Monitoring Fungsi Pernafasan dan Perawatan Pasien dengan Ventilator
Komponen observasi pernapasan meliputi :
•Rate
•Pola napas
•Fungsi Paru
•Kondisi Kulit Pasien : cyanosis, pucat, capillary refill time
Volume & Kapasitas Paru
vENtiLAtor
•Adalah alat pernafasan tekanan negatip atau positip yang dalam mempertahankan ventilasi dan pemberian oksigen pada periode waktu yang panjang.
Indikasi
•PaO2 < 50 mm Hg dengan FiO2 > 0.60
•PaO2 > 50 mm Hg dengan pH < 7.25
•Vital capacity < 2 kali tidal volume
•Negative inspiratory force < 25 cm H2O
•Respiratory rate > 35/min
Klasifikasi ventilator
•Dua kategori umum :
1) negative-pressure
2) positive-pressure ventilators.
Negative-Pressure Ventilators
•Memberikan tekanan negatif diluar dada
•Simpel dapat digunakan di rumah
•Tidak tepat untuk pasien yang mengalami perubahan cepat status pernafasan.
Positive-Pressure Ventilators
•Memberi takanan positip kepada alveoli
•Ada 3 tipe :
1) pressure-cycled,
2) time-cycled, and
&nbrp; 3) volume-cycled.
Pressure-cycled ventilators
•Memberikan tekanan sampai tekanan yang ditetapkan tercapai.
•Kelemahan : keterbatasan vlume gas dan tekanan / compliance paru yang berbeda dapat mengakibatkan tidal volume yang tidak konsisten.
Time-cycled ventilators
-Mengakhiri atau mengontrol inspirasi setelah waktu yang ditetapkan
-Volume udara yang diterima pasien diatur penjangnya inspirasi dan rata-rata aliran udaranya
-Ventilator ini digunakan untuk newborn dan bayi : dewasa jarang menggunakan time cycled.
Volume-cycled ventilators
•Paling banyak digunakan.
Noninvasive positive-pressure ventilation
•Dapat diberikan melalui masker wajah yang membungkus hidung dan mulut, masker nasal, atau peralatan nasal lainnya. --> mengurangi kebutuhan intubasi endotrakeal dan trakeostomi
•Dapat diatur pada pasien dengan backup rate minimum dengan periode apnea.
-Digunakan untuk kegagalan nafas akut maupun kronis, edema pulmonal, COPD, atau kegagalan jantung kronis dengan gangguan nafas saat tidur.
-Kontra indikasi untuk pasien dengan riwayat henti nafas, disrithmia serius, gangguan coqnitif, trauma wajah atau kepala.
-Dapat untuk pasien terminal dimana tidak ingin dipasang endotrakeal tube.tetapi memerlukan dukungan ventilator jangka pendek atau lama.
Mode-Mode Ventilator :
Mode Controlled Ventilation :
•Aliran udara dikontrol ventilator. Volume udara yang telah disiapkan dihembuskan dengan tekanan positip. Usaha napas pasien dikunci.
Mode Assist-Control Ventilation
•Volume gas yang diatur dengan rate, pasien mungkin ada usaha inspirasi negatif
Mode Synchronized Intermittent Mandatory Ventilation (SIMV)
•Jumlah nafas yang diatur mesin disinkronkan dengan napas pasien, ada saat pasien melakukan inspirasi spontan pada berbagai volume.
Mode Positive end Expiratory Pressure (PEEP)
•Pada akhir ekspirasi, udara tidak dibiarkan kembali ke nol --> FRC ditingkatkan.
Mode Continuous Positive Airway Pressure (CPAP)
Ket gambar-gambar sbb :
•CPAP Digunakan hanya untuk ventilasi spontan : pasien napas spontan lewat ventilator dan tekanan dinaikkan pada seluruh siklus pernafasan.
Mode Pressure Support Ventilation (PSV)
•Pasien napas spontan, mesin memberi bantuan tekanan pada setiap inspirasi spontan
Proportional Assist Ventilation (PAV),
•Mode relatif baru ;--> Ventilator memberikan dukungan dengan tekanan yang proporsional sesuai dengan usaha inspirasi pasien.
•Setiap napas pasien, ventilator disesuaikan dengan napas pasien.
•Lebih mengadakan tekanan inspirasi, menguatkan usaha inspirasi pasien tanpa target tekanan atau volumenya.
•Secara umum adalah : menambah otot tambahan pernafasan; kedalaman dan frekuensi napas diatur oleh pasien.
