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EFFECTIVENESS OF STRUCTURED TEACHING PROGRAM FOR NURSES ON CARE OF PATIENTS WITH VENTILATOR AND THE
OUTCOME OF VENTILATOR CARE IN THE SELECTED HOSPITALS AT NELLORE, ANDRA PRADESH.
Thesis submitted in Partial fulfillment for the award of Degree of Doctor of Philosophy in Nursing
By
Ms. A. INDIRA
VINAYAKA MISSIONS UNIVERSITY,
SALEM, TAMILNADU, INDIA
June – 2012
CERTIFICATE BY THE GUIDE
I, Dr. ESTHER SIRRA, certify that the thesis entitled Effectiveness of
Structured Teaching Program for Nurses on Care of Patients with
Ventilator and the Outcome of Ventilator Care in the Selected Hospitals
at Nellore, Andhra Pradesh, submitted for the Degree of Doctor of
Philosophy in Nursing by Ms. INDIRA. A, is the record of research work
carried out by her during the period from January 2005 to June 2012, under
my guidance and supervision and that this work has not formed the basis for
the award of any degree, diploma, associate ship, fellowship or other titles in
this university or any other university or Institution of higher learning.
Place: Signature of the Supervisor
Date: Designation:
TABLE OF CONTENTS
Chapter No.
Content Page No
1
1.1
1.2
1.3
1.4
1.5
INTRODUCTION
Need for the study
Statement of the problem
Operational definitions
Objectives & Hypothesis
Delimitations
3
6
9
9
10-11
11
2
2.1
2.2
REVIEW OF LITERATURE
Studies related to the knowledge, practice and
outcome of care of the patients with ventilator.
Conceptual framework
12
13-59
60-62
3
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
3.9
METHODOLOGY
Research approach
Research design
Setting of the study
Population
Sample
Sampling technique
Sample size
Criteria for sample selection
Inclusion criteria
63
63
63
64
65
65
65
66
66
66
3.10
3.11
3.12
3.13
3.14
3.15
3.16
Exclusion criteria
Variables of the study
Content validity & Reliability
Ethical Consideration
Description of the tool
Pilot study
Data collection procedure
66
67
67
67
68
70
71
4 DATA ANALYSIS AND INTERPRETATIONS 72-120
5 DISCUSSION 121-128
6
6.1
6.2
6.3
6.4
6.5
6.6
6.7
6.8
6.9
SUMMARY, RECOMMENDATIONS AND
IMPLICATIONS
Summary of the study
Implications of the study
Nursing Practice
Nursing Education
Nursing Administration
Nursing Research
Limitations
Recommendations
BIBLIOGRAPHY
ANNEXURES
129
129
131
132
132
133
133
133
133
133
134-144
LIST OF TABLES
Table Title Page No
1 1.a. Frequency and percentage distribution of age 74
1.b. Frequency and percentage distribution of sex 75
1.c. Frequency and percentage distribution of education 76
1.d. Frequency and percentage distribution of ward 77
1.e. Frequency and percentage distribution of experience 78
2
2.I. Comparison of pre test and post test level of knowledge in
experimental group and control group
79
2. II a. Comparison of pretest and post test level of oral
hygiene practice among experimental and control
group
81
2.II b. Comparison of pretest and post test level of tracheostomy
care practice among experimental and control group
83
2.II c. Comparision of pretest and post test level of endotracheal
tube suctioning practice among experimental and control
group
85
2.II d. Comparision of pretest and post test weaning
process practice
87
3
3.I Comparison of post test level of knowledge in
experimental and control group - independent “z” test
89
3.IIa. Comparision of post – test oral hygiene practice levels in
experimental and control group- independent “z” test
91
3.IIb. Comparision of post – test tracheostomy care practice
levels in experimental and control group - independent
“z” test
92
3.IIc. Comparision of post – test endotracheal tube
suctioning practice levels in experimental and control
group - independent “ z ” test
93
3.IId. Comparision of post – test weaning process practice
levels in experimental and control group - independent
“z” test
94
4 4.Ia. Correlation of post test knowledge and practice of oral
hygiene in experimental group
95
4.Ib. Correlation of post test knowledge and practice of
tracheostomy care in experimental group
96
4.Ic. Correlation of post test knowledge and practice of
endotracheal tube suctioning in experimental group
97
4.Id. Correlation of post test knowledge and practice of
weaning process practice in experimental group:
98
5 5.Ia. Association of pre test knowledge with demographic
variables in experimental group.
100
5.Ib. Association of pre test oral hygiene level with
demographic variables in experimental group.
101
5.Ic. Association of pre test tracheostomy care level with
demographic variables in experimental group.
