Question

Mr. Nguyen is a 58-year-old patient that had septic shock and developed Acute Respiratory Distress Syndrome. He is orally intubated and on a mechanical ventilator. He is paralyzed and sedated.

• What manifestations might you observe for a patient with ARDS?
• What complications can Mr. Nguyen develop from being mechanically ventilated?
• List priority nursing interventions to prevent complications associated with ventilatory support.
• What interventions can be implemented specifically to prevent the development of Ventilator Acquired Pneumonia (VAP)?
• You are orienting in the ICU, the nurse you are working with is not implementing the VAP interventions. What would you do?

Answer 1

Acute respiratory distress syndrome previously called adult respiratory distress syndrome. It is characterized by sudden and progressive pulmonary edema , reduced lung potential to stretch and expand , insufficient arterial oxygenation evenwith optimal levels of oxygen supplementation and increasing bilateral infiltrates which is visualized in chest X ray.

1.Clinical manifestations may be :

• Severe shortness of breath
• Tachycardia, Tachypnea
• Low blood pressure
• Cough ,confusion
• Cyanosis due to Inadequate level of oxygen in blood
• Fever due to pneumonia

2. Mechaniical ventilation feels strange to patient which may cause anxiety in them and they may struggle . Patient is given sedatives , neuromuscular blocking agents to paralyse them , so that this allows the patient to be ventilated easily. When Mr. Nguyen is given those paralysing agents , patient appears unconscious , loses motor function , cant breathe or talk or blink independently. So he should be monitored closely or he may be developing complications like corneal abrasions( as he cannot blink , so his corneal may become dry), deep venous thrombi ( so apply stockings and daily foot care, including physiotherapy), skin ulcers( daily body care should be given and also patient should be turned to sides or provide water bed).

Complications due to mechanical ventilation :

• Reduced cardiac output
• Systemic hypotension
• Pain
• Pulmonary hypertension
• Decreased nutrition
• Infections especially pneumonia
• Injury to alveoli
• Pneumothorax
• Sepsis

3.Priority nursing interventions are :

• Regular pulmonary auscultation
• Interpretation of arterial blood gas measurements
• Physical assessment of patient
• Provide suctioning and oral care whenever necessary
• Providing hygienic measures to patient
• Promote optimal level of mobility and position the patient as he may not aspirate
• Monitor for any alterations in cardiac function

4. Ventilator acquired pneumonia is the most mmon infection in intensive care unit for a patient on ventilator . Some of the interventions to prevent VAP are :

• Exercise aseptic techniques
• Provide feeding via NG tube
• Provide semi-recumbent position and elevate bed (30 to 45 degrees) if indicated
• Regular suctioning to remove the secretions and prevent aspiration
• Position the ventilator tubing so that there is minimal pulling or distortion of the tube preventing injury to trachea. Injury may lead to any infection
• Use of CASS tube( Continuous aspiration of subglottic secretions )This tube allows to suction the oral secretions pooling above the ET tube cuff , preventing aspiration of secretions .

5. Talk with the nurse and request her to follow hand hygiene and other measures . Always a nurse should be an advocate to the patient. A nurse's action should bring beneficence to patient . If the nurse in ICU still don't implement the interventions , notify the ICU nurse manager or supervisor or even the attending physician if necessary. A patient deserves utmost care and safety in a hospital .