Ventilator Questions

Susie2310 · Nov 27, 2015

Are you on orientation? What does your ventilator training involve - does it address these questions? What do your unit/facility policies and procedures say?

BeatsPerMinute, BSN, RN · Nov 27, 2015

Please no "check your policy" comments.... They are not helpful.

Obviously we have policies that we follow. People are very willing to teach and answer my questions. These are just questions that pop into my head as I study. This is a place to share information. I'm curious how others practice. Let me be curious.

Susie2310 · Nov 27, 2015

Please no "check your policy" comments.... They are not helpful.
Obviously we have policies that we follow. People are very willing to teach and answer my questions. These are just questions that pop into my head as I study. This is a place to share information. I'm curious how others practice. Let me be curious.

I presume you were referring to my post, and I assure you I was trying to be helpful by first trying to ascertain what knowledge/training and resources were available to you. It is common practice to ascertain someone's knowledge base if one wishes to offer an appropriate reply to a question they are asking, particularly one that may require a complex answer, such as ventilator management. However, your rather rude comment has dissuaded me from offering any further suggestions. Good luck to you, and I suggest, in future, being more polite.

Coffee Nurse, BSN, RN · Nov 27, 2015

Please no "check your policy" comments.... They are not helpful.
Obviously we have policies that we follow. People are very willing to teach and answer my questions. These are just questions that pop into my head as I study. This is a place to share information. I'm curious how others practice. Let me be curious.

Actually, "check your policy" comments are the only thing that will be helpful, if and when you ever get called to account for why you did/didn't do something for a patient under your care.

iluvivt, BSN, RN · Nov 28, 2015

Coffee nurse, that is simply NOT TRUE.You as an RN are held to the standard of care even if the policies at your facility are lacking, incorrect, or outdated.There is no way facilities can,nor should they list every possible clinical scenario.The RN clinician is still held to the current standard of care. Many hospitals fail to update their policies fast enough so it is best to make sure you know the current standards.

MunoRN, RN · Nov 28, 2015

Actually, "check your policy" comments are the only thing that will be helpful, if and when you ever get called to account for why you did/didn't do something for a patient under your care.

Nurses are actually legally required to determine if the policies they are encourage to follow are safe and appropriate. "Just follow your policy" is potentially disastrous advice.

I also disagree with the implied suggestion that good patient care varies widely from one facility to another, the physiological response and therapeutic effect of ventilator management do not change at all from one facility to another.

NanikRN · Nov 28, 2015

CoffeeNurse said to CHECK your policies-- not blindly follow them .

It is your responsibility to know those policies. If you believe the policies are out of date and patients are not getting the best care, you then have a duty to let your superviser/ education dept know immediately

And if you don't follow policy- and something goes wrong- the hospital then has every opportunityto distance themself from you legally. Because, after all, you weren't following policy....

Susie2310 · Nov 28, 2015

I don't believe Coffee Nurse meant that a nurse should follow a policy unintelligently/blindly.

sjalv · Nov 28, 2015

There have been literally 7 replies to this post and none of them have answered the OP's question. Yes, OP needs to know the hospital's policies, but they were asking US as nurses with experience with vents how we handle certain situations. That's it.

If I know I have a vent'd patient, I make sure I'm getting a pristine, crisp pleth on their Spo2 sensor because a consistent, accurate reading of their pulse ox is important. If they start to desat, you want to know it's a legit reading.

Check their sedation/narcotic drips. This will vary by facility but where I work, most of our vent'd patients have propofol/fentanyl going. Whatever the drugs your facility uses, make sure you know the ranges (low and high) you can titrate to, and how you should titrate the drug (how big of a dose change should you make at one time, how long should you wait before evaluating if it's been an effective change, etc). Be aware of the drug's half-life & peak times, as well as potential side effects. For example, if the patient is already hypotensive, it can be a fine line between titrating pressors & their sedation. On one hand, you don't want them breathing 40 times a minute. On the other hand, you don't want to face an uphill battle against your pressure because you're oversedating the patient.

Check your vent tubing and make sure it has slack. This is a simple concept but I can't tell you how many times I've seen nurses accidentally disconnect the vent tubing from the ET tube when turning a pt just because it was caught up on the bed.

If your vent alarms, don't just silence it; try to find a cause. RT is a valuable resource for understanding the vents. I'm a new nurse (6 months in) and if I don't understand why a pt might be throwing a certain alarm, I get RT to evaluate it and explain to me what's going on. Some patients are going to have high peak pressures, for example if they are going into ARDS, and there might be little you can do for them. Alternatively, a pt may have trouble taking in the breaths and just need suctioned.

Do oral care at least q2h. Most facilities have a policy on this anyway but this is to prevent ventilator-acquired pneumonia, and it helps control oral secretions. That being said, make sure you have two suction cannisters set up, and have a yaunker for oral suctioning close by if needed. The oral care kits we use at my facility has one that comes in each kit that has a plastic sheath you can cover it with, and it's reusable. We replace them every 24 hours.

