Page 71 - Critical Care Nursing Demystified

56 CRITICAL CARE NURSING DeMYSTIFIED

of tube feedings should be done at frequent intervals throughout the day: usu-
ally every 4 hours and whenever needed. However, when to hold the tube
feedings varies from institution to institution. Consult your institutional guide-
lines. If the aspirate exceeds guidelines hold the feedings until it returns to
baseline. Insufflating the gastric port with air and listening over the stomach is
no longer an acceptable practice to determine gastric placement.

Ventilator-Associated Pneumonia (VAP)
Once the airways are violated with a device that goes into the lower airway, pneu-
monia is a possible consequence. There is a wealth of research in the nursing litera-
ture on VAP. Frequent hand washing is a must in preventing infection. Much
research is focused on oral secretions contaminating the lung fields. Good oral
hygiene several times a shift is important to prevent VAP. All suctioning must be
done maintaining a sterile system. Most health care facilities use in-line suction
devices in an effort to decrease suction catheter contamination. Trauma to the
airways by a hard suction catheter can be decreased by the use of soft, more pliable
red rubber catheters, but these can not be used in an in-line suction device. To
prevent secretion pooling above ETT or tracheotomies, some tubes now come with
a subglottic suction port to allow suctioning above the balloons of the tubes. Lavag-
ing with normal saline solution is no longer an acceptable practice and has been 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.
shown to increase the chance of infection. Also, keeping the head of the bed in an
elevated position of 30 degrees or higher helps decrease the chance of aspiration.

Airway Trauma From Pressure
Forcing air into the lungs can have dire effects. When PPV is instituted, the
increased pressure to the lungs can rupture the alveoli. This is called a pneumotho-
rax. Patients more prone to this are those who already have very fragile lungs;
those with COPD are most prone. Also, patients on positive end-expiratory pres-
sure (PEEP) are more prone to pneumothorax as there is always higher pressure
in the lungs at expiration. The fragility of the lungs, just like a balloon if over-
stretched, can cause them to pop. When this occurs, the nurse will see less chest
wall movement on the affected side, hear diminished breath sounds, and the high-
pressure alarm will sound on the ventilator. If the nurse suspects a pneumothorax
she or he should take the patient off the ventilator and use a BVM to support
breathing and call the MD stat. She/he will order a chest x-ray. Manually ventilat-
ing a patient will decrease the chance of developing a tension pneumothorax.
A tension pneumothorax is caused when unrelieved pressure builds up in
the chest. The pressure pushes the heart, great vessels, and trachea away from
the affected side. Because these structures are compressed, the patient will lose
his or her breathing and circulatory ability and a cardiac/respiratory arrest can
occur quickly. The pressure that builds up would be similar to someone placing