Saat memonitor pasien dengan ventilator, perawat harus mencatat / memperhatikan sbb :
• Tipe ventilator (volume, pressure, atau negative pressure)
• Mode ventilator
• Seting Tidal Volume dan Rate (Tidal volume biasanya 10 – 15 ml/KgBB, Rate biasanya 12 – 16 X /mnt
• Setting FiO2 (fraksi oksigen yang diinspirasi)
meMULAI vENTILASI :
•Setel mesin memberi tidal volume 10 – 15 ml / Kg BB
•Atur pemberian oksigen paling rendah untuk mempertahankan PaO2 (80 – 100 mmHg). Mungkin pemberian dapat tinggi sesuai yang dibutuhkan, lalu diturunkan sesuai perbaikan kondisi gas darah.
•Catat Peak Inspiratory Pressure
•Setel mode dan rate sesuai pesan-pesan medis. Set PEEP dan pressure Support sesuai order.
•Atur sensitifitas sehingga pasien dapat memicu ventilator dengan usaha minimal (biasanya 2 mmHg negative inspiratory force)
•Catat minute volume dan ukur PaCO2, pH, dan PaO2 setelah 20 menit dari mulai dipasang ventilator.
•Setel FiO2 dan Rate sesuai hasil analisa gas darah atau sesuai pesan-pesan dokter.
•Bila pasien tiba-tiba bingung, gelisah, mulai melawan ventilator, kaji tanda hipoksia, dan mulai ventilasi memakai resuscitation bag dengan oksigen 100%
glOSARy
•Assist-control mode
ventilator memberikan rata-rata yang telah ditetapkan ; pasien dapat memulai napas-napas tambahan, yang dapat memicu ventilator memberikan tidak volume yang ditetapkan pada tekanan positip
.
•Continuous positive airway pressure (CPAP)
Seting ventilator dimana ventilator memberikan tekanan positip di seluruh siklus pernafasan (inspirasi maupun ekspirasi). Mode CPAP ini hanya bekerja pada pasien yang mampu bernafas spontan.
•Control mode
Ventilator memberikan tidal volume yang ditetapkan pada rata-rata yang ditetapkan pula,meskipun pasien juga bernapas spontan.
•Fraction of inspired oxygen (FIO2)
Adalah jumlah oksigen yang diberikan kepada pasien oleh ventilator. Satuannya adalah persen (%) maksudnya adalah konsentrasi oksigen yang diberikan.
•Inspiratory-expiratory (I:E)
Adalah perbandingan lama lama inspirasidan lama ekspirasi.Rasio pernafasan spontan normal I : E adalah 1 : 2, artinya 1 kali lama inspirasi sepanjang 2 kali ekspirasi.
•Inspiratory flow rate (IFR)
Menunjukkan tidak volume yang diberikan dalam waktu tertentu : nilainya sekitar 20 - 120 L /mnt.
•Minute ventilation or minute volume (VE)
Hasil perkalian dari rata-rata respirasi dan tidal volume.
•Peak inspiratory pressure (PIP)
Diukur dengan manometer tekanan pada ventilator, menyatakan jumlah tekanan yang dibutuhkan untuk memberikan tidal volume yang disetel.
•Positive end-expiratory pressure (PEEP)
Pada mode ini ventilator dipicu untuk melakukan tekanan positip pada akhir setiap ekspirasi untuk meningkatkan area pertukaran oksigen dengan menolong meniup dan menjaga alveoli yang kolaps terbuka.
•Pressure support ventilation (PSV)
Pada mode ini membuat ventilator melakukan jumlah tekanan positip yang disetel saat pasien melakukan ispirasi spontan. PSV meningkatkan tidal volume.
•Respiratory rate = frekuensi
Jumlah napas per menit
•Sensitivity setting
setting yang menentukan jumlah usaha pasien yang harus dikeluarkan untuk memicu siklus inspirasi ventilator.
•Sigh volume
Napas yang diberikan ventilator sebesar 1 ½ kali besar jumlah tidal volume pasien.
•Synchronized intermittent mandatory ventilation (SIMV)
Ventilator memberikan jumlah napas pada tidal volume yang spesifik yang telah disetel. Pasien dapat memberikan napasnya sendiri, yang mana tidal volume dan rate ditentukan oleh kemampuan inspirasi pasien sendiri.
