Learning ICU nursing guidlines procedures

https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Continuous_positive_airway_pressure_(CPAP)_and_non-invasive_ventilation_(NIV)/

Physical Assessment / Observations – during therapy

Patients should receive a complete nursing respiratory assessment at least once at the commencement of each shift, where the patient’s respiratory status changes, or where CPAP/NIV settings are adjusted.
Monitor patient for and document hourly on EMR, in the Ventilator Pressures row, under Observations:

  • Level of consciousness
  • Breath rate, pattern, and effort
  • Heart rate
  • Use of accessory muscles
  • Oxygen requirement
  • Pulse oximetry
  • Compliance/comfort with therapy
  • Patient respiratory synchronization with bi-level ventilation

Mechanical Driver/Device Assessment / Observations

At the commencement of each nursing shift the ventilator settings should be checked against the medical orders and documented on EMR, in the Ventilator Pressures row, under Observations.
Monitor device each shift or when resuming treatment

  • Ventilation Settings:
    • Mode
    • Inspiratory Pressure
    • Expiratory Pressure
    • Rate
    • Inspiratory Time
    • TiMin / TiMax http://www.cpaptalk.com/viewtopic/t173578/explanation-needed-for-Timin-and-Timax.html Definition:TiMin is the minimum amount of time that it will stay at IPAP.

      TiMax is the maximum amount of time it'll stay at IPAP.
    • Trigger Definition:Trigger is how sensitive the machine is to your starting to take a breath... the lower the trigger, the more of a breath you have to take before the machine goes "AHA! time to switch to IPAP".
    • Ramp
    • Cycle Definition:Cycle is how sensitive the machine is to your starting to exhale.... and when it'll drop the pressure back to EPAP, (if TiMax hasn't already expired, if TiMax expires, then the machine goes back to EPAP then.
  • Alarm settings
  • Synchronization of device with patient respirations when on bi-level NIV in S, T and ST mode
  • Battery back-up (as required)
  • Secondary driver/device back-up (as required)
Oxygen therapy

  • Oxygen supply appropriately connected
  • FiO2 / Oxygen flow rate
  • Nasal prong oxygen for patients receiving NPV
  • Oxygen Analyzer calibrated to FiO2 of 0.21 (low) and 0.50 (high)
  • Interface and Circuit
  • Mask fit  and leak
  • Curaiss/Collar fit  and leak
  • Pressure areas from mask / strapping
  • CO2 exhalation port present and patent
  • Anti-asphyxiation port insitu and patent full face and total face mask
  • Circuit patency
Humidification

  • Humidifier settings
  • Humidifier alarms
  • Heat adaptor wire and temperature probe (MR850 only)
  • Device specific humidifier
  • Humidifier chamber water level
  • Excess condensation in circuit (‘rain out’)

Ongoing assessment

The Respiratory and Sleep Medicine Consultant, or their delegate, is responsible for arranging assessment and documentation of ongoing CPAP/NIV requirements.

Inpatient Care Needs

  • All NIV must be initiated and supervised by competent medical and nursing staff. 
  • All NIV inpatients should receive care coordination from a nurse care manager.
  • Allied health providers should be engaged dependant on individual patient requirements.

Investigations


  • Blood gas analysis may need to be performed PRN.Definition:PRN is an abbreviation for the Latin term, "pro re nata" which loosely translates to "as needed." PRN is a term commonly used by health care employers and professionals to describe short-term, contract, part-time, or fill-in work by a nurse or allied health professionals
  • TcCO2 or EtCO2 monitoring may need be performed as clinically indicated
  • Downloadable pulse oximetry PRN.
  • Sleep studies in select patients prior to discharge, and in most patients after discharge, with timing to be determined by treating physician.

Hygiene


  • Increased need for regular oral hygiene.
  • Increased need for pressure area assessment and skin care.

Nutrition


  • Enteral feeds can be administered during periods of CPAP/NIV. However carers should be mindful of the increased risk of abdominal distension and need for increased venting/aspiration of nasogastric (NGT) or other gastrostomy tubes.
  • Time spent on NIV may impinge on the patient’s ability and opportunity to take adequate nutrition and/or fluids orally. Therefore alternate feeding methods may need to be used.

If the patient has an NGT, a nasojenunal tube (NJT) or a nasopharyngeal airway (NPA) insitu there is an increased risk of pressure area formation and leak. 

Safety


  • The patient receiving any form of CPAP/NIV needs to be medically assessed for their capacity to self ventilate adequately in case of ventilator, circuit or interface failure.  Where a patient cannot self ventilate adequately there should be provision for the immediate availability of a backup mechanical device/driver, battery, circuit and interface.
    • Document start of shift primary and secondary patient survey
    • Complete standard bedside safety checks
    • Check that ventilator settings correlate with documented medical orders
    • Familiarize yourself with equipment checklist at the start of shift 
If documented or correlating medical orders are not present, seek medical input. 

