RESPIRATORY SYSTEM MONITORING
STANDARDS OF NURSING CARE IN CCTC (SONC)

1. Monitor Respiratory System
2. Monitor SpO2
3. Communicate Findings
4. Monitor Blood Gases

5. Provide Emergency Equipment
6. Maintain Positioning
7. Suction as Required
8. Change Chest Tube Dressings
9. Maintain Chest Drainage Systems

STANDARD OF NURSING CARE

 1.

Monitor Respiratory System

Breath sounds are assessed at the start of each shift and prn. Respiratory rate, rhythm and effort is monitored continuously for all ventilated patients. Clinical Nurses assess the patients rate, minute volume, airway pressures and ventilator settings q1h and prn, and document findings in the graphic record. Clinical Nurses provide continuous respiratory monitoring and report significant findings to the Respiratory Therapist and the physician.

 1.

To provide continuous monitoring for changes in oxygen saturation.

 2.

Monitor SpO2

All CCTC patients have continuous SpO2 monitoring, unless otherwise ordered. When digits are used for monitoring, monitoring sites are rotated and the skin integrity assessed q2h.

SpO2 may be inaccurate in the presence of nail polish, carbon monoxide (e.g., smoke inhalation) or impaired peripheral perfusion. Blood gases provide more accurate assessment of oxygenation in these situations.

SpO2 alarms are on at all times. If alarms are disabled, the reason is documented in the AI record.

 2.

The Clinical Nurse is responsible for continuous monitoring and for communicating relevant findings to the appropriate member of the health care team. The respiratory therapist is responsible for the set-up and adjustment of the ventilator.

 3.

Communicate Findings

Ongoing communication between the Clinical Nurse and RRT responsible for the care of a patient is required. Planned changes are discussed in advance and communicated upon completion.

 3.

Many factors influence a patient's ventilation requirements including hemodynamic stability, acute brain injury, procedural or operating room plans and level of sedation. Interventions must be made with a full knowledge of the treatment plan and of the patient's condition. Clinical Nurses and RRTs must work as a team to ensure optimal ventilatory support.

 4.

Monitor Blood Gases

All patients require daily blood gas evaluation unless otherwise ordered. Frequency reductions are indicated for stable, long-stay patients.

Blood gases are repeated within one hour of a ventilator change for acute admissions or unstable patients and to evaluate respiratory status following spontaneous breathing trials.

If changes are made to the FiO2 or PEEP to correct a low PaO2, gases do not need to be repeated if the SpO2 demonstrates an appropriate response. SpO2 may not be reliable in the presence of carbon monoxide or poor peripheral circulation.

When patients are switched from full ventilation to PS mode, blood gas evaluation is not required if the patient remains comfortable, RR is WNL, and the minute volume remains unchanged. Repeat gases If signs of respiratory distress develops.

PRN blood gases are repeated for evidence of respiratory distress, to evaluate or monitor acid-base disturbances (e.g., increased or low bicarbonate on electrolyte panel, elevated lactate, renal or hepatic failure, DKA), to assess hemodynamic instability or identify causes for new arrhythmias. Documentation in the AI record.

 4.

Blood gases are indicated to identify acid-base disturbances due to respiratory or metabolic problems. Oxygen saturation monitoring indicates oxygenation status but does not provide information regarding the adequacy of ventilation.

 5.

Provide Emergency Equipment

Each bedside will have a manual resuscitation bag connected to oxygen and a ventilation mask. If PEEP > 5, PEEP is added to the resuscitation bag.

An intubation box is kept in each Bay.

 5.

To respond to a loss of mechanical ventilation or spontaneous extubation. To protect against loss of PEEP.

Maintain Positioning

All intubated patients will be nursed with the head of bed elevated > 30 degrees unless contraindicated. The bed position will be documented in degrees in the graphic record each hour. If the HOB is not elevated > 30 degrees, the rationale is documented in the AI record.

HOB elevation reduces the risk for aspiration and VAP, especially among patients being enterally fed.

 7.

Suction as Required

Appropriate PPE is required when suctioning please refer to:

LHSC interprofessional suctioning guidelines.

LHSC Hand Hygiene Policy

LHSC Routine Practices Policy

LHSC Donning and Doffing Policy

Suctioning is done prn. Patients on neuromuscular blocking agents or who are paralyzed are suctioned twice per shift and prn with an assisted cough technique. A closed-system in-line technique is used.

Suctioning catheters are rinsed with sterile saline following each suctioning episode.

Suctioning efforts are documented in the graphic record. Findings not WNL are documented in AI record.

 7.

Suctioning is only done when indicated to reduce unnecessary airway trauma and patient discomfort. Patients with paralyzed diaphragms are more difficult to assess and often have secretions not detected audibly due to impaired cough. Assisted cough technique facilitates clearance in the absence of a cough.

 8.

Change Chest Tube Dressings

Chest tube dressings are changed q 2 days and prn. Ensure appropriate PPE is utilized when performing chest tube dressings (hand hygiene and non-sterile gloves).

LHSC Hand Hygiene Policy

LHSC Routine Practices Policy

LHSC Donning and Doffing Policy

Dressing changes are documented in the graphic record. Findings not WNL are documented in AI record.

 8.

9.

Maintain Chest Drainage Systems

At the start of each shift and prn, the underwater seal level and suction level is confirmed and evaluated for fluctuation and air leak and charted on the intake and output record. Abnormal findings are documented in the AI record.

Chest drainage is assessed hourly and documented in the AI record q1 - 4 h in the intake and output record.

9.

To ensure adequate underwater seal and suction and to evaluate therapy.