Questions and Correct
Answers
What may a high pressure vent alarm indicate? -
ANSWERS-Pt is biting on the tubing,
excessive secretions in the tubing, kinked tubing
What may a low pressure vent alarm indicate? -
ANSWERS-cuff leak or the tubing is
disconnected somewhere
,How do you verify positioning of an
endotracheal tube? - ANSWERS--auscultate
lung
bases and apices for bilateral breath sounds
-observe chest for symmetric chest wall
movement
-confirm with end tidal CO2 measure
GOLD STANDARD: chest x-ray
t/f: people with ET tubes should be suctioned
routinely - ANSWERS-FALSE-- they
should be suctioned on an as needed basis
what should ET tube cuff pressure be kept at? -
ANSWERS-20-25 mmHg
What measures should nurses take to avoid ET
tube problems? - ANSWERS--confirm that exit
mark on ET tube remains constant when
,providing patient care, repositioning, and
transporting patient
-maintain proper cuff inflation (listen for an air
leak-- if pt can talk, you must inflate more)
-continually monitor SpO2, RR, HR and rhythm,
mental status, and ABGs -pre-oxygenate before
suctioning
What should be done if a patient is not
tolerating ET tube suctioning? - ANSWERS-
STOP and manually hyperventilate with 100%
oxygen
Measures to prevent aspiration? - ANSWERS--
avoid bolus tube feedings
-monitor tube feeding residuals
-maintain HOB at LEAST 30 degrees or greater
-maintain proper ET tube cuff inflation
-perform frequent oral pharyngeal suctioning
, -maintain an NG tube connected to low,
intermittent suction if feeding tube is placed
below the pylorus
what are recommendations for preventing
ventilator associated pneumonia? - ANSWERS--
manage ventilated patients without sedatives
whenever possible
-interrupt sedation once a day (spontaneous
breathing trials)
-provide early exercise and mobility
-provide regular oral care
-minimize pooling of secretions above the ET
tube cuff
-use ET tubes with subglottic secretion drainage
for patients likely to require greater than 72
hours of intubation -keep HOB elevated 30-45
degress
-change ventilator circuit only if visibly soiled or
malfunctioning