?????????????? ???????? ???? ?????? ???????????????????? ????????????????

????????????????????:

? The registered nurse is responsible for the assessment, planning and delivery of care to the patient.

? Care of the ventilated patient can vary from the basic nursing care of activities of daily living to care for highly technical invasive monitoring equipment and managing and monitoring the effects of interventions.?

???????? ???? ?????? ????????????:

? It is of paramount importance that all cares and procedures are carried out with maintaining a patent airway always in mind.

? Always check the patient first. Observe the patient’s facial expression, colour, respiratory effort, vital signs and ECG tracing.

? Ensure the endotracheal tube (ETT) or tracheostomy tube is held securely in position but not too tightly to result in pressure area lesions.

? Check the placement of the ETT by listening for equal bilateral breath sounds, checking the CXR and noting the distance marks on the tube at the teeth, checking the previously documented level.

? Check and adjust (if necessary) the cuff pressure of the ETT/trachi. In order to minimize tracheal damage, the cuff pressure should be at the lowest pressure necessary to prevent an air leak.

?????????? ?????? ?????????????? ?????????????????? ??????????????????:

? An alternative means of ventilation eg. bag valve mask must be available & functional

? Yankeur sucker, suction catheters and functioning suction unit, airways and masks should be available.

??????????????????????:

? Ensure the ventilation tubing is not kinked and that it is adequately supported so as not drag on the ETT/trachi. Take care of the tube while turning or moving the patient.

? Check the ventilator and document the settings. Look at the alarm parameters and reset if necessary.

? Ensure the ventilator and the cardiac monitor are plugged into emergency power supply in case of power failure.

? Ensure that you have enough room to access the head of the bed in an emergency.

? Check the type of humidification, and when the filters and ventilation tubing were last changed.

? HME filters and end expiratory filters are changed routinely (and marked with the date and time) every 24 hours or more frequently if there is condensation visible.

? Ventilator circuits are changed weekly.?

?????????????????????? ?????? ???? ???????????????? ???????????????????? ?????????????? :

1. minute volume greater than 10 litres
2. chest trauma with pulmonary contusion
3. airway burns
4. severe asthma
5. hypothermia (<34? C)
6. pulmonary haemorrhage
7. severe sputum plugging/pulmonary oedema leading to HME occlusion
8. consultant order

? Pooled secretions above the ETT/trachi cuff are associated with ventilator associated pneumonia (VAP). This is a result of aspiration of bacteria colonizing the oropharynx or GIT and subsequently leaking below the cuff into the trachea. Therefore thorough oropharyngeal suctioning should be performed before letting down the cuff to reposition the ETT or to check cuff pressure.?

?????????????? ???? ???? ???????????????????? ????????????:

? To maintain a patent airway

? To promote improved gas exchange

? To obtain tracheal aspirate specimens

? To prevent effects of retained secretions eg. infection, consolidation , atelectasis, increased airway pressures or a blocked tube.

? It is important to oxygenate before and after suctioning?

? Closed suction catheters should be rinsed post suctioning to remove mucous and to reduce the likelihood of bacterial growth.

? Tracheal suctioning should be attended 2 - 3 hourly, more often if necessary

? Suction the oropharynx to remove potentially infected secretions.

????????????????:

? Check the level of any invasive monitoring transducers and zero them.

? Check the alarm parameters and reset if necessary.

? Document the patient’s vital signs hourly and when there is a deviation from the usual.

? Check and document a manual blood pressure to assess the accuracy of the arterial trace once a shift.?

???????? ????????:

? The aim of oral care and assessment is to promote normal hygiene while preventing infection and trauma.

? The presence of an ETT can cause hyper salivation in some patients and an uncomfortably dry mouth in others.

? A soft toothbrush can be used for oral hygiene and a small amount of toothpaste can help the cleansing action. Using large amounts of toothpaste may leave a residual coating and produce a burning sensation if it is not rinsed away properly.

? Properly diluted sodium bicarbonate may be used to remove resistant coating on the tongue, debris or tenacious secretions but again overuse may cause superficial burns.

? The lips should be kept moisturized to stop them becoming sore and cracked.

? 2nd hourly oral care is recommended, using water, not saline, and oral swabs and thorough suctioning of oral secretions, a toothbrush & paste should be used at least once a shift and more often if indicated.?

?????? ????????:

? The unconscious, sedated or paralyzed patient is at risk of developing eye problems ranging from mild conjunctivitis to serious corneal injury and ulceration. Permanent eye damage may result from ulceration, perforation, vascularization and scarring of the cornea.

? Sedation and muscle relaxants can lead to inadequate closure of the eye, lack of random eye movements and a loss of the blink reflex, all of which can lead to complications.

? Fluid imbalances and increased permeability can promote conjunctival oedema.

? Constrictive securing tapes can compromise venous return from the head leading to venous congestion and maybe an increase in interocular pressure and therefore an increase in conjunctival oedema.

? 2nd hourly eye care using saline soaked gauze to clean the eye and the application of lactrilube regularly in the ventilated patient is recommended to help reduce the risk of complications.?

???????????????????????????????? ?????????? :

? Intubated patients must have a nasogastric tube for gastric decompression or nutritional support or any other means of feeding.

? The presence of bowel sounds and the turgor of the abdomen should be assessed during the initial assessment.

