Ventilated Patient Assessment
Assess q1–2h: respiratory rate, SpO2, ABG trends, breath sounds, ET tube position and security, cuff pressure (20–30 cmH2O), sedation level (RASS), pain (CPOT), delirium (CAM-ICU).
Ventilator Alarms
High pressure: patient biting, secretions, coughing, pneumothorax, kinked tube. Low pressure: disconnection, leak. Low SpO2: check circuit, suction, ABG. Always check the PATIENT before silencing an alarm.
Ventilator Bundle
IHI VAP bundle: (1) HOB 30–45°. (2) Daily sedation interruption. (3) Daily SBT. (4) Peptic ulcer prophylaxis. (5) DVT prophylaxis. (6) Oral care with CHG q6h. Bundle compliance reduces VAP by 60–70%.
Sedation Management
Target: lightest sedation (RASS -1 to 0). Daily sedation vacation: hold sedation, assess, restart at 50% dose. Pain first (CPOT), then sedation (propofol, dexmedetomidine). Delirium monitoring: CAM-ICU every shift.
Weaning
Readiness: PEEP ≤8, FiO2 ≤50%, hemodynamically stable. SBT: 30-min trial on T-piece or low PS. Pass criteria: RR <30, SpO2 >90%, stable HR/BP. Extubation: passed SBT, can protect airway, follows commands.
Important Notes
- Suction when clinically indicated — NOT on a set schedule.
- Cuff pressure below 20 cmH2O allows aspiration; above 30 cmH2O causes tracheal ischemia.
Clinical Tips
- "Sedate to a goal, not to a floor" — over-sedation prolongs ventilation and increases delirium.
Summary
Mechanical ventilation nursing requires comprehensive assessment, alarm management, strict bundle compliance, evidence-based sedation, and collaborative weaning to minimize complications.
