Critical Care Clinical Conference - Vanessa Gonzales

Report
The Role of the
Nurse In Mechanical
Ventilation Weaning
Submitted in partial fulfillment of the requirements in the course
N451 Clinical Management of Adult Health Nursing III
Old Dominion University
NORFOLK, VIRGINIA
Fall, 2013
Introduction
Presenters
• Chad del Rosario
• Joe Crossman
• Amanda Coffin
• Vanessa Gonzales
Reason for Topic Choice
• This semester has been our first time in the critical care unit caring for
some patients with severe medical conditions that required mechanical
ventilation. While each patient was admitted for different diagnoses,
one commonality between most patients on the unit was the use of
mechanical ventilation. We were able to witness successful extubations,
extubations that resulted in re-intubations, and ET tubes that
progressed into tracheostomy ventilation. As nursing students, we
wanted to identify the nursing interventions related to weaning in order
to achieve successful extubations with limited re-intubations and
tracheostomy ventilation.
Purpose
Goal
• The learner will be able to identify the importance of weaning a
patient from mechanical ventilation as well as the nursing
interventions and desired outcomes required to do so.
Learner Objectives
• The learner will be given a brief review of what mechanical
ventilation entails, followed by a Post Test to evaluate
comprehension.
• The learner will be able to determine which type of patient will
require mechanical ventilation through scenario-based questions
following a brief lecture.
• The learner will be able to identify possible complications of
mechanical ventilation and the nursing interventions necessary for
prevention.
• The learner will be educated through a lecture on the nursing
interventions required in the process of mechanical ventilation
weaning based on nursing research and be able to identify the
nursing interventions to ensure optimal patient outcomes.
Teaching Plan
Goal: The learner will be able to identify the importance of weaning a patient from mechanical
ventilation as well as the nursing interventions and desired outcomes required to do so.
Objectives
Content
Outline
Method of
Instruction
Time
Allotted
Resource
Method of Evaluation
(Met/Unment)
The learner will be given a brief
review of what mechanical ventilation
entails, followed by a Post Test to
evaluate comprehension.
Review of MV
• Definition
• Modes
• Settings
Lecture
2-3 minutes
PowerPoint
Post Test
The learner will be able to determine
which type of patient will require
mechanical ventilation through
scenario-based questions following a
brief lecture.
Medical Indications
for MV
• Patient inability
(Airway, Gas
Exchange,
Ventilation)
• Surgery
Lecture
followed
with
interactive
scenariobased
questions
2-3 minutes
PowerPoint
Scenario-based Post Test
The learner will be able to identify
possible complications of mechanical
ventilation and the nursing
interventions necessary for
prevention.
Explanation/Descrip
tion of Medical
Complications
• Pretest
• Complication
• Prevention
Interactive
Pre Test
with
answers
provided
through
lecture
2-3 minutes
PowerPoint
Pre Test and with
answered provided by
lecture
The learner will be educated through
a lecture on the nursing interventions
required in the process of mechanical
ventilation weaning based on nursing
research and be able to identify the
nursing interventions to ensure
optimal patient outcomes.
Research Articles 1
and 2
• Description
• Findings
• Nursing
Interventions
Lecture
10 minutes
PowerPoint
Nurse Driven Protocol
Weaning
• Interactive
Questionnaire
Emotional Responses
during MV Weaning
• Post Test
Significance of Mechanical
Ventilation to Critical Care
• To facilitate:
• Airway
• Gas Exchange
• Ventilation
Review: What is Mechanical
Ventilation?
• Use of an external system to control the movement of air in
and out of the lungs
• Bag Valve Mask (BVM)
• Ventilators
• Rescue Breaths
• Modes
• Volume controlled
• Pressure controlled
• Fi02
• PEEP (Positive end-expiratory pressure)
• Inhalation/Exhalation (I/E) Ratio
• Normal 1:2
Mechanical Ventilation Post Test
The nurse notices that the patient’s I/E ratio is set to 2:1. What
does this mean?
Medical Indications: Who needs
Mechanical Ventilation?
• Patient can no longer control/regulate their own airway or
breathing
• Airway
• Obstructive Apnea, Asthma, COPD
• Gas exchange
• Atelectasis, Pneumonia, Heart Failure
• Ventilation
• Spinal injury, Drug overdose, Sedation
• Hypoxemia
• PaO2 < 55 mmHg
• PaCO2 >50 mmHg/ pH < 7.32
• Trauma
• Surgery
Scenario-Based Post Test
• A patient arrives to the ER via ambulance with multiple
gunshot wounds. The following clinical signs are noted: RR 34,
PaCO2 60, pH 7.20, and use of accessary muscles. The patient
is being prepped for the OR.
• Should this patient be intubated/ventilated?
Complications of Mechanical
Ventilation
What is a medical complication?
• A complication is, “A disease or condition that happens in
addition to another disease or condition: a problem that
makes a disease or condition more dangerous or harder
to treat.” (Merriam-Webster)
Complications and Prevention
Pre-Test
Can you think of possible complications of mechanical
ventilation?