? Nutrition and hydration are essential to build respiratory muscle strength necessary when a patient is being weaned from a ventilator. Patients who have inadequate nutritional stores are prone to infection, fluid and electrolyte imbalance, intestinal fluid retention, weight loss, pressure areas and poor wound healing.

? Patients with a functioning GI tract should be fed enterally. TPN may be used if there are contraindications to enteral feeding.

? The enterally fed patient should be monitored for diarrhoea, dehydration, fluid overload, constipation or abdominal cramping. These observations can be a guide in determining the strength and rate of increase of the feeds.

? NG tubes should be flushed with 20-30 mls of water before and after administering medications.

? Fine bore tubes cannot be aspirated but should be flushed 4 hourly with water.?

? If the patient is not being fed enterally the NG tube should be on free drainage and aspirated and flushed 6 hourly with water.

? If the enterally fed patient has large aspirates (>200mls or > 4 hours feed) consult with medical staff regarding reducing the feed and/or discarding the aspirate.

? Otherwise the aspirate is generally returned if less that 200 mls or < 4 hours feed.

? Elevating the head of the bed to 30 - 45 degrees (unless contraindicated) is effective in reducing the risk of aspiration.

? Elimination should be recorded and aperients given if necessary.

??????????????/?????????????? ??????????:

? Indwelling urinary catheter predisposes urinary tract infections.

? Routine urinalysis should be twice a day

? Regular penil/perineum catheter care should be done.

? The catheter should be secured to the leg carefully and repositioned as necessary to prevent pressure areas.

? Hourly urine monitoring is carried out and medical staff informed of abnormally high or low measurements. Aim for a urine output of 0.5ml/kg.

?????????????????????????? ?????? ???????????????? ???????? ????????:

? Attending to the patient’s hygiene protects the skin and ensures dignity and comfort

? Ventilated patients are at a higher risk of developing nosocomial infections and

pressure areas due to their immobility, their underlying disease process and the

presence of invasive monitoring lines and equipment.

? ?????????????????????????? ?????? ?????????????? ?????????????????? ?????? ?? ???????????? ???? ???????????????? ??????????????:

1. Routine turning and positioning assists in the mobilization of secretions
2. Prevents the development of pressure areas, joint stiffness and deformities
3. Improves oxygenation and can encourage weaning from the ventilator.
4. Provides a different view on the environment for the patient
5. The patient should be repositioned 2nd hourly if possible, taking care to position the limbs in proper alignment and supporting them to prevent dependant oedema.

? If the patient has leg splints on they should be on for 2 hours and off for 2 hours.

They should not be bandaged and the skin integrity should be checked with each turn.?

? The ETT and other lines should be safeguarded during turning and care should be taken to ensure that there are no lines or other equipment under the patient turned.

? The skin should be kept dry and should be inspected with each change of position, including under restraints.

? The head of the bed should be elevated if the patient’s condition allows to help prevent aspiration and improve oxygenation.

? If the patient has any signs of developing pressure areas he/she should be nursed on an air mattress.

? The ETT should be repositioned at alternate sides of the mouth to prevent pressure areas developing.

? The NG tube should be secured in such a way as to minimize pressure on the nares to the and changed at least daily.

? If the patient has a hard collar it should be changed to an Aspen collar as soon as possible and the back of the head and neck checked once a shift for the presence of pressure areas.

????????????????????:

1. ????????????????. (2002) ‘???? ??????? ????? ???????????????? ??????? ???????????????‘, ?????? ??????????????? ????? 6 (1) ??????? 1329-1874.??

2. ??????????????,??. (1997) ‘????????????? ??????? ??? ????? ??????????????????????? ?????????????????? ????????????? ???? ?????: 1, ????????????? ????????????? ??? ????????????? ????? 6 (9) ?????, 447-454.??

3. ???????????????, ?. (1998) ‘????? ??????????????? ?????? ????????????????? ??? ???????????????? ??????? ?????????? ????????? ????? ?????????? ????????????? ???????????’, ????????????? ??? ??????????????? ????????????? ????? 28 (5) ?????,1020-1029.??

4. ?????????????, ??. (2002) ‘??????????? ????? ????? ????????????????????? ???????????????????? ??????’, ??? ????? 65 (7) ????????, 42-44, 46, 48-49.??

5. ????????????,??, ??????,?.?, ???????,??. (98) ‘????????????? ????????????????? ??? ???????????? ??????????????????-?????????????????? ????????????????, ???????? ???????????????? ?????????? ????? 9 (1) ????, 76-90.??

6. ????????????????,??, ??????????,?, ????????,??. (1998) ‘?? ??????????? ??? ????????????????????? ?????????????????? ???????? ??????????????????????? ??? ????????’, ??????????????? ????????????? ??? ???????????????? ??????? ????? 7 (4) 256.??

7.??????????,??.?. (1998) ‘??????????????????- ?????????????????? ???????????????? ?????? ???????????????? ??? ?????????????? ????????????’, ??????????????? ????????????? ??? ??????????????? ???????????? ????? 26 (1) ????, 71-73.??

8. ??????,?.??.??, ????,??.?.(1997) ??????????????? ??????? ???????????, 4???? ???, ??.246, ???????, ??????????????????? & ???????????????.