•Tidal volume (VT)
Menyatakan volume udara yang diberikan kepada pasien pada setiap siklus (inspirasi dan ekspirasi), biasanya 12 - 15 cc / Kg BB
• Inspiratory pressure reached and pressure limit (normal is 15 to 20 cm H2O; this increases if there is increased airway resistance or decreased compliance)
• Sensitivity (a 2-cm H2O inspiratory force should trigger the ventilator)
• Inspiratory-to-expiratory ratio (usually 13 [1 second of inspiration to 3 seconds of expiration] or 12)
• Minute volume (tidal volume × respiratory rate, usually 6 to 8 L/min)
• Sigh settings (usually 1.5 times the tidal volume and ranging from 1 to 3 per hour), if applicable
• Water in the tubing, disconnection or kinking of the tubing
• Humidification (humidifier filled with water) and temperature
• Alarms (turned on and functioning properly)
• PEEP and/or pressure support level, if applicable. PEEP is usually 5 to 15 cm H2O
Problem saat ventilasi :
•Dapat berasal dari pasien
•Dapat pula berasal dari mesin.
Pasien melawan ventilator
•Penyebab :
anxiety, hypoxia, increased secretions,hypercapnia, inadequate minute volume, and pulmonary edema.
•Intervensi
Muscle relaxants, tranquilizers, analgesic agents, and paralyzing
•Low-pressure alarm
Posible Cause :
Tube disconnected from ventilator
Endotracheal (ET) tube displaced above vocal cords or tracheostomy tube extubated
Leaking tidal volume from low cuff pressure (from an underinflated or ruptured cuff or a leak in the cuff or one-way valve)
Ventilator malfunction
Leak in ventilator circuitry (from loose connection or hole in tubing, loss of temperature-sensitive device, or cracked humidification jar)
• High-pressure alarm
Posible Cause :
Increased airway pressure or decreased lung compliance caused by worsening disease
Patient biting on oral ET tube
Secretions in airway
Condensate in large-bore tubing
Intubation of right mainstem bronchus
Patient coughing, gagging, or attempting to talk
Chest wall resistance
Failure of high-pressure relief valve
Bronchospasm
NURSING PROCES
•Pengkajian
Patient’s physiologic status and how he or she is coping with mechanical ventilation.
Systematic assessment of all body systems, with an in-depth focus on the respiratory system.
Respiratory assessment includes vital signs, respiratory rate and pattern, breath sounds, evaluation of spontaneous ventilatory effort, and potential evidence of hypoxia. Increased adventitious breath sounds may indicate a need for suctioning.
The nurse also evaluates the settings and functioning of the mechanical ventilator as described previously.
Assessment also addresses the patient’s neurologic status and effectiveness of coping with the need for assisted ventilation and the changes that accompany it.
The nurse should assess the patient’s comfort level and ability to communicate as well.
Finally, weaning from mechanical ventilation requires adequate nutrition.
Therefore, it is important to assess the function of the gastrointestinal
System and nutritional status.
Diagnosa keperawatan
•Impaired gas exchange related to underlying illness, or ventilator setting adjustment during stabilization or weaning.
•Ineffective airway clearance related to increased mucus production associated with continuous positive-pressure mechanical ventilation
•Risk for trauma and infection related to endotracheal intubation or tracheostomy
•Impaired physical mobility related to ventilator dependency
•Impaired verbal communication related to endotracheal tube and attachment to ventilator
•Defensive coping and powerlessness related to ventilator dependency
Masalah Kolaboratif / Potensial Komplikasi :
•Alterations in cardiac function
•Barotrauma (trauma to the alveoli) and pneumothorax
•Pulmonary infection
•Sepsis
Intervensi 1 : Enhancing gas exchange
•administration of analgesic agents to relieve pain without suppressing the respiratory drive and
•Frequent repositioning to diminish the pulmonary effects of immobility.
•Monitors for adequate liquid balance by assessing for the presence of peripheral edema, calculating daily intake and output, and monitoring daily weights.
•Administers medications prescribed to control the primary disease and monitors for their side effects.
Intervensi 2 : Promoting effective airway clearance
•auscultation at least every 2 to 4 hours.
•suctioning, chest physiotherapy, frequent position changes,and increased mobility as soon as possible.
•Frequency of suctioning should be determined by patient assessment.
•The sigh mechanism on the ventilator may be adjusted to deliver at least one to three sighs per hour at 1.5 times the tidal volume if the patient is on assist–control.
•Periodic sighing prevents atelectasis and the further retention of secretions.
•Humidification of the airway via the ventilator is maintained to help liquefy secretions so they are more easily removed.
