3. Instruct the patient to relax and
breathe normally.
4. Monitor the respiratory rate, vital
signs, ABGs, diaphoresis and use of
accessory muscles frequently.
If signs of fatique or respiratory distress
develop
• Discontinue weaning trials.
Sign of Weaning Intolerance Criteria
• Diaphoresis
• Dyspnea & Labored respiratory
pattern
• Increased anxiety ,Restlessness,
Decrease in level of consciousness
• Dysrhythmia,Increase or decrease in
heart rate of > 20 beats /min. or
heart rate > 110b/m
• Sustained heart rate >20% higher or
lower than baseline • Increase or
decrease in blood pressure of 20 mm
Hg
• Systolic blood pressure >180 mm Hg
or <90 mm Hg
• Increase in respiratory rate of > 10
above baseline or > 30 Sustained
respiratory rate greater than 35
breaths/minute
• Tidal volume <5 mL/kg, Sustained
minute ventilation <200
mL/kg/minute
• SaO2 <90%, PaO2 <60 mmHg,
decrease in PH of <7.35
• Increase in PaCO2
Role of Nurse After Weaning
1. Ensure that extubation criteria are
met
2. Decannulate or extubate
3. Documentation
TOPIC: NON-INVASIVE
VENTILATION
BiPAP/NIV DEFINITIONS
• Bi-level Positive Airway Pressure is a
type of non-invasive ventilation to
provide positive pressure ventilation
supporting patient's spontaneous
breathing.
• A higher pressure (IPAP) for breath in
and a lower pressure (EPAP) for
breath out in order to:
• work of breathing
• Improve oxygenation and ventilation
INDICATIONS
• Decompensate obstructive sleep
apnea with hypercapnia.
• airway resistance e.g. COPD
exacerbation.
• Respiratory/accessory muscle
distress, fatigue or failure.
• Acute-on-chronic hypercapnic
respiratory failure due to chest wall
deformity or neuromuscular disease.
• Post-extubation ventilator support.
• Acute Pulmonary Oedema. Nursing
assessment
CONTRAINDICATION
• Facial trauma/burns
• Recent facial, upper airway, or
upper gastrointestinal tract surgery
• Upper airway obstruction
 • Inability to protect airway and clear
respiratory secretions
• Impaired consciousness (GCS<10)
• Severe confusion/agitation
• Vomiting and risk of aspiration
• Allergy or sensitivity to mask materials
EQUIPMENT
1. BiPAP machine
2. BiPAP disposable circuit with
disposable proximal pressure line
and exhalation port (flushes exhaled
gas from the circuit)
3. Low resistance bacterial filter
4. BiPAP Total Face Mask, Full Face
Mask or Nasal Mask plus head strap.
5. Disposable Humidifier
6. Distilled water
7. Duoderm for skin protection.
CAP MODE (Continuous
Positive Airway Pressure)
• There is no automatic delivery of a
breath if patient do not inhale.
• A constant preset pressure (CPAP)
will be delivered continuously either
inhalation or exhalation.
• No IPAP and EPAP setting.
SPONTANEOUS/TIMED (S/T)
MODE
• A bi-level pressure respond and
support patient spontaneous
inhalation (IPAP) and exhalation
(EPAP).
• Once patient do not start inhaling
within a set time, device
automatically starts inhalation (IPAP).
• After inhalation, device
automatically decreases the
pressure (EPAP) for patient
exhalation.
MACHINE CONTROL SETTING
• Mode: CPAP or S/T mode
• FiO2: Oxygen (21%~100%)
• RR: Mandatory
• RR setting
• IPAP: Inspiratory Positive Airway
Pressure
• EPAP: Expiratory Positive Airway
Pressure
• Tinsp: Time of inspiratory (0.5-3sec)
• Rise Time: Time from EPAP to IPAP.
1. Enhances patient-ventilator
synchrony
2. Enhances patient comfort 4 set
point: 0.05, 0.1, 0.2, 0.4
NOTES
IPAP: Inspiratory Positive Airway Pressure
(Max. 40cmH20)
1. Supports inspiratory effort, reducing
WOB
2. TV
3. C02 removal
EPAP: Expiratory Positive Airway Pressure
(Max. 20cmH20)
1. Keeps alveoli partially inflated
2. lung volume,
3. functional residual capacity (FRC)
alveolar gas exchange
4. oxygenation
PATIENT STATUS MONITORING
• Vt: Tidal Volume
• Respiratory Rate: RR
• MV: Minute Volume=TV x RR
• PIP: Peak Inspiratory Pressure
• Patient leak: Leakage from the mask
 • Tot. Leakage: Total leakage from 2. Record baseline To monitor progress
mask + exhalation port if exhalation haemodynamic of therapy
port test unsuccessful parameters.