102
5.Id. Association of pre test endotracheal tube suctioning level
with demographic variables in experimental group.
103
5.Ie. Association of pre test weaning process level with
demographic variables in experimental group.
104
5.IIa. Association of pre test knowledge level with demographic
variables in control group
105
5.IIb. Association of pre test practice of oral hygiene with
demographic variables in control group
106
5.IIc. Association of pre test practice of tracheostomy care with
demographic variables in control group
107
5.IId. Association of pre test practice of endotracheal tube suctioning with demographic variables in control group
108
5.IIe. Association of pre test practice of weaning process with
demographic variables in control group
109
5 5.If. Association of post test knowledge level with demographic
variables in experimental group
110
5.Ig. Association of post test practice of oral hygiene with
demographic variables in experimental group
111
5.Ih. Association of post test practice of tracheostomy care with
demographic variables in experimental group
112
5.Ii. Association of post test practice of endotracheal tube
suctioning with demographic variables in experimental group
113
5.Ij. Association of post test practice of weaning process with
demographic variables in experimental group
114
5.IIf. Association between pre and post test knowledge level with
demographic variables in control group
115
5.IIg. Association between post test practice of oral hygiene with
demographic variables in control group
116
5.IIh. Association between post test practice of tracheostomy care
with demographic variables in control group
117
5.IIi. Association between post test practice of endotracheal tube
suctioning with demographic variables in control group
118
5.IIj. Association between post test practice of weaning process
with demographic variables in control group
119
6 6.a. Pre and post test value of the outcome of the patient care
with mechanical ventilator
120
9
LIST OF FIGURES
Table Title Page No
01 Conceptual frame work based on modified general system
model Ludwig von Bertanlanffy (1968)
62
1 a. Frequency and percentage distribution of age 74
b. Frequency and percentage distribution of sex 75
c. Frequency and percentage distribution of education 76
d. Frequency and percentage distribution of ward 77
e. Frequency and percentage distribution of experience 78
2 i. Comparison of pretest and post test level of knowledge in
experimental group and control group
80
iia. Comparison of pretest and post test level of oral hygiene
practice among experimental and control group
82
iib. Comparison of pretest and post test level of tracheostomy
care practice among experimental and control group
84
iic. Comparison of pretest and post test level of endotracheal tube
suctioning practice among experimental and control group
86
iid. Comparison of pretest and post test weaning process
practice
88
10
VINAYAKA MISSIONS UNIVERSITY
VINAYAKA MISSIONS UNIVERSITY
DECLARATION
I, INDIRA. A, declare that the thesis entitled Effectiveness of Structured
Teaching Program for Nurses on Care of Patients with Ventilator and the
Outcome of Ventilator Care in the Selected Hospitals at Nellore, Andhra
Pradesh, submitted by me for the Degree of Doctor of Philosophy, is the record
of work carried out by me during the period January, 2005 to June, 2012, under
the guidance of Dr. Esther Sirra, Professor & Research guide, Mother
Vannani College of Nursing, Tadepalligudam and has not formed the basis for
the award of any degree, diploma, associate ship, fellowship or other titles in this
university or any other university or Institution of higher learning.
Place: Signature of the Candidate
Date:
11
Acknowledgements
I thank the almighty who gave strength to complete this PhD
programme.
I thank Dr. P. Narayana, Chairman, Narayana Group of Educational
Institutions who has contributed immensely to my personal and
professional career at Narayana Group of institutions.
I thank Dr. Shanmuga Sundaram, Chairman, Vinayaka Mission’s
University, who has given me this great and valuable elegant opportunity to
complete this program.
I am especially grateful to Dr. Esther Sirra, PhD, who has been my
research guide and provided impression and time to time guidance
throughout the study.
I take this opportunity to convey my gratitude to Dr. Rajendran,
Dean, Research, Vinayaka Missions, University, Salem for his great
valuable guidance and everlasting help to complete my work towards this
thesis for PhD program.
My sincere thanks go to my professional pioneers Dr. Sumathi
Kumaraswamy, PhD, Govt. College of Nursing, Madras Medical College,
Dr. Jayamohan Raj, PhD, Govt. College of Nursing, Madras Medical
College, Dr. Rajeswari Vaidhyanadhan, PhD, Govt. College of Nursing,
Madras Medical College and Dr. Mangala Gowri, PhD, Govt. College of
12
Nursing, Madras Medical College who helped me with the content validity
and reliability of the instrument for data collection.
My great thanks to Mr. J. Kishore, Office Manager, Narayana
College of Nursing who had helped me for typing, editing and completing
this thesis.
My thanks go to Ms. Lakshmi, PA, Narayana College of Nursing who
helped me with the work related to thesis.
