A mechanical ventilator moves air in and out of a patient’s lungs. Although the equipment ventilates a patient, it doesn’t ensure adequate gas exchange. Mechanical ventilation may use either positive or negative pressure to ventilate a patient.
Positive-pressure ventilators exert a positive pressure on the airway, which causes inspiration while increasing tidal volume. The inspiratory cycles of these ventilators may vary in volume, pressure, or time. A high-frequency ventilator uses high respiratory rates and low tidal volume to maintain alveolar ventilation.
Negative-pressure ventilators create negative pressure, which pulls the thorax outward and allows air to flow into the lungs. Examples of such ventilators are the iron lung, the cuirass (chest shell), and the body wrap. Negative-pressure ventilators are mainly used to treat neuro-muscular disorders, such as Guillain-Barré syndrome, myasthenia gravis, and poliomyelitis.
Other indications for ventilator use include central nervous system disorders, such as cerebral hemorrhage and spinal cord transection; acute respiratory distress syndrome; pulmonary edema; chronic obstructive pulmonary disease; flail chest, and acute hypoventilation.
Essential Documentation
The nurse should document the date and time that mechanical ventilation began. Note the type of ventilator used as well as its settings, such as ventilatory mode, tidal volume, rate, fraction of inspired oxygen, positive end-expiratory pressure (PEEP), and peak inspiratory flow. Record the size of the endotracheal (ET) tube, centimeter mark of the ET tube, and cuff pressure or if the patient has a tracheostomy. Describe the patient’s subjective and objective responses to mechanical ventilation, including vital signs, pulse oximetry reading, arterial blood gas (ABG) results, breath sounds, use of accessory muscles, comfort level, and physical appearance.
Throughout mechanical ventilation, list any complications and subsequent interventions. Record pertinent laboratory data, including ABG analyses and oxygen saturation findings. Also record tracheal suctioning and the character of secretions.
If the patient is receiving pressure-support ventilation or is using a T-piece or tracheostomy collar, note the duration of spontaneous breathing and the patient’s ability to maintain the weaning schedule. If the patient is receiving intermittent mandatory ventilation, with or without pressure-support ventilation, record the control breath rate, the time of each breath reduction, and the rate of spontaneous respirations.
Record adjustments made in ventilator settings as a result of ABG levels, and document adjustments of ventilator components, such as changing, cleaning, or discarding the tubing. Also, record teaching efforts and emotional support given.
Mechanical Ventilation
3/16/2019
1015
NURSING ASSESSMENT: Pt. on Servo ventilator set at TV 750, Fio2 45%, 5 cm PEEP, AC 12. RR 20 and nonlabored; no SOB noted. #8 ETT in right corner of mouth taped securely at 22-cm mark. ____________________
NURSING INTERVENTION: Suctioned via ETT for large amt. of thick white secretions. ____________________________________________
NURSING ASSESSMENT: Pulse oximetry reading 98%. Left lung clear. Right lung with basilar crackles and expiratory wheezes. _________
NURSING INTERVENTION: Dr. M. Short notified at 1000; no treatment at this time. _________________________________________________
PATIENT TEACHING: Explained all procedures including suctioning to pt. Pt. nodded head “yes” when asked if he understood explanations. ______________________________________ Janice Del Vecchia, RN
MEDICAL ADVICE, PATIENT OR FAMILY REQUEST FOR
A patient or family member may seek the nurse’s advice about a particular treatment the patient is receiving. The nurse should be careful to provide objective information and not advice about the treatment. Giving medical advice can be looked upon as providing medical treatment without a license and could subject the nurse to legal concerns. Instead of offering advice, offer rationales for the treatment rather than recommending alternative treatment options or comparing one treatment to another.
Evaluate what patients know and understand about their treatment and what they understand about what the health care provider has told them about their treatment. Then, explain how the treatment works to alleviate or cure the patient’s condition. Suggest that the patient should speak to his or her health care provider if the patient still does not understand the explanation or has questions or doubts. Inform the health care provider of the patient’s or family member’s concerns and the information or teaching that has been provided, and suggest that the health care provider speak to the patient or family member.