POTENTIAL COMPLICATIONS 3. Ensure correct Unfitting mask can

• Cardiovascular compromise size of mask cause nasal bridge
• Skin break down and discomfort pressure sores, air
leakage and
from mask
conjunctivitis
• Gastric distention
• Risk of aspiration
4. Skin protection Assess regularly
• Pulmonary barotrauma
for the prevention and apply
• Risk of sputum retention
of pressure sore Duoderm
• Respiratory fatigue, failure or arrest
especially on the
bridge of nose.
MONITORING CLINICAL FEATURES
5.Turn BIPAP Calculate gases
• Vital signs e.g. cardiac monitoring,
machine on, a volume exhalated
RR, BP and Sp02. quick self-test will from port in
• Breathing pattern/chest movement occur and then run different pressure
• Patient-ventilator synchronization. "Exhalation Port
• Accessory muscle recruitment. Test"
• General assessment: sweating
/dsypnoeic. 6. Verify the mode Note Inspiratory
and setting. pressure support =
• Auscultation of the chest.
Suggested initial IPAP-EPAP
• Patient comfort. settings:
• Coughing effort and risk of sputum CPAP mode: PEEP
retention. 5-10cmH20
• Neurological status - signs of S/T mode: IPAP
confusion/tiredness 12cmH20
EPAP: 5cmH20
Resp. rate: 10 bpm.
Time of inspiratory:
GENERAL NURSING INTERVENTIONS 1 sec
• Wash hands, standard precaution Rise Time: 0.1 sec
Explain procedure Fi02 according to
• Setting comply with physician order patient's
• Place the fitting mask on patient requirements
• Secure mask with head strap.
Tighten straps just enough to prevent 7. Once Psychological
leaks. (A small leak from mask is commenced BiPAP, support and
allowed) stay with patient a observe patient
• Set alarms appropriately moment. response

Nursing Rationale 8. Make Inform physician if

Intervention adjustments per necessary
1. Explain the Patient need to physical
rational of BiPAP to understand and parameters,
patient. gain cooperation doctor's instructions
and patient's • Adjust Fi02 in appropriate level.
comfort.
Is ventilation inadequate/low TV?
9. Set all alarm • Observe chest expansion
parameters To ensure safe • IPAP
including apnoea, practice • inspiratory time
high and low • RR (to increase MV)
pressure, and • Consider other mode of ventilation
respiratory rate.
10. Monitoring To monitor patient PaC02 improves but Pa02 remains low
clinical and progress, and to • FI02
physiological detect • Consider + EPAP
parameters e.g. complications,
Cardiac worsening TROUBLE SHOOTING
monitoring, BP, RR, respiratory function
SpO2, ABG, chest and need for
Low Pressure Low MV
wall movement, intubation.
• Ensure no leakage, fitting mask,
auscultate chest tubing disconnection, appropriate
and CXR IPAP and RR setting.
inspection.
High Pressure High MV
11. Provide suction Avoid sputum • Patient-ventilator dysynchrony, avoid
if necessary and retention and occlusion to exhalation port, kinked
add a humidifier drying of tubing, sputum retention, inform
secretions. medical if tachypnoea.
12. Provide mouth For patient
and eye care comfort. Prevention Low RR
of oral ulcer and • Assess conscious level and breathing
conjunctivitis. effort, request medical review,
change of mode (S/T mode), 1RR
setting, intubation if necessary.
High RR
TREATMENT FAILURE IN NIV • Find out the cause e.g. leakage,
restless, assess chest movement and
Is the treatment optimal? breathing pattern, request medical
• Check medical treatment review.
prescribed.
• Consider physiotherapy for sputum Apnea
retention. • Rule out respiratory fatigue, check
conscious level, vital sign, chest
Have any complications developed? movement, inform medical to 1RR
• Vital sign frequently observe. setting or intubation if necessary.
• Consider a pneumothorax,
aspiration pneumonia etc. I level of conscious 1 confusion/agitation
• Check ABG for hypercarbia and
Is there excessive leakage or PaC02? request medical review, BiPAP may
• Fitting of mask. no longer appropriate.
• Consider other type of mask.