Compare the patient's set respiratory rate with their actual rate of breathing. Are their breathing with (symmetrically) the vent, or over the vent? Are they 'stacking' their breaths? If they are breathing over the vent, look for possible causes: are they in pain? Are they completely awake and alert? We shoot for a -2 on the RASS scale at my facility, so while we don't want to completely snow a patient, we want them to be lightly sedated.

Get in the habit of assessing the location of the tube throughout your shift. You should be told in report where the tube is at and by what landmark (the lips, the gums, or the teeth). You can assess its location by seeing where the number falls at the teeth/lips/gums and see if the tube has been displaced or moved at all.

As far as the actual process of intubation, usually as the nurse you'll get the drugs the physician wants, draw them up, and get ready to push them as the physician requests. Where I work, RT is at the bedside ready to connect the pt to the vent once the ET tube has been placed. Then you get to push the bed back to the wall and pick up after the physician because they think a bed being in the middle of the room is normal.

You'll have (or should have) an orientation to ventilators, and there's a lot to learn about them. I wouldn't claim to be an expert by any means at all, but you want to become familiar enough with them that you're not intimidated by seeing an intubated patient.

TheCommuter, BSN, RN · Nov 28, 2015

This thread has been moved to our Critical Care Nursing forum to accrue responses from ICU nurses and those who work with ventilators on a regular basis.

BeatsPerMinute, BSN, RN · Nov 28, 2015

There have been literally 7 replies to this post and none of them have answered the OP's question. Yes, OP needs to know the hospital's policies, but they were asking US as nurses with experience with vents how we handle certain situations. That's it.
If I know I have a vent'd patient, I make sure I'm getting a pristine, crisp pleth on their Spo2 sensor because a consistent, accurate reading of their pulse ox is important. If they start to desat, you want to know it's a legit reading.
Check their sedation/narcotic drips. This will vary by facility but where I work, most of our vent'd patients have propofol/fentanyl going. Whatever the drugs your facility uses, make sure you know the ranges (low and high) you can titrate to, and how you should titrate the drug (how big of a dose change should you make at one time, how long should you wait before evaluating if it's been an effective change, etc). Be aware of the drug's half-life & peak times, as well as potential side effects. For example, if the patient is already hypotensive, it can be a fine line between titrating pressors & their sedation. On one hand, you don't want them breathing 40 times a minute. On the other hand, you don't want to face an uphill battle against your pressure because you're oversedating the patient.
Check your vent tubing and make sure it has slack. This is a simple concept but I can't tell you how many times I've seen nurses accidentally disconnect the vent tubing from the ET tube when turning a pt just because it was caught up on the bed.
If your vent alarms, don't just silence it; try to find a cause. RT is a valuable resource for understanding the vents. I'm a new nurse (6 months in) and if I don't understand why a pt might be throwing a certain alarm, I get RT to evaluate it and explain to me what's going on. Some patients are going to have high peak pressures, for example if they are going into ARDS, and there might be little you can do for them. Alternatively, a pt may have trouble taking in the breaths and just need suctioned.
Do oral care at least q2h. Most facilities have a policy on this anyway but this is to prevent ventilator-acquired pneumonia, and it helps control oral secretions. That being said, make sure you have two suction cannisters set up, and have a yaunker for oral suctioning close by if needed. The oral care kits we use at my facility has one that comes in each kit that has a plastic sheath you can cover it with, and it's reusable. We replace them every 24 hours.
Compare the patient's set respiratory rate with their actual rate of breathing. Are their breathing with (symmetrically) the vent, or over the vent? Are they 'stacking' their breaths? If they are breathing over the vent, look for possible causes: are they in pain? Are they completely awake and alert? We shoot for a -2 on the RASS scale at my facility, so while we don't want to completely snow a patient, we want them to be lightly sedated.
Get in the habit of assessing the location of the tube throughout your shift. You should be told in report where the tube is at and by what landmark (the lips, the gums, or the teeth). You can assess its location by seeing where the number falls at the teeth/lips/gums and see if the tube has been displaced or moved at all.
As far as the actual process of intubation, usually as the nurse you'll get the drugs the physician wants, draw them up, and get ready to push them as the physician requests. Where I work, RT is at the bedside ready to connect the pt to the vent once the ET tube has been placed. Then you get to push the bed back to the wall and pick up after the physician because they think a bed being in the middle of the room is normal.
You'll have (or should have) an orientation to ventilators, and there's a lot to learn about them. I wouldn't claim to be an expert by any means at all, but you want to become familiar enough with them that you're not intimidated by seeing an intubated patient.

Thank you very much for answering my questions. This is exactly what I was looking for.

I'm sorry about sounding rude, but every single time I post a question, I'm bombarded with comments that question whether or not I'm going to be a safe nurse and we go completely off topic. I hate the idea of having to explain myself or adding a disclaimer first...