The application of ventilator has played a positive role in rescuing patients with respiratory failure, and it is because of its positive effect that it is more and more widely used in clinical practice, enabling many patients to be revived. From January 2008 to December 2010, 225 patients with mechanical ventilation were admitted to our ICU, of which 196 had obvious effects.
1 Clinical data
Data: The 225 patients in this group were admitted to the ICU from January 2008 to December 2010 with mechanical ventilation, 130 males and 95 females, the oldest being 93 years old and the youngest 7 months old, with an average age of 46 years. There were 105 cases of respiratory failure, which met international diagnostic criteria , 19 cases of hand, foot and mouth disease, 61 cases of cranial surgery, 24 cases of thoracic surgery and 11 cases of abdominal surgery. The other 5 cases were used for a maximum of 781 hours and a minimum of 2 days.
2 Mechanical ventilation care
2.1 Airway characteristics after the establishment of artificial airway, the air sac starts at the acoustic valve and forms an artificial dead space between the catheter and the tracheal wall, where the temperature is suitable for bacterial growth and reproduction. When the patient is stimulated to cough, the air sac is instantly retracted by pressure, so that the secretions deposited in the upper part of the air sac flow into the lungs by gravity, causing infection.
2.2 Oral care Due to the characteristics of the airway after the artificial airway is established, it is especially important to keep the oral cavity clean. 2-3 times a day, 0.9% saline is used as the common nursing solution, and different nursing solutions are selected for patients with oral odor and stomatitis, and the optional nursing solutions are: hydrogen peroxide, Dopey’s solution, sodium bicarbonate, chlorhexidine, 0.1% chlorhexidine, etc. Awake cooperative patients apply tooth brushing and mouth rinsing attraction method , and comatose patients routine oral care. The dental pads and fixed pipe bandages are changed daily, and the oral secretions are frequently aspirated for those who have a lot of secretions, and the fixed belt is kept clean and dry, so that it can be changed as it gets dirty.
2.3 Eye care Some comatose patients whose eyelids cannot be closed can be covered with a sterile square of sand by applying gentamycin to the bulbar conjunctiva or by closing the upper and lower eyelids with breathable tape to protect the eye from bulbar conjunctival ulceration.
2.4 Postural care The quality of postural care in mechanical ventilation directly reflects the quality of care management in the ward. After mechanical ventilation, patients are required to lie in a certain angle if there is no contraindication, keep the patient’s head, neck and shoulders at a horizontal level, swing the head of the bed up by 15-30° according to the patient’s comfort level, and change the angle of the head of the bed once every 1-2 hours. Prevent the pillow from being too high to make the airway narrow and affect the airflow through to reduce the therapeutic effect. If the angle is not too large when turning over, put a soft object behind the back for 1-2 hours. To protect the skin of the back will not feel fatigue due to prolonged pressure, the patient can easily accept.
2.5 Psychological care before and after treatment Patients have fear and anxiety when receiving treatment. Therefore, human-machine confrontation often occurs, and this period is also the period when the most human-machine confrontation occurs . The difficulty in breathing and the sense of near death are aggravated. Fear of not being able to withdraw the machine in time creates dependence or safety and reliability of use. Many problems show the importance of psychological care. Before treatment, patients and family members should be guided, the purpose of treatment and the approximate time of use should be explained, and the patient and family members should be relieved of their anxiety by using easy-to-understand dialects or demonstration methods according to their literacy. After the treatment, teach the awake patients to use eye and body language to dispel the patients’ worries about not being able to communicate and express their emotions.
3 Specialized care
3.1 Ventilator tube care The length outside the tube should be closely observed through the oral and nasal cannulae, shift handover and make records, fix the tongue pad and catheter, and the ligature should be loose enough to pass through one index finger. And to regularly check, disinfection and sterilization.
3.2 Monitoring of airway pressure Closely observe the airway pressure. If the airway pressure is too high, check whether the tube is folded, the pneumonectomy cannula is dislodged to the skin, or there is more sputum in the airway. High airway pressure can lead to increased intrathoracic pressure, obstructing venous return to lower blood pressure, affecting oxygen diffusion, and excessive airflow can cause discomfort to patients, such as restlessness, reducing compliance with treatment. Evaluate the effect of ventilator application in patients daily, report abnormalities immediately to the doctor to adjust the parameters, and record the adjusted parameters in the mechanical ventilation treatment book. The handover of parameter settings was carefully done and made clear and concise.
3.3 Ventilation volume monitoring Tidal volume is the amount of gas per inhalation or exhalation in the resting state , tidal volume and ventilation volume increase or decrease should be checked and analyzed for reasons. The decrease in tidal volume is mostly due to unstable articulation at the articulation of the tube, after dumping the water in the evacuation cup, replacing the tube and suctioning, which occurred in 5 cases in adults and 2 cases in children with hand, foot and mouth disease among 225 patients, but no change in condition occurred due to timely detection and treatment.
3.4 Oxygen monitoring The main monitoring of pulmonary oxygenation function, nursing routine monitoring is PH, arterial partial pressure of oxygen, arterial partial pressure of carbon dioxide. The most important is the application of percutaneous noninvasive monitoring of oxygen and carbon dioxide. Oxygen clips are placed on the patient’s fingers or toes. The site is changed every 4 hours. When the oxygen saturation is less than 94?G, check the correct position of the oxygen clip and the color and warmth of the end of the hand and foot to determine whether it is pseudo-hypoxia or true hypoxia. A bedside blood gas analyzer, which is the most direct means, will also not be used as an adjunct to check for phlebotomy due to repeated blood draws.
3.5 Airway warming and humidification The establishment of artificial airway destroys the normal nasopharyngeal cavity and respiratory tract to warm and humidify the inhaled gas, making airway secretions concentrated and dry, forming sputum crusts or blood crusts that are not easily discharged, leading to bacterial invasion causing lung infection
3.6 The operation of clearing respiratory sputum is one of the most basic nursing techniques that ICU nurses should master. In the investigation of Yu Wanru et al, it was found that frequent aspiration (≥8 times/d) was an important factor in causing infection. In addition, there were two cases of lung atrophy caused by improper aspiration. To prevent the occurrence of hypoxemia, pure oxygen inhalation was given for 3 min before and after open aspiration, the number of aspiration was strictly controlled, and the aspiration time was <15s, and two people completed the aspiration operation together. Patients treated with high PEEP were treated with disposable closed suction tubes. When suctioning, rotate while suctioning to avoid pulling the respiratory line and avoid repeated lifting and inserting in the guide/cannula, which may cause ineffective suctioning.
In conclusion, professional knowledge is the basis for improving the quality of care of mechanically ventilated patients, and basic care and specialized care are effective nursing measures and guarantees for preventing other complications.