Is the patient on too much oxygen?

 TOPIC
Instructions
1. Connect oxygen and power cord.
2. Plug the tubing from outlet to
humidifier.
3. Plug the tubing from humidifier to
patient
4. Switch on the machine.
5. Press "Test Exhalation Port" button
and follow the procedure. Then
waiting "Test Complete" to appear
on the screen.
6. Press "Monitoring" to begin
operation.
Instructions
1. Press "Parameters" button and
control knob to select different
setting.
2. Change mode setting with "mode"
button and confirm with "Activate
New Mode" button
3. Change the alarm setting with
*Alarm" button.
4. Place the fitting mask on patient.
5. Stay with patient for a moment to
ensure tolerate the machine and
setting.
TOPIC: ENDOTRACHEAL
INTUBATION
INDICATIONS
An artificial airway is necessary in the
following circumstances:
• Apnoea The provision of mechanical
ventilation, unconsciousness, severe
respiratory muscle weakness, e.g.
self- poisoning.
• Respiratory failure - The provision of
mechanical ventilation, e.g. ARDS,
pneumonia
• Airway protection Unconciousness,
trauma, aspiration risk, poisoning
• Airway obstruction - To maintain
airway patency, e.g. trauma,
laryngeal oedema, tumour, burns
• Haemodynamic instability - To
facilitate mechanical ventilation,
e.g. shock, cardiac arrest.
CHOICE OF ENDOTRACHEAL TUBE
• Most adults require a standard high
volume, low pressure cuffed
endotracheal tube.
• The average sized adult will require a
size 9.0mm id tube (size 8.0mm id for
females) cut to length of 23cm
(21cm for females).
• Obviously, different size patients may
require changes to these sizes and
particular problems with the upper
airway, e.g. trauma, oedema, may
require a smaller tube.
• In specific situations non-standard
tubes may be used, e.g. jet
ventilation, armored tubes (where
head mobility is expected or for
patients who are to be positioned
prone), double lumen tubes to
isolate the right or left lung.
ROUTE OF INTUBATION
• The usual routes of intubation are
oro-tracheal and naso-tracheal.
• Oro-tracheal intubation in preferred.
• The naso-tracheal route has the
advantages of increased pateint
comfort and the possibility of easier
blind placement; it is also easier to
secure the tube.
• However, there are several
disadvantages.
• The tube is usually smaller, there is a
risk of sinusitis and otitis media and
 the route is contrandicated in
coagulopathy, CF leak and nasal
fractures.
DIFFICULT INTUBATION
• If a difficult intubation is predicted is
should not be attempted by an
inexperienced operator.
• Difficulty may be predicted in the
patient with a small mouth, high
arched palate, large upper incisors,
hypognathia, large tongue, anterior
larynx, short neck, immobile
temporomandibular joints, immobile
cervical joints or morbid obesity.
• If a difficult intubation present
unexpectedly the use of a stylet, a
straight bladed laryngoscope or a
fibreoptic laryngoscope may help.
• It is important not to persist for too
long; revert to bag and mask
ventilation to ensure adequate
oxygenation.
COMPLICATIONS OF INTUBATION
Early complications
• Trauma, e.g. hemorrhage,
mediastinal perforation
• Haemodynamic collapse, e.g.
positive pressure ventilation,
vasodilation, arrhythmias or rapid
correction of hypercapnia.
• Tube malposition, e.g. failed or
endobronchial intubation.
Later complications
• Infection including maxillary sinusitis if
nasally intubated
• Cuff pressure trauma (maintain cuff
pressure <25cmH20)
• Mouth /Lip trauma
EQUIPMENT REQUIRED
• Suction (Yankauer tip)
• Oxyen, rebreathing bag and mask
• Laryngoscope (two curved blades
and straight blade)
• Stylet / bougie
• Endotracheal tubes (preferred size
and smaller)
• Magill forceps
• Drugs (Induction agent, muscle
relaxant, sedative, anticholinergic)
• Syringe for cuff inflation
• Tape to secure tube
TOPIC: AUTOMATED
EXTERNAL DEFIBRILLATOR
(AED)
• An AED is an electronic device that
analyzes the heart rhythm and, if
necessary, delivers an electric shock,
known as defibrillation, to the heart
of the person in cardiac arrest.
• What does this shock do?
• A normal and healthy heart has
its own pacemaker that regulates
the heart beat. The shock stops all
electrical activity of the heart so
the pacemaker can take over
again.
COMMON ELEMENTS
• About AEDS:
- Many different models exist. Follow
the displays, controls, and options for
the model you are using.
- The AED enables first aid providers
and other rescuers to deliver early
defibrillation with only minimal
training.
USING AN AED
• Turn on the AED.
 • Attach the pads to the person's bare,