I thank Mr. Nagendra Babu, Narayana College of Nursing who
helped for Printing, editing and statistics in this thesis.
I thank the Medical Superintendent, Nursing Superintendent and
other people in the Narayana Groups of Institutions.
I thank Dr. Sathish, Narayana Super Specialty Hospital, Nellore, who
evaluated my structured teaching programme.
I thank Dr. Subramanian, PhD, Statistician, who helped me in all the
statistical analysis and application of statistical methods in this thesis.
I thank Mr. Lakshman, Hardware Computer Operator, Narayana
College of Nursing, who helped me with printing and binding the thesis.
In my attempted measurements of the penetration depth from
pictures, diagrams, images to Conceptual framework, I thank Mr.
Nagarjuna, Computer Operator, Narayana College of Nursing.
I thank Mrs. S.Nasira, Coordinator of Narayana College of Nursing
who has helped me in the completion of thesis.
13
I thank Mr. Vasu, Photographer, Narayana College of Nursing, who
helped me in the art of photographic presentation.
I immensely thank all our nurses, who were my samples, with their
cooperation only, I could complete this work.
I am deeply grateful to my family members for their continuous
encouragement and support.
14
ABSTRACT
“A study to evaluate Effectiveness of structured teaching
programme for nurses on care of the patients with ventilator and the
outcome of ventilator care in the selected hospitals at Nellore, Andhra
Pradesh”.
INTRODUCTION:
According to Tripp reimer and Cohen (1990) there is no cure
without care. In medicine, mechanical ventilation is a method to assist
mechanically or replace the spontaneous breathing when patients cannot
breathe by themselves. The nurses are prime position in documenting the
respiratory status and maintaining breathing circulation, nutritional needs,
elimination needs, rest and sleep, active and passive exercise,
maintenance of skin care, total integrity function of body on total stay of
the patient in mechanical ventilator.
OBJECTIVES OF THE STUDY : 1. To assess the knowledge and practice
regarding ventilator care, to compare the pre and post test knowledge and
practice regarding ventilator care, to correlate the post test knowledge and
practice regarding ventilator care and to determine the association
between the knowledge and practice regarding ventilator care with their
selected demographic variables among the nurses working in the selected
hospitals at Nellore, A.P. 2.To find out the outcome of ventilator care in
selected hospitals at Nellore, A.P. The hypotheses tested are 1.The
knowledge and practice regarding ventilator care among the nurses will be
highly significant between pre and post test level. 2. The Structured
teaching programme will improve the knowledge and practice of nurses
regarding nursing care of the patients with ventilator. 3. There will be an
association between the knowledge, practice with selected demographic
variables among nurses working in selected hospitals. 4. The knowledge
15
and practice will have positive correlation on ventilator care among
nurses. 5. The outcome of ventilator care after structured teaching
programme will be highly significant. The Outcome of the patient care
showed that the skin integrity was maintained, no VAP, Tube patency was
maintained, and infection rate was reduced to 50% and hospital stay was
reduced to 40% in comparing with pretest. In pre test experimental group
out of 250 nurses, 60.8% had inadequate 38.4% had moderately
adequate and 0.8% had adequate knowledge. In pre test control group
57.6% had inadequate, 42.4% had moderately adequate knowledge. In
the post test experimental group nobody had inadequate knowledge,
19.2% had moderately adequate 80.8% had adequate knowledge. In the
Post test control group 57.6% had inadequate, 42.4% had moderately
adequate and nobody had adequate knowledge.
The knowledge and practice regarding ventilator care among the
nurses was highly significant with ‘Z’ value of 34.67 which was greater
than the Z-tab value. Regarding oral hygiene practice, 76.8% had good,
20% had average, and 3.2% had poor practice. It was highly significant
with ‘Z’ value of 635.6. Regarding tracheostomy care practice, the ‘Z’
value 42.098 which was significant. Comparision of endotracheal
suctioning practice the ‘Z’ value was significant (34.27). In weaning
practice, the ‘Z’ value 34.27 was significant. So all the hypotheses were
accepted. There was a significant difference between the knowledge,
practice with selected demographic variables like education, working area
and experience among nurses working in selected hospitals. The
knowledge and practice had positive correlation on ventilator care among
nurses.
It was understood that this structured teaching programme
regarding nursing care of the patient with mechanical ventilator had
increased the knowledge and practice of nurses and a positive outcome
was existed among patients.
16
CHAPTER - I
INTRODUCTION
1.1 Introduction
Mechanical pioneers have experimented with the idea of artificially
mimicking the respiratory function of the lungs to sustain human life.