If the patient or family member is asking for the nurse’s opinion about the abilities of a particular health care provider, the nurse must be careful to avoid negative comments because he or she could be charged with defamation of character. Ask if a friend or family member has had previous experience with the health care provider. If the patient or family member is questioning the care that the patient is receiving, the nurse can suggest that the patient seek a second opinion. In fact, most health care providers will suggest that the patient should ask for a second opinion before treatment is performed. If the patient or family member is asking about the skill of the health care provider, the nurse should ask what concerns are causing these questions to identify any underlying issues.
Essential Documentation
The nurse’s progress notes should document the patient’s or family member’s questions or concerns as well as the response provided. The nurse should also document any teaching that was provided and the response to that teaching. If the nurse told the patient or family member that the nurse would speak to the health care provider document when the health care provider was called and whom the nurse spoke to.
Patient or Family Request for Medical Advice
4/29/2019
0045
PATIENT TEACHING: Called to pt.’s room because pt. says he’s worried about his medications. Pt. asked me if I thought the doctor prescribed the correct medications for his condition. He states that his brother had the “same thing” and he was on a different heart medication and feels wonderful now. I explained the purpose of lisinopril and metoprolol to pt. Pt. verbalized his understanding of his medications and their purpose but still had questions as to why his doctor chose these medications and not the ones his brother is on. I suggested he clarify his medications with his doctor. _________________________
NURSING INTERVENTION: Told pt. I would leave a message for Dr. C. Ward to speak to him. _________________________________________________________________________________ Callie Burns, RN
4/29/2019
0630
NURSING INTERVENTION: Reported to morning shift nurse Jill Spillane, RN, that pt. has a concern about his cardiac medications and that they’re not the same as his brother takes for his heart condition. Pt. still wishes to speak to Dr. Ward. Jill Spillane states she would contact Dr. Ward’s nurse, Barb Lawson, who accompanies him on morning rounds, that the patient wishes to discuss his medications with him. ___________________________________________ Callie Burns, RN
MEDICATION ERROR
Medication errors are the most common, and potentially the most dangerous, errors. Mistakes in dosage, patient identification, or drug selection by nurses have led to vision loss, brain damage, cardiac arrest, and death. (See Lawsuits and medication errors, page 246.)
LEGAL CASEBOOK
LAWSUITS AND MEDICATION ERRORS
Unfortunately, lawsuits involving nurses’ drug errors are common. The court determines liability based on the standards of care required of nurses who administer drugs. In many instances, if the nurse had known more about the proper dosage, administration route, or procedure connected with a drug’s use, the nurse might have avoided the mistake.
In Norton v. Argonaut Insurance Co. (1962), an infant died after a nurse administered injectable digoxin at a dosage level appropriate for an elixir of Lanoxin, an oral drug. The nurse was unaware that digoxin was available in an oral form. The nurse questioned two health care providers who were not treating the infant about the order but failed to mention to them that the order was written for elixir of Lanoxin. She also failed to clarify the order with the health care provider who wrote it.
The nurse, the health care provider who ordered the drug, and the hospital were found liable.
ACCUCHART
MEDICATION EVENT QUALITY REVIEW FORM
When a medication error occurs, most facilities require the nurse to complete a medication event report. The information is used to investigate the incident and develop an action plan to avoid future incidents.
A medication event report or incident report should be completed when a medication error is discovered. The nurse who discovers the medication error is responsible for completing the medication error report or incident report and for communicating the error to the patient’s health care provider and the nursing practitioner. It is essential for the nurse to be aware of the agency’s policy and procedure for medication error reporting.
Essential Documentation
The nurse’s note should describe the situation objectively and include the name of the health care provider notified, the time of notification, and the provider’s response. Avoid the use of such terms as “by mistake,” “somehow,” “unintentionally,” “miscalculated,” and “confusing,” which can be interpreted as admissions of wrongdoing. Document the medication error on an incident report or medication event report. (See Medication event quality review form, pages 247 and 248.)
MEDICATIONS, RECONCILING
Reconciling medications is a process that develops an accurate, up-to-date medication list for patients at admission and then compares that list against the health care provider’s admission orders. Any discrepancies in the patient’s medications will be brought to the attention of the health care provider, and changes will be made to the orders as necessary. The process is designed to promote communication and information transfer during patient transfer and prevent errors, such as omissions, duplications, dosing errors, or drug interactions.
Only gold members can continue reading. Log In or Register to continue
LEGAL CASEBOOK
ACCUCHART