dry chest, as shown on the pads.
• Make sure no one is touching the
person and say "Clear!"
• Allow the AED to analyze the rhythm.
• Follow the prompts.
- The AED will either direct you to
push the Shock Button or to begin
CPR.
• Give 5 sets of CPR unless the person
moves, begins to breathe, or wakes
up.
• Repeat Steps 3 and 4 until the
person moves, begins to breathe, or
wakes up.
TOPIC: CHEST TUBE
DRAINAGE
PURPOSES:
A. Therapeutic:
- To remove air and fluid from the
thoracic cavity
- To facilitate re-expansion of the lung.
B. Diagnostic:
- To determine presence of
intrathoracic bleeding and to
measure amount and rate of
hemorrhage
NURSING ALERT:
• Make certain that bottles are
airtight.
• Tubing should be free of kinks and
dependent loops.
• Be sure that the tube from pleural
cavity is attached to tubing
connected to a glass tube and ends
under sterile water.
• Never lift drainage bottle above
level of the client‘s chest.
EQUIPMENT:
• Prescribed drainage system
• Water suction system and sterile
water
• Chest tube tray
• Dressings sterile gloves
• Rubber-tipped haemostats for each
test tube (2)
• 1 inch adhesive tape
NURSING PRELIMINARIES:
• Review the patient chart for the
reason for the chest tube and
location and insertion date. To
obtain baseline data
• Assemble equipment to bedside
Prepares equipment and allows for
smooth, organized completion of
procedure.
• Wash hands. Reduces transmission of
microorganisms
• Explain procedure and rationale to
the patient. Reduces anxiety and
Encourages cooperation.
• Complete respiratory assessment,
ensure patient has minimal pain, and
measure vital signs. Place patient in
semi-Fowler‘s position for easier
breathing. Changes in these
parameters may indicate worsening
of the condition
STEP-BY-STEP PROCEDURES
1. Move the patient‘s gown to expose
the chest tube insertion site. Keep
the patient covered as much as
possible. Observe the dressing
around insertion site and ensure that
it is dry, intact, and occlusive.
2. Check that all connections are
securely taped. Gently palpate
around the insertion site, feeling for
 subcutaneous emphysema, a
collection of air or gas under the
skin. Prevents atmospheric air from
leakage into the system and the
client’s intrapleural space.
3. Check drainage tubing to ensure
that there are no dependent loops
or kinks. Position the drainage
collection device below the tube
insertion site. Prevents excess tubing
from hanging over the edge of the
mattress in a dependent loop.
Drainage could collect in the loop
and occlude drainage system
4. If the chest tube is ordered to be
suctioned, note the fluid level in the
suction chamber and check it with
the amount of ordered suction. Look
for bubbling in the suction chamber.
Temporarily disconnect the suction
to check the level of water in the
chamber. Add sterile water or saline
to maintain correct amount of
suction.
5. Observe the water-seal chamber for
fluctuations of the water level with
the patient‘s inspiration and
expiration (tidaling). If suction is used,
temporarily disconnect the suction
to observe for fluctuation. Assess for
the presence of bubbling in the
water- seal chamber. Add water, if
necessary, to maintain the level at
the 2-cm mark. Fluid continues to
fluctuate in the water seal on
inspiration & expiration until the lung
is reexpanded or the system
becomes occluded.
INDICATIONS OF CHEST TUBE DRAINAGE
• pneumothorax
• pleural effusion
• hemothorax
RISKS OF CHEST TUBE DRAINAGE
• pain
• bleeding
• infection
PROCEDURE
1. Open the sterile package
2. Fill the water seal drainage
3. Patient Connection
4. Applying Suction.
5. Check Suction Bellows
6. Change Suction Pressure
7. Place chest drainage in floor or bed
hanger
8. Assess the insertion site
9. Record drainage volume
10. Check tubing for Air Leak
11. Check Tidaling
COMPLICATIONS OF TUBE DRAINAGE
• subq crepitus/ emphysema
• tidaling
• respiratory distress
NURSING PRELIMINARIES
• Assess the amount and type of fluid
drainage.
• Measure drainage output at the end
of each shift, mark the level on the
container or placing a small piece of
tape to indicate date and time.
• Remove gloves.
• Assist patient to a comfortable
position
• Wash hands
TOPIC: PERITONEAL
DIALYSIS
DEFINITION
- Procedure is a type of dialysis which
uses the peritoneum in as person’s
abdomen as the primary membrane
through which fluid, solution and
dissolved substances are
exchanged with the blood.
PURPOSE
 1. Remove excess body fluid
2. Correct electrolyte problems
3. Remove and collect toxin waste
product in those with kidney failure