Twenty eight centuries ago references to supportive ventilation appear in
the bible. In the history of mechanical ventilation, it was first introduced by
the ‘VESALIUS’, by inserting a reed or cane into the trachea of animals
and then blowing into this tube. Sixteenth century Paracelsus placed a
tube in the mouth of a patient and used a fire place bellows to inflate the
lungs and assist his ventilation. In the late 1800”s the first successful use
of an endotracheal tube was reported. In 1908, GEORGE “POE”
demonstrated his mechanical respirator by asphyxiating dogs and
seemingly bringing them back to life. The Roman physician Galen may
have been first to describe mechanical ventilation. Modern mechanical
ventilation is a result of the popularity and technology of the iron lung
developed by Drake and Shaw in 1929. Mechanical ventilation has been
used to support the respiratory function of patients with various degrees of
respiratory distress or failure. Mechanical ventilation functions as a
substitute for the bellows action of the thoracic cage and diaphragm.
Patients who have weak or absence spontaneous respiratory efforts
usually require mechanical support to assist in ventilation and
oxygenation. The mechanical ventilation can maintain ventilation
automatically for prolonged periods. In medicine, mechanical ventilation is
17
a method to replace the spontaneous breathing when patients cannot do
so by themselves. In an emergency setting, it is typically administered
after invasive intubations, a procedure of tracheotomy tube is inserted into
the airway through which air is directly delivered. The iron lung used
primarily for polio victims, provided ventilator support without the use of Et
intubation or tracheotomy. The mechanical ventilators are developed as,
negative pressure ventilators, positive pressure ventilators and modular
concept ventilators. Current generations’ ventilators incorporate
computerized systems to deliver and monitor ventilator parameters. The
future we can expect high frequency oscillatory ventilators.
Coachman., (2007) formulated the care of the mechanically
ventilated patient. It is a fundamental component of a nurse’s clinical
practice in the Intensive Care Unit. Published work relating to the
numerous nursing issues of the care of the mechanically ventilated patient
in the Intensive Care Unit is growing significantly, yet is fragmentary by
nature. The purpose of this study is to provide a single comprehensive
examination of the evidence related to the care of the mechanically
ventilated patient. The evidence on nursing care of the mechanically
ventilated patient was explored with specific focus on patient safety.
Study, part two, examine the evidence related to the mechanically
ventilated patient’s comfort: patient position, hygiene, and management of
stressors (such as communication, sleep disturbance and isolation), pain
18
management and sedation which showed that the need of nursing care for
quality of service.
Mechanical ventilation is indicated when the patient’s
spontaneous ventilation is inadequate to maintain life as discussed earlier.
It is also indicated as prophylaxis for imminent collapse or ineffective gas
exchange in the lungs. Neurologic disease or trauma, drug over dose,
post cardiac or respiratory arrest and post operative aesthesia is
examples of patient conditions that may require ventilator support.
Because the ventilator care is an integral and vital part of life support in
the Intensive Care Unit, it is a vital role of the nurse to provide Holistic
care. When caring for a ventilated client, it must be concerned with the
client first and ventilator second. Nurses need to understand the clients’
chronic health problems, chronic obstructive pulmonary disease, left sided
heart failure, anemia and malnutrition. Three nursing goals in caring for
the client with mechanical ventilation are: 1. To monitor and evaluate the
response of the ventilator, 2. To manage the ventilator system safely and
3. To prevent complications. Another important aspect in ventilator care is
weaning. It is the process of moving from ventilator dependence to
spontaneous breathing. The need is increasing day by day for quality
service the nurses also should enhance their knowledge and practice in all
dimensions for caring the patient in mechanical ventilator.
19
1.1 Need For The Study:
Long term mechanical ventilation is associated with 47% in
hospital mortality and 35% of clients survive for one year. Many of the
survivors of long term mechanical ventilation have a need for continuous
care in an extended care facility, many reports a poor quality of life. 5% to
20% of the patients supported with mechanical ventilation in the Intensive
Care Unit will not wean in 2-4 days. 20% of patients are receiving
mechanical ventilation on day 1 of Intensive Care Unit admission.
Approximately 3-7% of patients are receiving mechanical ventilation at a
given time of a day. The nursing care is required of an extremely fragile
population. As the ventilator care was incorporated into clinical practice,
numerous primary nurses learned the idiosyncratic care needs of the
individual patients, but collective information has not existed.
Although mechanical ventilation can be lifesaving, it is associated
with numerous complications. Patients who are ventilated mechanically
are susceptible to infection, pneumothorax, gastrointestinal disturbances
and cardiovascular compromise related to increased thoracic pressure.