•Adrenergic bronchodilators --> simpatomimetik
•Medications include albuterol (Proventil, Ventolin), isoetharine (Bronkosol), isoproterenol dan lain-lain -->Tachycardia, heart palpitations, and tremors
•Anticholinergic bronchodilators such as ipratropium (Atrovent) and ipratropium with albuterol (Combivent) produce airway relaxation -->dizziness, nausea, decreased oxygen saturation, hypokalemia, increased heart rate, and urine retention.
•Mucolytic --> assessment for an adequate cough re.ex, sputum characteristics, and improvement in incentive spirometry --> Side effects include nausea, vomiting, bronchospasm, stomatitis (oral ulcers), urticaria, and runny nose
Intervensi 3 : Preventing trauma and infection
•Airway management must involve maintaining the endotracheal or tracheostomy tube. The nurse positions the ventilator tubing so that there is minimal pulling or distortion of the tube in the trachea; this reduces the risk of trauma to the trachea.
•Cuff pressure is monitored every 8 hours to maintain the pressure at less than 25 cm H2O.
•The nurse evaluates for the presence of a cuff leak at the same time.
•Tracheostomy care is performed at least every 8 hours, and more frequently if needed,because of the increased risk of infection.
•The ventilator circuit and in-line suction tubing is replaced periodically, according to infection control guidelines, to decrease the risk of infection.
•The nurse administers oral hygiene frequently because the oral cavity is a primary source of contamination of the lungs in the intubated and compromised patient.
•The nurse positions the patient with the head elevated above the stomach as much as possible.
•Antiulcer medications such as sucralfate (Carafate) are given to maintain normal gastric pH; research has demonstrated a lower incidence of aspiration pneumonia when sucralfate is administered (Scanlan, Wilkins & Stoller, 1999).
Intervensi4 : Promoting optimal level of mobility
•The nurse should assist a patient whose condition has become stable to get out of bed and to a chair as soon as possible. Mobility and muscle activity are beneficial because they stimulate respirations and improve morale.
•If the patient cannot get out of bed, the nurse encourages the patient to perform active range-of-motion exercises every 6 to 8 hours.
•If the patient cannot perform these exercises, the nurse performs passive range-ofmotion exercises every 8 hours to prevent contractures and venous stasis.
Intervensi 5 :Promoting optimal communication
•It is important to develop alternative methods of communication for the patient on a ventilator.
•Questions to consider when assessing the ventilator-dependent patient’s ability to communicate include the following:
1) Is the patient conscious and able to communicate?
2) Can the patient nod or shake the head?
3) Is the patient’s mouth unobstructed by the tube so that words can be mouthed?
4) Is the patient’s hand strong and available for writing? (For example, if the patient is right-handed, the intravenous line is placed in the left arm if possible so that the right hand is free.)
•offers several appropriate communication approaches: lip reading (use single key words), pad and pencil or Magic Slate, communication board, gesturing, or electric larynx.
•Use of a “talking” or fenestrated tracheostomy tube may be suggested to the physician; this allows the patient to talk while on the ventilator. If indicated, the nurse should make sure that the patient’s eyeglasses and hearing aid and a translator are available to enhance the patient’s ability to communicate.
•The patient must be assisted to find the most suitable communication method. Some methods may be frustrating to the patient,family, and nurse; these need to be identified and minimized.
•A speech therapist can assist in determining the most appropriate method.
Intervensi 6 : Promoting coping ability
•Encouraging the family to verbalize their feelings about the ventilator, the patient’s condition, and the environment in general is beneficial.
•Explaining procedures every time they are performed helps to reduceanxiety and familiarizes the patient with ventilator procedures.
•To restore a sense of control, the nurse encourages the patient to participate in decisions about care, schedules, and treatment when possible.
•The patient may become withdrawn or depressed while on mechanical ventilation, especially if its use is prolonged.
•To promote effective coping, the nurse informs the patient about progress when appropriate. It is important to provide diversions such as watching television, playing music, or taking a walk (if appropriate and possible).
•Stress reduction techniques (eg, a backrub, relaxation measures) help relieve tension and help the patient to deal with anxieties and fears about both the condition and the dependence on the ventilator.
Intervensi7 : Monitoring and managing potential complications
Alterations in Cardiac Function :
•The positive intrathoracic pressure during inspiration compresses the heart and great vessels, thereby reducing venous return and cardiac output. This is usually corrected during exhalation when the positive pressure is off.
•Patients may have decreased cardiac output and resultant decreased tissue perfusion and oxygenation.