ADVANTAGES

1. Procedure is simple and does not require

highly skilled personnel or sophisticated
equipment.

2. Does not require access to the

bloodstream.

DISADVANTAGES

1) Repeated treatment may lead to

peritonitis.

2) Requires 6 times longer than

hemodialysis to achieve the same
results.

3) Often painful especially when

increased glucose concentrations
are use to achieve ultrafiltration.

TYPES OF PERITONEAL DIALYSIS

Continuous Cycling Peritoneal (CCPD)

- Connecting the peritoneal catheter

to an automated peritoneal dialysis
machine
- It performs 3-5 cycles during the
TYPES OF DIALYSIS night while patient sleeps
- Last bag of solution remains in
abdomen during daytime.

Continuous Ambulatory Peritoneal (CAPD)
- A permanent peritoneal dialysis
catheter is inserted into the
abdomen
- A connector joins the transfer set to
the bag of the fluid. Plastic bags are
used
- Performs 3 to 5 exchanges daily
- Last bag of solution remains in the
abdomen overnight.
Intermittent Peritoneal (IPD)
- Connected for about 10 hours
- With cycle changing every 30 to 60
minutes;
- Abdomen is left dry between
sessions
Dialysis Solution Content
- Glucose, Na, K, Ca, Mg, Cl, Lactate
-
NURSING RESPONSIBILITIES
BEFORE
> Have patient empty the bladder to avoid
puncturing it during catheter insertion.
> Measure and record weight, abdominal
girth, temperature, pulse, respiration, blood
pressure.
> Measure and record blood chemistry
values like BUN, creatinine, Na, K,
Hematocrit.
> Sterile technique during insertion of
catheter.
> After insertion of catheter, observe for
perforation of bowel (dialysate outflow
stained with feces or blood) or bladder
(pink or blood- tinged)
> Warm tubing to remove air, connect to
catheter, anchor connections and tubings
securely and be sure there are no kinks in
the tubings.
DURING
> Measure and record output, weight,
regularly and TPR, BP every 10 min. till
stable then every 2 to 4 hrs. as ordered.
> Keep accurate record of dialysis cycles
(inflow, dwell, outflow times).
> Record strength of solutions used,
additions made, fluid balance (amount
retained or lost).
> Observe for peritonitis (collect samples of
dialysate for culture and sensitivity tests
whenever solution is turbid, bloody, or has
an odor or when routinely ordered).
> Observe for respiratory embarrassment
(dyspnea and rales) which results from
abdomen being too full of fluid or leakage
of dialysate into the thoracic cavity
through defect in the diaphragm.
> Have client change position frequently,
do ROM exercises, and do deep breathing.
> Determine fluid balance (measure
weight, TPR, BP,Abdominal girth)
> Check blood chemistry (BUN, Creatinine,
Na, K)
> Maintain adequate nutrition, adhering to
high protein diet which is needed to
replace those lost during the procedure.
PROCEDURES OF PERITONEAL
DIALYSIS
1. Warm dialysate solution to body
temperature. Avoids hypothermia and
shock during procedure.
2. Apply mask, then prepare dialysis
administration set. Have client wear mask
during connection and disconnection of
administration set.
Avoids introducing pathogens into
peritoneal cavity
3. Place drainage bag below client.
Facilities drainage by gravity
4. Connect outflow tubing to drainage bag.
Provides route for removal of dialysate
solution
5. Connect dialysis infusion lines to the
bag/bottles of dialysate, and hang at
bedside.
6. Place client in supine position when
equipment & solution are ready.
Promote comfort & relaxation. When tube is
new, supine position helps prevent hernia
7. Prime infusion tubing by allowing solution
to fill tube. Keeping clamp closed, connect
one infusion line to the abdominal
catheter.
Maintains integrity of system & prevents air
from entering the line
8. Check patency of catheter: Ensures that
catheter is ready for use & that client will
tolerate initiation of treatment
9. Open the clamp on the infusion lines
> Infuse the prescribed amount of dialysate
over 5 to 10 min.
> Allow solution to dwell for prescribed
interval
> Remove and discard gloves, and
perform hand hygiene.
Rationale: Fluid dwell time varies,
dependent on concentration of
electrolytes to be removed