The patient receiving mechanical ventilation must be monitored carefully
for complications related to ventilation and the ventilator itself. The
weaning process will be prolonged if complications occur. Caring for
patient on a mechanical ventilator has become an integral part of nursing
care in critical care units, on general medical, surgical units, in extended
care facilities, and even in the home. Understanding the principles of
20
mechanical ventilation and the care of a patient on the ventilator is
necessary for achieving nursing goals. The ongoing problem in recruiting
qualified nurses in general has affected and continuous to be a problem
for all aspects of Wholistic care. In order to deliver wholistic care and high
quality nursing care, the nurses must have an adequate knowledge
towards various areas of ventilator care such as airway maintenance,
prevention of injury and infection, promotion of the optimal level of mobility
and promotion of communication skill. The nursing cares of mechanically
ventilated patients require technical and inter personal skills. Spring of
et.al (2004) United States Of America stated that 50% of patient in the
hospital in Critical Care Unit depend on mechanical ventilation for brief of
operative surgery or severe medical problems. Makro et.al (2004) carried
out the study on Clinical skills of care plan approach to nurse led
extubation ventilator. The nurses are the key role players in reducing the
time on a mechanical ventilator for patients. Bonsai. E. (2001) carried out
a study on “modes of ventilator support and weaning parameters in
children” said that nurses carrying for these children must possess an
adequate knowledge of the underlying disease process and the uses of
ventilators. The incidence of risk factors and the outcome of mechanically
ventilated patients are chronic interstitial lung diseases (10.3%) Acute
Respiratory Distress Syndrome (6.5%) pneumonia (4.3%) barotraumas
(2.9%) Chronic Obstructive Pulmnary Disease (2.9%) and asthma (6.3%).
Joan et al. (1999) finds Complication during ventilator
21
management include alkalemia, metabolic alkalosis, Atelectasis, tracheal
and laryngeal damage, pulmonary embolism, cardiac arrhythmias, fluid
and electrolyte imbalance, pulmonary embolism and septicemia. The
nurse’s responsibility in care of patients with ventilator is the maintenance
of artificial airway, tube placement, cuff inflation, fluid, electrolyte balance,
monitoring oxygen saturation and ventilator associated complications.
Crocker C 2002 conducted a study on “Nurse led” weaning from
the ventilator and respiratory support and revealed that staff nurses are
not initiating proper guidelines early because they have a lack of
knowledge on ventilation. Parson et al (2004) study findings revealed that
the extubation success rate was 94% where performs according to Arteial
Blood Gas analysis. So staff nurses require knowledge regarding Arteial
Blood Gas analysis. Turner.P.et.al. (2003). Found out that “Care of the
patient regarding Mechanical ventilation” and said that the nurses need
basic knowledge in the care of patients on a mechanical ventilator to
prevent complications. Vittacca.M (2005) Suggested that nurses should be
trained to have comprehensive theoretical and practical knowledge on the
ventilator care.
Arlene F. Tolentino. et al (2007) proved that the knowledge of the
nurses improved, and they performed better after the education session.
Labeau. S and et. al (2007) prepared an evidence based guidelines for the
nurses to prevent the complication of mechanical ventilation and proved
that teaching program improved the knowledge and practice of nurses.
22
Sally crofts (2007) described ventilator bundle was adopted and 95%
compliance achieved in six weeks. Now, due to extended scope for
nurses, experienced nurses who are well trained in care of patients with
ventilator were migrated to abroad. The investigator during her regular
clinical visits to the intensive Care Unit found that nurses are providing
care to patients who were ventilated. On her observation the investigator
also noticed that because of lack of knowledge, practice and experience
the nurses failed to provide quality care to those patients who finally led to
complications, and they lost their qualitative life. It also found that mostly
the nurses who are inexperienced with inadequate knowledge about
ventilator care are found. The researcher develop a structured Teaching
Program for nurses on care of patients. She develops rating scale to
evaluate the practicing skill and the outcome of the ventilator care.
1.2 Statement Of The Problem:
Effectiveness of structured teaching programme for nurses on care
of the patients with ventilator and the outcome of ventilator care in the
selected hospitals at Nellore, Andhra Pradesh”.
1.3 Operational Definitions:
Effectiveness:
It is the desired change by introducing the structured teaching
program on nursing care of patients with ventilator to improve the
knowledge and practice level among nurses.
Structured Teaching Programme:
23
It refers to the systematically planned and formulated teaching
program designed to provide information regarding ventilator care.
Nursing care:
It is nurturing the patient by providing holistic nursing care by
registered nurses working in a hospital. It is caring the mechanically
ventilated patients by practicing specifically, oral hygiene, endotracheal
suctioning, tracheostomy care and weaning process with adequate
knowledge by registered nurses.
