Page 60 - Critical Care Nursing Demystified

Chapter 2 CARE OF THE PATIENT WITH CRITICAL RESPIRATORY NEEDS 45

6. Assist the health care provider during intubation by suctioning as needed and
assisting with cuff inflation.
7. Secure the ETT with a commercially prepared holder.
8. Assess the following:
a. Vital signs, SaO , end-tidal CO and cardiac rhythm (observe for hypotension)
2 2
b. Breath sounds bilaterally; they should be of equal intensity
c. Symmetry of chest wall movement (raise on the right side only could indi-
cate intubation of the right mainstem bronchus and the ETT will need to be
repositioned)
d. Presence of the correct tidal volume on the ventilator
9. Call for an immediate portable chest x-ray after insertion to confirm proper
tube placement
10. Insert a nasogastric tube to decompress the stomach and lessen the chance
of aspiration.

11. Document:
a. Patient response; vital signs, SaO , end-tidal CO
2 2
b. Presence of breath sounds, symmetry of chest wall movement
c. Location in centimeters of ETT as it exits the lips Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission.
d. Premedications

NURSING ALERT

ETT placement at the lip line (documented in centimeters) must be documented to ensure
continued proper placement. The patient on long term ventilation will eventually
need a tracheostomy.

Nursing Interventions

1. Continuously explain all procedures to the patient and provide emotional
support.

2. Suction as necessary following strict aseptic technique to prevent infec-
tion and aspiration.

3. Provide oral care to remove secretions and prevent ventilator associated
pneumonia.

4. Elevate the head of the bed 30 degrees to prevent aspiration.
5. Monitor the tubing for kinks and blockages.
6. Auscultate lung sounds to determine airway patency.