Ongoing management

Potential Complications – Clinical

  • Pneumothorax
  • Decreased cardiac output
  • Gastric distension
  • Mucus plugging
  • Secretion build up inside mask
  • Oral and Nasal dryness
  • Eye irritation from air leak
  • Nasal congestion
  • Aspiration
  • Abdominal distension
  • Pressure areas from mask, tubing and strapping
  • Pressure areas from nasogastric tubing

Potential Complications - Mechanical

  • Inadequate ventilation (ie: hypoxaemia, hypercapnoea)
  • Overventilation (ie. hypocapnoea) 
  • Mechanical failure of ventilation delivery device
  • Mechanical failure of humidification device
  • Non ‘synchronisation’ with device
  • Interface leak, damage and misfit
  • Circuit leak and damage
  • Inadequate humidification
  • Change in FiO2 related to leak or change in minute volume

Complications/troubleshooting

  • Assess patient for adequacy of airway and breathing / ventilation
  • Troubleshoot interface, circuit and device
  • Seek medical review when necessary
  • During hours contact on-call respiratory fellow, respiratory consultant, respiratory nurse, or clinical technologist.
  • After hours contact on-call respiratory fellow, after hours clinical support nurse, respiratory consultant on call, or PICU medical staff/clinical technologist.

Education (patient, parent and care-giver)

  • NIV and CPAP via tracheostomy: Education for patients and caregivers will be coordinated by the Clinical Technologist.
  • Mask CPAP: Education for patients and caregivers will be coordinated by the Respiratory Nurse Consultant.
  • Reinforcement of education for parents and caregivers will be provided by suitably competent ward nurses, supporting the education programmes of the Clinical Technologist and Respiratory nurse.  

Education needs (Nurse)

  • Nurses caring for patients on NIV should have successfully completed The Royal Children’s Hospital Mechanical Ventilation and NIV Ventilation competencies or their equivalent.

Discharge planning and community-based management

  • Weekly ventilation group meetings.
  • Education from Respiratory Nurses or Clinical Technologists.
  • Referral to Complex Care support.

Follow-up / Review 

  • Daily medical review by home team with consultation as required by the Respiratory Team
  • Ventilation orders should be medically reviewed daily
  • Parent/Carer should be given a hard copy of CPAP/NIV medical order prior to discharge.

Special considerations

Infection Control

  • Change / clean circuit weekly or PRN
  • Clean mask daily or PRN
  • Refresh water daily (wash & air dry humidifier reservoir on applicable drivers as per home care plan)
  • Use bottled sterile water for irrigation or 1 litre I.V.I. sterile water

Patient Safety Alerts

  • Presence of CO2 exhalation port on interface
  • Presence of anti-asphyxiation valve on full and total face masks
  • Patient ability to self ventilate in event of power, device, circuit or interface failure

Home Circuits/Equipment

Unless otherwise indicated, patients who are managed on CPAP/NIV in the home environment will use reusable ventilation circuits.

If patients are to be discharged home on CPAP/NIV they should use the home (reusable) circuit for at least one to two nights prior to discharge in order that compliance and efficacy can be assessed.

When managed as inpatients, unless otherwise indicated, patients receiving CPAP/NIV should be managed on disposable circuits.

Where patients who are established on long-term NIV are readmitted they should use their home driver and equipment, unless otherwise clinically indicated.

Companion documents

RCH Nursing Competency documents


Nursing Guidelines and Clinical Practice Guidelines (CPG)

Parent/Carer Information

References

  • Annane D, Orlikowski D, Chevret S, Chevrolet J, & Raphaël J. (2007). Nocturnal mechanical ventilation for chronic hypoventilation in patients with neuromuscular and chest wall disorders. Cochrane database of systematic reviews. Issue 4. Art No: CD001941.
  • Bhalla, A., Newth, C., and Khemani, R.  (2015)  Respiratory Support in Children. Paediatrics and Child Health 25:5 pp214-221
  • Dehlink, E and Tan, H. (2016).  Update on Paediatric Obstructive Sleep Apnoea. Journal of Thoracic Disease. Feb 8(2):224-235
  • Fauroux, B., Aubertin, G., Lafaso, F.  (2008) European Respiratory Monograph, 41, 272-286.
  • Hammer, J. (2013) Acute Respiratory Failure in Children.  Paediatric Respiratory Reviews 14, pp64-69
  • Kaditis et al.  (2016).  Obstructive Sleep Disordered Breathing in 2 to 18 Year Old Children:  Diagnosis and Management.  European Respiratory Journal.  Jan:47(1):69-94 
  • Marcus, CL. Radcliffe, J. Konstantinopoulou, S. Beck, SE. Cornaglia, A. Traylor, J. DiFeo, N. Karamessinis, LR. Gallagher, PR. Meltzer, LJ. (2012) Effects of positive airway pressure therapy on neurobehavior outcomes in children with obstructive sleep apnea. American Journal of Respiratory Critical Care Medicine 185(9):998-1003.
  • Pham, L. and Schwartz, A. (2015).  The Pathogenesis of Obstructive Sleep Apnoea.  Journal of Thoracic Disease. Aug: 7(8) pp1358-72
  • Ventilatory Support at Home for Children (2008).  A Consensus Statement from the Australian Paediatric Respiratory Group.  The Thoracic Society of Australia and New Zealand.
  • Wallis, C. Patton, JY. Beaton, S. Jardine, E. (2011) Children on long term ventilatory support: 10 years of progress. Archives of Disease in Childhood. 96(11):998-1002.

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 ICU ventilator mode settings

https://www.youtube.com/watch?v=E5uLM41URmE

 

also no latex can be used in the construction of ventilator because of alllergies

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