Ventilator:
It is a mechanical device which supports ventilation to the lungs.
Outcome:
Evaluation of the outcome of ventilator care results with the
intended or projected results.
1.4 Objectives:
1. To assess the knowledge and practice regarding ventilator care
among the nurses, working in the selected hospitals at Nellore, A.P.
2. To compare the pre and post test knowledge and practice
regarding ventilator care among the nurses, working in the selected
hospitals at Nellore, A.P.
3. To correlate the post test knowledge and practice regarding
ventilator care among nurses, working in the selected hospitals at
Nellore, A.P.
24
4. To find out the outcome of the ventilator care in the selected
hospitals at Nellore, A.P.
5. To determine the association between knowledge and practice
regarding ventilator care with the selected demographic variables
among nurses, working in the selected hospitals at Nellore, A.P.
Hypothesis-I: The knowledge and practice regarding ventilator care
among the nurses will be a significant difference between the
experimental group and control group.
Hypothesis-II: There will be a significant difference in nurses’ knowledge
and practice on ventilator care of the patients before and after structured
teaching program among the experimental group.
Hypothesis-III: The knowledge and practice will have a positive
correlation on ventilator care among nurses.
Hypothesis-IV: There will be an association between the knowledge,
practice of ventilator care with selected demographic variables among
nurses working in selected hospitals.
Hypothesis-V: The outcome of ventilator care after structured teaching
programme will be highly significant.
Delimitation:
1. The study is limited to the registered nurses who are working in the
selected hospitals at Nellore.
2. The data collection procedure is limited to 6 months only
25
CHAPTER - II
2. REVIEW OF LITERATURE
A literature review is a body of text that aims to review the critical
points of current knowledge, theory and methodology of a particular topic.
Literature reviews are secondary sources, which do not report any new or
original experimental work. Also, a literature review can be interpreted as
a review of an abstract accomplishment. Most often associated with
academic-oriented literature, such as a thesis, a literature review usually
precedes a research proposal and results section. Its main goal is to
situate the current study within the body of literature. It provides context
for the particular reader. A well-structured literature review is
characterized by a logical flow of ideas; current and relevant references
with consistent, appropriate referencing style; proper use of terminology;
and a comprehensive view of the previous research on the topic. It is
useful to construct methodology, prepare questionnaire, guide for data
collection procedures, develop statistical analysis and interpretation, to
compare previous works in given problem and formulate the conceptual
framework. It is the base for evidence based practice in nursing.
In this study, the Review of Literature consists of two parts:
26
Part I: a) Studies and literature related to Nurse knowledge on
care of patient with ventilator.
b) Nurses practice on care of the patient with ventilator
c) Outcome of ventilator care of the patients.
Part II: Conceptual frame work based on modified general system model.
2.1 PART – I
(a) Nurses Knowledge On Nursing Care Of The Patients With
Mechanical Ventilator:
Espana E., (2010) reported to assess Southern European Intensive
Care Unit Nurses Knowledge About Evidence-Based Guidelines For The
Prevention Of Ventilator-Associated Pneumonia And To Compare These
Findings With A Pan-European Perspective. A sub analysis from an
observational study performed using a multiple-choice questionnaire.
Six Southern European countries, selected from 22 participant European
countries. Volunteer nurses from intensive care units 3329 questionnaires
were obtained, 1182 of them belonging to Southern European countries
with a 75.8% response rate. Global average score was 45.1%, being it
significantly better in the South of Europe (46.6%, P<.001). A linear
Multiple Regression Analysis showed that years of working experience
(per class of increase) (Multiple Regression Analysis =0.154 ± (Sd) 0.045)
(95% CI (0.066-0.242) (p=0.001) and working in a smaller intensive care
unit (Multiple Regression Analysis=-0.210 ± (Sd) 0.059) (95% CI) -0.326-
0.094)(P<.001) was independently associated with better test scores.
27
Southern European critical care nurses' knowledge about ventilator-
associated pneumonia prevention is poor, but significantly better than in
the pan-European countries.(24)
Westwell S. (2008) stated that the prevention of Ventilator-
Associated Pneumonia requires a complex approach that should include
factors affecting Health Care Workers behavior. This study attempted to
assess change of individual factors throughout a multifaceted program
focusing on Ventilator-Associated Pneumonia prevention. The prevention
program involved all Health Care Workers in a 20-bed medical Intensive
Care Unit and included a multidisciplinary task force, an educational
session, direct observations and performance feedback, technical
improvements, and reminders. Knowledge, beliefs, and perceptions
(cognitive factors) were assessed with a test and a self-reporting
questionnaire based on social-cognitive theories. They were completed
before and 1 and 12 months after the educational session. Of the 100
Health Care Workers initially evaluated, 84 were present 1 year later.