10. When dwell time is completed
Open the outflow and allow the solution
to drain into the collection bag.
Client may need to change position, roll
from side to side.
Rationale: Position helps to eliminate all of
dialysate
11. Repeat the cycles of infusion-dwell-
drainage until the prescribed amount of
dialysate & the prescribed number of
cycle have been achieved. Prescribed
cycling is necessary to achieved desired
fluid and electrolyte balance
12. When dialysis treatment is complete,
disconnect the inflow line from the
catheter, place a sterile cap over the
catheter end, then discard gloves.
Avoid introducing pathogens into the
peritoneal cavity
TOPIC: COLOSTOMY CARE
DEFINITION
Ostomy – is an opening made to allow
passage of feces.
Stoma– the piece if intestine that is brought
out onto client‘s abdomen.
Effluent – the drainage from a stoma
Enterostomy – is any surgical procedure
that produces an artificial d stoma in a
portion of intestine through the abdominal
wall.
FORMS OF ENTEROSTOMY
Ileostomy – which involves the ileum of the
small intestine.
Colostomy – involve various segments of
the colon.
PURPOSES
1. To assess and care for the peristomal
skin.
2. To collect effluent for assessment of the
amount and type of output.
3. To minimize odors for the client‘s comfort
and self-esteem.

TYPES OF STOOL
INDICATIONS
OSTOMY DRAINAGE
ILLEOSTOMY
• Chron’s disease • Depends on the location of the
• Ulcerative colitis ostomy:
• FAP
• Colon cancer - Ileostomy and ascending colon –
• Rectal cancer liquid feces.
• Bowel perforation
• Bowel ischemia - Transverse colostomy – mushy stool
• Rectal trauma
• Fecal incontinence - Descending colon – soft to solid
• Fecal diversion
• Colonic dysmotility
• Toxic colitis TYPES OF STOMAS
• Anastomotic leak
• Distal obstruction
• Enterocutaneous fistula

COLOSTOMY
• Colon cancer
• Rectal cancer
• Diverticulitis
• Rectal trauma
• Radiation procitis
• Distal obstruction
• Fecal incontinence
• Complex fistula

TYPES OF OSTOMIES
COLOSTOMY CARE

EQUIPMENT

- Ensure smooth flow of procedure.

Optimizes the use of time

1. Pouch, clear drainable colostomy

ileostomy
2. Pouch closure device, such clamp
3. Clean disposable gloves
4. Gauze pads or washcloth
5. Towel Plan on changing skin barrier pouch at
6. Basin with warm tap water times of less effluent output. Avoid
7. Scissors changing after meals when gastro colic
8. Skin barrier such as sealant wipes reflux increases chance of fecal effluent
9. Tape or ostomy belt output.

COLOSTOMY COMPLICATIONS
ASSESS THE STOMA
a) Cutaneous irritation with ulceration
1. Auscultate for bowel sounds. Determines b) Ostomy necrosis
presence of peristalsis. c) Ostomy prolapse
d) Ostomy retraction
2. Observe existing skin barrier and pouch e) Ostomy stenosis
for leakage and length of time in place. f) Parastomal hernia
Determines likelihood of pouch loosening
from stoma and failing to collect effluent.

3. provide for privacy and explain

procedure to client.

4. Position client into standing, supine or

drape position. When in supine position
there are fewer skin wrinkles Which allows
for ease of application of the pouching
system.
10. Remove the used pouch and skin
barrier. Gently remove by pushing skin
5. Wash Hands
away from barrier. An adhesive remover
may be used to facilitate removal of skin
6. Apply gloves
barrier. Reduces skin trauma.
Improper removal of pouch and barrier
7. Place a towel under client. Protects bed
can irritate client’s skin and can cause skin
linen.
tears.