Can those complications be prevented?
Complications
• Volutrauma
• Volutrauma occurs when high volumes of air are
forced into the lungs. Air takes the path of least
resistance, avoiding the injured alveoli and
concentrating in the healthier alveoli. It is associated
with high Tidal Volumes and PEEP. Can lead to overdistention of alveoli, loss of surfactant, and alveolar
rupture.
• Barotrauma
• Barotrauma occurs when pressure inside the lungs
exceeds what the alveoli are able to accommodate.
This can result in alveolar rupture, causing air to leak
into the thorax. Pneumopericardium, subcutaneous
emphysema, and pneumothorax are only some of the
complications associated with barotrauma.
Complications
• Ulcerations
• Ulcerations can occur on the nose or mouth,
depending on where the patient was intubated.
The pressure of a tube pressing against the skin
can cause breakdown and further complicate the
situation.
• Infection
• Sinus infections are a significant risk for patients
who have ventilatory tubes placed through the
nares. Infections can cause purulent drainage to
leak through the trachea and into the lungs,
increasing the risk of Ventilator Associated
Pneumonia.
Complications
• Accidental Extubation/ Displacement
• Accidental extubation/ displacement can occur if the
patient pulls the ET Tube out, or when it becomes
dislodged during routine care. (Turning the patient or
transferring him/her to another bed).
• Tracheal and Laryngeal Damage
• Damage can occur when the patient is
unintentionally extubated while the cuff is still
inflated. Other causes of damage are
laryngoedema from extubation, and cranial nerve
damage.
Complications
• Ventilator Associated Pneumonia (VAP)
• Ventilator Associated Pneumonia is an
infection of the lungs occurring more than 48
hours after intubation. It is due to pathogens
bypassing normal defense mechanisms and
entering the pulmonary tissue. The patient’s
chest x-ray will show progressive infiltrate that
was not present on admission.
• VAP has a high mortality rate because it is
difficult to treat and further complicates the
patient’s disease process.
Prevention is Key!
• Volutrauma and Barotrauma
• Low Tidal Volumes with a higher rate
• Ideally PEEP should be kept at 5
• Monitor pressures (Inspiratory, Plateau, Expiratory)
• Ulcerations and infections
• Mouth care- petroleum jelly
• Nurse may switch side of mouth Ventilator is on
• Secretions- suction
Prevention is Key!
• Accidental Extubations/ Displacement
• Ensure you have enough slack in the circuit before moving the
patient
• Monitor sedation. If the patient is grabbing at the ventilator you may
need an order for more sedation or light wrist restraints as a
reminder to keep their hands away from the vent.
• Placement at the lips
• No movement in the epigastric area
• Tracheal and Laryngeal Trauma
• Prevent accidental extubations
• Ensure the cuff is fully deflated before extubation
• VAP
•
•
•
•
Head of bed up to at least 30 degrees
Mouth care including chlorhexidine, suctioning, and brushing teeth
CASS tubes
Change the circuit per protocol and PRN
Prevention is Key!
• The number one way to prevent complications related to
ventilators is to wean as early as possible. Get your
patient off the vent!
Description of the Study: Nurse-Driven
Protocol Weaning
A comparison of nurse-driven protocol-directed weaning
from mechanical ventilation and physician-driven weaning
from mechanical ventilation.
Background
• Usual care
• RT staffing
• Studies show protocol procedures may shorten the
duration of mechanical ventilation and decrease
ICU/hospital length of stay.
• First study of its kind.
Description of the Study: Nurse-Driven
Protocol Weaning
Purpose
• Compare Nurse vs. Physician weaning of mechanical
ventilation
• Outcomes
• South Korean study
Study Design
• A prospective and nonrandomized study with retrospective
historical control.
Description of the Study: Nurse-Driven
Protocol Weaning
Patient Selection
• Inclusion
• 1. Received mechanical ventilation for longer than 24 hours in the
ICU
• 2. Vent weaning trial was initiated while in the ICU
• 3. 18 years or older
• Exclusion
• 1. Died before initiation of vent weaning
• 2. Terminally weaned from mechanical ventilation before
initiation of weaning trial.
• 3. Tracheostomy at the time of ICU admission.