Overall, individual factors (knowledge and cognitive factors) changed
positively and significantly, immediately after the educational session. Five
cognitive factors were significantly associated with knowledge, perceived
susceptibility, seriousness, knowledge, benefits, and self-efficacy
(P < 0.05). The other factors, i.e., perceived barriers, subjective and
behavioral norm, intention to perform action, and motivation, were not.
The positive cognitive change was significantly reinforced at 1 year. Three
28
distinct cognitive profiles derived from answers to the baseline
questionnaire were individualized. The positive impact of behavioral
approach was highest for the Health Care Workers group with the lowest
baseline cognitive profiles. Behavior changed gradually throughout the
program of Health Care Workers with the lowest baseline cognitive
profiles.(25)
Rose L (2011) conducted a study on clinical application of
ventilator modes Ventilator strategies for lung protection Identification of
the mortality reducing effect of lung protective ventilation using low tidal
volumes and pressure limitation is one of the biggest advances in the
application of mechanical ventilation. The studies continue to demonstrate
the low adoption of ventilation. Critical care nurses in Australia and New
Zealand have a high level of responsibility and autonomy for mechanical
ventilation and weaning practices. It required in-depth knowledge of
ventilator technology, its clinical application and the current evidence for
effective ventilation strategies is to present an overview of current
knowledge and research relating to lung protective ventilation. A multi
database literature search using the terms protective ventilation, open
lung, high frequency oscillatory ventilation, airway pressure release
ventilation, and weaning. Based on clinical trials and physiological
evidence lung protective strategies using low tidal volumes and moderate
levels of Peep. It prevent tidal alveolar collapse and over distension in
patients with Acquired Respiratory Distress Syndorome. Evidence now
29
suggests these strategies may also be beneficial in patients with normal
lungs. Lung protective ventilation may be applied with either volume or
pressure-controlled ventilation. Pressure-controlled ventilation allows
regulation over injurious peak inspiratory pressures; however no study has
identified the superiority of pressure-controlled ventilation over low tidal
volume strategies using volume-control. Other lung protective ventilation
strategies include moderate to high positive-end expiratory pressure,
recruitment maneuvers, high frequency oscillatory ventilation, and airway
pressure release ventilation though definitive trials identifying consistently
improved patient outcomes are still needed. No ventilation strategy can be
more lung protective than the timely discontinuation of mechanical
ventilation. Despite the above recommendations, evidence suggests the
decision to commence weaning and attempt extubation continue to be
delayed. Critical care nurses play a vital role in recognition of patients
capable of spontaneous breathing and ready for extubation.
Organizational interventions such as weaning protocols are able to
manage to weaning processes effectively. Lung protective ventilatory
strategies are not consistently applied, and weaning and extubation
continue to be delayed. Critical care nurses need to establish a strong
knowledge base and effective management of patients.(26)
Rose L., et. al., (2008) conducted a study on work place profile,
organization structure, role and responsibility for ventilation and weaning
practices. Self-administer questionnaire was used among 54 nurses. The
30
results of this survey suggested that, nurses participate actively in
ventilation and weaning decisions. The results supported an association
between the education profile and skill of nurses collaborative practice in
Intensive Care Unit.(27)
Jin Xiong Lian RN (2008) reported that the critical care nurses
can identify subtle changes in a patient's clinical status and initiate
appropriate nursing interventions rapidly and effectively. The main
components of nursing care for mechanically ventilated patients include
the following: Performing frequent assessments including level of
consciousness and vital signs. Verifying prescribed ventilator settings and
appropriate alarm limits. Nurses should also properly secure the
endotracheal tube and respond to and troubleshoot ventilator alarms,
adhere to infection control guidelines, and identify complications or
mechanical problems associated with Mechanicl Ventilator, such as an air
leak or kink in the ventilator circuit. Ensuring emergency equipment, such
as manual resuscitation bags and oropharyngeal and nasopharyngeal
airways, assessed the adequacy of cardiac output. Mechanical Ventilator
compromises hemodynamic status and predisposes patients to
hypotension and renal dysfunction. Maintaining adequate perfusion is
paramount by evaluating the adequacy of oxygenation. Oxygen saturation
and partial pressure of arterial oxygen (PaO2) are key indicators of
oxygenation is assessed the adequacy of ventilation. It is essential to
monitor the patient's PaO2, PaCO2, and acid-base balance and also
31
monitoring of the patient-ventilator interaction. Common causes include
increasing airway resistance as a result of bronchospasm, excessive
sputum, or small Endotracheal tube size.2, 9, 10, and 36. When the flow
delivered by a ventilator does not meet patient needs, flow dyssynchrony
occurs. The inspiratory flow rate is adjusted to decrease the WOB and
alleviate patient discomfort. If the termination of the inspiratory flow by a
ventilator does not synchronize with the end of a patient's neural
inspiration, it results in cycle dyssynchrony. With pressure-support
ventilation, optimizing flow cycle threshold will ameliorate cycle
dyssynchrony2, 9, 10, and 32. It is important for Educating patients and
their families (with the patient's consent) about the patient's illness and the
need for respiratory support and the application of Mechanical Ventilator.