11. Cleanse Peritomal skin gently with

warm water .
ASSESS THE STOMA
Use gauze pads or clean washcloth; don‘t
8. Observe stoma for color, swelling, scrub skin; dry completely by patting skin
trauma and healing. Stoma should be with gauze or towel.
moist and reddish pink. Assess type of
Stoma. Avoid use of soap as it leaves a residue on
skin interferes w/ pouch adhesion to skin.
Stoma characteristics should be one of the
Skin must be dry as pouch does not adhere
factors to consider in selecting pouching
to wet skin.
system.
If rubbed, stoma may ooze some blood as
9. Observe effluent from stoma and record
a result of cleaning process.
of intake and output.
If blood appears do not be alarmed.
Stoma’s surface is highly vascular mucous
membrane.
12. Measure stoma for correct size of
pouch. Removing backing from barrier and
adhesive. Using manufacturer‘s measuring
guide. Ensures accuracy in determining
correct pouch size needed. With ileostomy,
apply thin circle barrier paste around
opening in pouch; allow to dry. Paste
facilitates seal and protects the skin.
13. Apply skin barrier and pouch. If creases
next t stoma occur, use barrier paste to fill
in; let dry 1 to 2 minutes.
a. Use skin sealant wipes on skin directly
under adhesive skin barrier or pouch, allow
to dry. Press adhesive of pouch smoothly
against skin, starting from bottom and
working up and around sides. Ensures
smooth, wrinkle free seal.
b. Hold pouch by barrier, center over
stoma and press down gently on barrier,
bottom of pouch should point toward
client‘s knees.
c. Maintain gentle pressure around barrier
for 1 to 2 minutes
14. Apply non-allergenic paper tape
around skin barrier. In a picture frame
method. Half of the tape should be on skin
barrier and half on client‘s skin. Someclients
prefer a belt for extra security rather than
tape. “Picture framing” skin barrier adds to
security of keeping pouch system
attached secure.
15. Fold bottom of drainable open-ended
pouches up once a close using a closure
device such as clamp. Maintains secure
seal to prevent leaking.
16. Dispose of all contaminated supplies
correctly.
17. Remove gloves and wash hands.
Remove gloves and wash hands.
18. Change pouch every 3 to 7
days unless leaking. Avoids unnecessary
trauma to skin from too-frequent changes.
19. Document the findings and procedure
done.
 TOPIC: COLOSTOMY
IRRIGATION
PURPOSES
1. To cleanse the bowel of feces before
tests or surgical procedures.
2. To relieve constipation.
3. To establish a pattern of regular bowel
elimination after ostomy surgery.
EQUIPMENT
Ensure smooth flow of procedure.
Optimizes the use of time
1. Ostomy irrigation set that consists of an
irrigation solution bag and tubing with a
fluid control clamp and cone tip.
2. Water-soluble lubricant
3. Ostomy pouch and skin barrier or stoma
cap cover
4. Clean disposable gloves
5. Toilet facilities
6. Irrigation sleeve
PROCEDURE
1. ASSESS THE STOMA. Assess frequency of
defecation, character of stool, placement
of stoma, abdominal distention and
nutritional pattern. May indicate need to
irrigate to stimulate elimination function.
Assess time when client normally irrigates
colostomy. Maintains established routine
for bowel emptying.
2. CLIENT PRIVACY
3. Position client into standing, supine or
drape position
a. On toilet or in chair in front of toilet, if
ambulatory.
b. On side, with head slightly elevated, if
unable to be out of bed.
4. WASH HANDS
5. APPLY GLOVES
6. Fill Irrigation Bag with 0.5- 1L to 1L Warm
Irrigation Solution
> Use either tap water or normal saline
> Clear tubing of air
> Start with 500 ml just sufficient to distend
the colon and effect evacuation.
Allows solution to slowly enter colon and
avoids cramping. Cold irrigation solution
could trigger syncope and bowel
cramping. Hot solution could damage
stoma and intestinal mucosa. Air entering
the colon may trigger cramping.
7. Hang Irrigation Container on a Hook.
Ensure that end of bag is no higher than
client‘s shoulder height when sitting or 18 to
20 inches above stoma.This position prevents
too high pressure and reduces possibility of
bowel damage.
8. Remove the used pouch and skin
barrier. Gently remove by pushing skin
away from barrier. Reduces skin trauma.
Improper removal of pouch and barrier
can irritate client’s skin and can cause skin
tears.
9. Apply Irrigation Sleeve over Stoma
- Ensure that the tip of sleeve should rest in
water in toilet or in bedpan.
- Directs flow of stool into toilet or bedpan;
if in toilet, also controls odor and splashing
10. Lubricate cone tip, reach through top of
irrigation sleeve and hold cone tip snugly
against stomal opening.
> Do not force cone into stoma or
try to put entire cone to stoma.
> Start inflow of solution.
> Adjust direction of cone to facilitate
inflow of solution.
Prevents trauma to stoma; cone tip avoids
perforation of bowel. Cone aids in retaining
solution during inflow
11. Allow 15-20 mins for Initial Evacuation.
>Apply gloves. Dry tip of irrigation sleeve
and close bottom. Fold sleeve up and over
top, leave in place for 30 to 45 minutes.
Discard gloves. Client may walk around.
Prevents leakage; optimizes evacuation of
stool.
>Apply gloves, unclamp sleeve, empty any
fecal contents, remove sleeve. Rinse with
liquid cleanser and cool water. Hang
sleeve to dry.
Maintains sleeve in clean condition for
future use.
 They may involve removal of all or part of

