• Observe the physical signs such as color, secretions, breathing pattern and state of consciousness.
  • Observe the tidal volume and pressure manometer regularly. Intervene when they are abnormal (i.e. suction if airway pressure increases).
  • The nurse should continually assess the patient for adequate gas exchange, signs and symptoms of hypoxia, and response to treatment.
  • Continuous PPV increases the production of secretions regardless of the patient's underlying condition. The nurse should assess for the presence of secretions by lung
    auscultation every 2-4 hours.
  • Perform measures to clear the airway of secretions by doing suctioning, chest physiotherapy, frequent position changes, and increased mobility as soon as possible.
  • Maintain humidification of the airway via the ventilator to liquefy secretions so that are easily removed.
  • Monitor vital signs as directed.
  • Monitor for adequate fluid balance by assessing for the presence of pulmonary edema, calculation daily intake and output, and monitoring daily weights.
  • Maintain oral hygiene frequently in the intubated and compromised patient because oral cavity is a primary sources of contamination of the lungs in such patients.
  • maintain aseptic technique to prevent infection.
  • The nurse should assist a patient whose condition has become stable to get out of bed and to a chair as soon as possible. If the patient cannot move out of bed, the nurse encourages the patient to perform active range-of-motion exercises every 6-8 hours. If the patient cannot perform these exercises, the nurse performs passive range of motion exercises every 8 hours to prevent contractures and venous stasis.
  • Develop alternative methods of communication for the patient on a ventilator, such as lip reading, notepad and pencil or magic slate, gesturing, etc.


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