•To evaluate cardiac function, the nurse first looks for signs and symptoms of hypoxia (restlessness, apprehension, confusion, tachycardia, tachypnea, labored breathing, pallor progressing to cyanosis, diaphoresis, transient hypertension, and decreased urine output).
•If a pulmonary artery catheter is in place, cardiac output,cardiac index, and other hemodynamic values can be used toassess the patient’s status.
Barotrauma and Pneumothorax :
•Excessive positive pressure may cause barotrauma, which results in a spontaneous pneumothorax. This may quickly develop into a tension pneumothorax, further compromising venous return,cardiac output, and blood pressure.
•The nurse should consider any sudden onset of changes in oxygen saturation or respiratory distress to be a life-threatening emergency requiring immediate action.
Pulmonary Infection :
•The patient is at high risk for infection, as described above. The nurse should report fever or a change in the color or odor of sputum to the physician for follow-up.
Expected patient outcomes / Kriterian Hasil :
1. Exhibits adequate gas exchange, as evidenced by normalbreath sounds, acceptable arterial blood gas levels, and vitalsigns
2. Demonstrates adequate ventilation with minimal mucusaccumulation
3. Is free of injury or infection, as evidenced by normal temperatureand white blood count
4. Is mobile within limits of abilitya.
a. Gets out of bed to chair, be`rs weight, or ambulates as soon as possible
b. Performs range-of-motion exercises every 6 to 8 hours
5. Communicates effectively through written messages, gestures, or other communication strategies
6. Copes effectively
a. Verbalizes fears and concerns about condition andequipment
b. Participates in decision making when possible
c. Uses stress reduction techniques when necessarx
7. Absence of complications
a. Absence of cardiac compromise, as evidenced by stable vital signs and adequate urine output
b. Absence of pneumothorax, as evidenced by bilateral chest excursion, normal chest x-ray, and adequate oxygenation
c. Absence of pulmonary infection, as evidenced by normal temperature, clear pulmonary secretions, and negative sputum cultures
Weaning (penyapihan) the patient from the ventilator :
Respiratory weaning, the process of withdrawing the patient from dependence on the ventilator, takes place in three stages: thepatient is gradually removed from the ventilator, then from the tube, and finally from oxygen.
Is performed at the earliest possible time consistent with patient safety.
The decision must be made from a physiologic rather than from a mechanical viewpoint. A thorough understanding of the patient’s clinical status is required in making this decision.
Weaning is started when the patient is recovering from the acute stage of medical and surgical problems and when the cause of respiratory failure is sufficiently reversed.
Successful weaning involves collaboration among the physician, respiratory therapist, and nurse. Each health care provider must understand the scope and function of other team members in relation to patient weaning to conserve the patient’s strength,use resources ef.ciently, and maximize successful outcomes.
Kriteria Weaning / penyapihan :
Vital capacity: the amount of air expired after maximum inspiration.Used to assess the patient’s ability to take deep breaths. Vital capacity should be 10 to 15 mL/kg to meet
Maximum inspiratory pressure (MIP): used to assess the patient’s respiratory muscle strength. It is also known as negative inspiratory pressure and should be at least -20 cm H2O.
Tidal volume: volume of air that is inhaled or exhaled from the lungs during an effortless breath. It is normally 7 to 9 mL/kg.
Minute ventilation: equal to the respiratory rate multiplied by tidal volume. Normal is about 6 L/min.
Rapid/shallow breathing index: used to assess the breathing pattern and is calculated by dividing the respiratory rate by tidal volume. Patients with indices below 100 breaths/min/Lare more likely to be successful at weaning.
Other measurements used to assess readiness for weaning include a PaO2 of greater than 60 mm Hg with an FiO2 of less than 40%.
Stable vital signs and arterial blood gases are also important predictors of successful weaning.
Once readiness has been determined, the nurse records baseline measurements of weaning indices to monitor progress (Cull & Inwood, 1999).
Gambar-gambar lain :
Spirometer :
Alat Fibrasi dada :
Fisioterapi & Vibrasi
A = clapping (fisioterapi dada)
B & C = vibrasi dada
Awas Posisi Trendelenburg dapat meningkatkan tekan intratoraks --> mengganggu Cardiac output (kontraindikasi untuk gangguan jantung dan peningkatan ICP)
Terimakasih.
Sumber :
•Brunner & Suddart. 2003,2006. Medical Surgical Nursing.
•Lippincot Manual of Nursing practice 8`ed. 2006