12. Apply the new Colostomy Pouch or

Stoma Cap Covering. Avoids soiling of clothes
or skin irritation from accidental leakage.

13. Dispose of all contaminated supplies

correctly, Remove gloves and wash hands.
the entire colon.
14. Remove gloves and wash hands

Ileoanal Reservoir
(J-Pouch)
TOPIC: ILEOSTOMY CARE - The colon and
most of the
rectum are
PURPOSE surgically
removed and an internal pouch is
1. To assess and care for the peristomal formed out of the terminal portion of
skin. 2. To collect effluent for assessment of the ileum.
the - An opening at the bottom of this
pouch is attached to the anus such
amount and type of output. that the existing anal sphincter
muscles can be used for continence.
3. To minimize odors for the client‘s comfort
and self-esteem. - This procedure should only be
performed on patients with
TYPES ulcerative colitis or familial polyposis
who have not previously lost their
anal sphincters.

- In addition to the "J" pouch, there

are "S" and "W" pouch geometric
variants.

Ileostomy diverts the ileum to a stoma.

It is a surgically created opening in the

small intestine, usually at the end of the
ileum.

The small intestine is brought through the TYPES OF J POUCH

abdominal wall to form a stoma.
 When in supine position there are fewer
skin wrinkles
Continent Ileostomy (Kock Pouch):
Which allows for ease of application of the
- A reservoir pouch is created inside pouching system
the abdomen with a portion of the
terminal ileum. 3. Wash hands.

- A valve is constructed in the pouch 4. Apply gloves.

and a stoma is brought through the
abdominal wall.
5. Assess the Patient. Determine client's
- A catheter or tube is inserted into the emotional response, knowledge, and
pouch. Several times a day to drain understanding of
feces from the r e s e r v o i r. continent
reservoir or
pouch. Assist in
determining
extent to which
client is able to
participate in
care and need
for teaching and information

6. Cleanse Peritomal skin gently

EQUPMENT > Draw 30 to 60 ml of NS into syringe.

1. Pouch, clear drainable colostomy / > Cleanse face of stoma with povidone-
ileostomy iodine swab
2. Pouch closure device, such clamp
3. Clean disposable gloves > Starting from center using circular motion
4. Gauze pads or washcloth to outer edge
5. Towel
6. Basin with warm tap water
7. Scissors
8. Skin barrier such as sealant wipes
9. Tape or ostomy belt

PROCEDURES

1. Provide for privacy and Explain

procedure to client.

2. Position client into standing, supine or

drape position
7.

9. Cleanse Peritomal skin gently. Use gauze

pads and liquid antimicrobial soap. Cover
Lubricate the tip of catheter with water stoma with stomal covering. Avoids soiling
soluble lubricant. of clothes.

> Insert it about 5cm (2in) at which point

some resistance maybe felt at valve or 10. Dispose of all contaminated supplies
nipple. Don’t use products containing correctly, Remove gloves and wash hands.
petroleum jelly.
11. Reduces spread of microorganisms.
If there is much resistance, while exerting
some pressure on fill a syringe with 20 ml of 12. Document
air or normal saline and inject through the
catheter. Prevents trauma

8. Place the other end of catheter in

drainage basin held below the level of
stoma.

> This process can be carried out at the

toilet with drainage delivered into toilet
bowl.

> Prevents splashing