• 102 (nurse group) 100 (physician group)
Nursing Intervention based on Hospital Protocol
DAILY NURSE SCREENING
-Awake and able to follow simple commands
-Vasopressors (equivalent to dopamine ≤ 5 mcg/kg/min)
and systolic Blood Pressure ≥ 90 mm Hg
-Heart Rate = 55 to 135 beats per minute
-Respiratory rate < 35 breaths per minute
-PaO2 / FIO2 ratio ≥ 200
-Positive end-expiratory pressure (PEEP) < 5 cm H2O
NO
Mechanical Ventilation
YES
ASSESSMENT OF RAPID SHALLOW BREATHING
INDEX (BRIEF SPONTANEOUS BREATHING TRIAL)
RSBI > 105
-Measure Rapid Shallow Breathing Index (RSBI) after brief
2-3 minutes on Pressure support (PS) = 5-8 cm H2O and
continuous positive airway pressure (CPAP) = 0-5 cm H2O
-RSBI = Respiratory rate (breaths/min) ÷ Tidal volume
(Liters)
RSBI < 105
SPONTANEOUS BREATHING TRIAL (SBT): 30-120 minutes
-Pressure support (PS) = 5-8 cm H2O and continuous positive
airway pressure (CPAP) = 0-5 cm H2O
TOLERANCE OF SBT
NO
-Respiratory Rate < 35 breaths per minute
-Heart rate between 55 and 135 beats per minute
-Systolic Blood Pressure (SBP) between 90 - 170 mmHg
-SpO2 ≥ 92%
-Patient showing no signs of diaphoresis, paradoxical respiration,
retractions, nasal flaring, agitation, somnolence, or complaining of
shortness of breath
YES
NO
Physician approval
YES
Extubation
Findings of the Study: Nurse-Driven
Protocol Weaning
• Median durations on mechanical ventilation
• Nurse 2 days
• Physician 4 days
• Median duration ICU length of stay
• Nurse 5 days
• Physician 7 days
• Median duration of mechanical ventilation before initiation of
weaning trail
• Nurse 2 days
• Physician 3 days
• No significant differences found in hospital length of stay,
hospital mortality, rates of VAP, reintubation rate, or
disposition.
What does this research contribute to
Nursing?
•
•
•
•
•
Easy to implement
Cost effective
Safe
Less time on mechanical ventilator
Less days in ICU
• Danckers, M., Grosu, H., Jean, R., Cruz, R. B., Fidellaga, A.,
Qifa, H., & ... Khouli, H. (2013). Nurse-driven, protocoldirected weaning from mechanical ventilation improves
clinical outcomes and is well accepted by intensive care unit
physicians. Journal Of Critical Care, 28(4), 433-441.
doi:10.1016/j.jcrc.2012.10.012
Description of the Study: Emotional
Responses to Weaning
• A qualitative study which focused on the feelings of the
patients’ after successful weaning attempts
• The study took place in three separate respiratory critical care
facilities and data was collected from all successful attempts at
weaning 20 participants from a general adult population.
• All participants were on a ventilator for a minimum of three
weeks
• Ventilator types included: SIMV, pressure support, CPAP, and
T-piece
• Data was collected over a nine month time frame via
interview based questions. The interviews lasted 45-90
minutes and were tape recorded.
• The nurse can competently understand and intervene for the
patient with knowledge regarding the feelings of the patient
during weaning and weaning trials.
Findings of the Study: Emotional
Responses to Weaning
General feelings of uncertainty regarding their preparation for the
weaning process and lack of explanation, manifested by three themes:
• Bystander
• Participants reported feeling as though the decisions were being made for
them instead of incorporating them
• “I felt that it was too soon to be off and couldn’t imagine not having the
ventilator to support me”
• Severity of Disease Process related to Safety of Weaning
• Participants felt concerned about the severity of their disease process and
how that would interfere with the safety of being weaned from the
ventilator.
• Statements made by the doctor that created these feelings in the
participants:
• “Your condition is unstable, we will be removing you from the ventilator soon”
• “We will be turning off the machine in a few days.”
• Loss of control
• Being breathless, feeling helpless, not knowing what to expect, feelings of
frustration, and wondering whether or not they should give up.
Nursing Interventions: How can we as
Nurses help?
Communication is Key – Establish means of Communication
• Bystander
• Ask
• Include
• Severity/Safety:
• Explain.
• Clarify.
• Empathize.
• Loss of control:
• Establish expectations
• Encourage
Post Test: What would you do?
WW is a ‘frequent flyer’ admitted for an exacerbation of COPD.
You have orders for his extubation to take place.
JP is a young mother of 3 who has been well on the road to
recovery. The doctor has just come out the room after talking
with both JP and her family. Mr. P looks very sad because the
doctor has stated he’s going to “turn off the machine” today.
• How can this situation be avoided?
What should you do for both of these patients?
Summary
Restating the goal
• The learner will be able to identify the importance of weaning a patient
from mechanical ventilation as well as the nursing interventions and
desired outcomes required to do so.
Restating the objectives
• The learner will be given a brief review of what mechanical ventilation
entails, followed by a Post Test to evaluate comprehension.
• The learner will be able to determine which type of patient will require
mechanical ventilation through scenario-based questions following a
brief lecture.
• The learner will be able to identify possible complications of
mechanical ventilation and the nursing interventions necessary for
prevention.
• The learner will be educated through a lecture on the nursing
interventions required in the process of mechanical ventilation weaning
based on nursing research and be able to identify the nursing
interventions to ensure optimal patient outcomes.
Summary
The goal has been met.
• The learner successfully completed the evaluation and is able
to determine nursing interventions and desired outcomes
related with effective ventilator weaning.
The objectives have been met.
• The learner was educated on each objectives and answered all
Post Tests, Pre Tests, and Interactive Questionnaires
appropriately.
Thank you!
Questions?

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