Wednesday, November 29, 2006
Nurses and VentilatorsHow much do nurses need to know about ventilators?
This is another of those questions found in the "search engine keywords" section of our counter software.
The answer is, it depends where you work.
In the US, for example, many (but not all) critical care units use Respiratory Therapists to do much of their ventilator management. The position of RT does not exist where I work, so nurses do all of the ventilation, guided by the senior medical staff.
In our PICU, I would hope that the new nurses would know at minimum:
- Which type of ventilator we use for which patients
- Which circuit size and type to choose when setting up
- How to set up and check each ventilator correctly (this is quite a lot more complicated than it sounds)
- How to strip and clean each ventilator without throwing anything important away!
- Standard settings for inspiratory time, PEEP, assist sensitivity and so on.
- How to set sensible alarm limits.
- How to manually ventilate safely and effectively using an anaesthetic bag.
- How to wean a patient from ventilation.
This is a fair bit of learning in itself, especially when you take into account all the different age groups and conditions that a nurse here might be expected to encounter. There's also all the attendant skills like being able to suction, change ETT taping, good positioning, preventing ETT-related pressure areas and the list goes on. Fortunately we never work in isolation, and there is always someone to ask in case of uncertainty.
More senior nurses would need to be able to:
- Set up, test and use our various transport ventilators.
- Set up, test and use a High Frequency Oscillator.
- Troubleshoot all ventilator types on the unit.
- Be able to distinguish between a machine problem and a patient problem (this can be a particularly hard skill to learn.)
- Have a sense of what their patient will tolerate in terms of weaning, level of activity, procedures, how much sedation is required, and so on. You can't teach this, it's experiential.
- Be able to spot deterioration early, and do something about it.
There will be a subset of the nurses, maybe four or five in the unit, for whom ventilation is a particular area of interest. They're good resources on ventilation and provide a sounding board for the team. Ditto some of the docs.
The junior medical staff are often unfamiliar with the ventilators depending on what their background has been. I say "junior", really they've been at this awhile because we don't have beginner docs rotating through PICU. Still, it's unrealistic to expect some of them to have anything more than the fundamentals of ventilator theory. They can tell me about Bernoulli's law but are not used to standing and watching the rise and fall of a chest, listening to the subtle changes in sound from the machine and the circuit, reading blood gases and the monitor with the patient and not just the textbook in mind.
They might, for example, understand in a basic sense what SIMV mode implies, but not know the details of how SIMV is delivered on one particular ventilator. Since all manufacturers have their own interpretation on SIMV, this can be distinctly different from machine to machine. Often senior nurses fill in the gaps in this understanding, which requires that you know the common modes on your ventilators inside and out. Not just the manual's description, but what you've learned about patient response to the mode during thousands of hours of observation.
Oh, and just in case you weren't feeling like you had enough responsibility yet:
You are your patient's last defence against hospital-acquired respiratory infection.
You are your patient's last defence against apnoea.
You are your patient's last defence against baro/volutrauma.
You are your patient's last defence against a bad ventilation order.
You are your patient's first and last defence against accidental extubation and airway occlusion.
We take it seriously because, well, it's breathing. Breathing is good. Not breathing is bad. In randomised controlled trials, 100% of patients who breathe do better than patients who do not. Scientific fact.
Posted by PaedsRN at 6:03 PM