It is a must to involve the patients in the decision making regarding
medical treatment and nursing care. Encouraging them to participate in
the ventilator weaning process. Mechanical Ventilator can cause
numerous complications. A sound knowledge of Mechanical Ventilator and
a patient's clinical status enables clinicians to fine-tune ventilator settings
to maximize the benefits of ventilatory support. Critical care nurses play a
crucial role in improving the effectiveness of Mechanical Ventilator.(28)
Waler et.al.(2008) conducted a retrospective cohort study on
‘’potential value of regionalized intensive care for mechanically ventilated
patients’’, their objective was to determine the number of patients who
would be affected by regionalization and the potential mortality reduction
32
under a regionalized system of care. They finally concluded that
regionalization of intensive care could potentially improve survival for
patients undergoing mechanical ventilation. Transfer distances are modest
for most patients.(29)
Advanced Critical Care (2007) reported that Ventilator-Associated
Pneumonia is a significant clinical problem associated with increased
Intensive Care Unit, Hospital Length of stay, substantial increases in
delivery cost, and associated morbidity and mortality. With system
changes and management of the environment of care, the incidence of
Ventilator-Associated Pneumonia was reduced in seven of their intensive
care units across the system. Steps necessary to reduce Ventilator-
Associated Pneumonia were identified and put into place in all the
intensive care units. Patient positioning, oral care, nutrition, and
management of comfort drugs are to reduce Ventilator-Associated
Pneumonia. Standardization of these essential care practices can reduce
the incidence of this nosocomial infection, and increases in the cost of
care delivery and mortality.(30)
Bambi S. (2009) conducted a prospective observational cohort
study on ‘’ evolution of mechanical ventilation in response to clinical
research’’. The use of non invasive ventilation increased among patient
with acute respiratory disaster syndrome. More patients were successfully
extubated after their first spontaneous breathing. The randomized trials
results have advanced mechanical ventilation practice internationally.(31)
33
Lavelle C, Dowling M. (2011) conducted a study on evidenced
based practice, use of the ventilator bundle to prevent Ventilator-
Associated Pneumonia. Changes in the nurses knowledge were evaluated
by the using a 10 item test given to 61 nurses working in Critical Care Unit
and Surgical Intensive Care Unit and evaluated before and after the
education sessions. Education sessions designed to inform nurses about
the ventilator bundle and its use to prevent ventilator associated
pneumonia. It has a significant effect on the participant knowledge, and
subsequent clinical practice.(32)
Blot SI (2007) stated that nurses' lack of knowledge may be a
barrier to adherence to evidence-based guidelines for preventing ventilator
associated pneumonia. The objective of the study is to develop a reliable
and valid questionnaire for evaluating Critical Care Nurses' knowledge of
evidence-based guidelines for preventing ventilator-associated
pneumonia. Ten nursing-related interventions were identified from a
review of evidence-based guidelines for preventing ventilator-associated
pneumonia. Selected interventions and multiple-choice questions (1
question per intervention) were subjected to face and content validation.
Item difficulty, item discrimination, and the quality of the response
alternatives or options for answers (possible responses) were evaluated
on the test results of 638 Critical Care Nurses. Face and content validity
were achieved for 9 items. Values for item difficulty ranged from 0.1 to 0.9.
Values for item discrimination ranged from 0.10 to 0.65. The quality of the
34
response alternatives led to the detection of widespread misconceptions
among Critical Care Nurses. The questionnaire is reliable and has a face
and content validity. Results of surveys with this questionnaire focused
educational programs on preventing ventilator-associated pneumonia.(33)
Yamauchi T. (2009): reported that, in Japan, more people require
care activities at home. In particular, patients with an invasive mechanical
ventilator in the home require extensive care by family caregivers.
Collaboration between their nurses and paid caregivers in the provision of
care activities, especially tracheal suctioning, is necessary. This three-
round Delphi study identifies the essential items required by nurses to
carry out tracheal suctioning on patients with an invasive mechanical
ventilator in the home. By the final round, three competencies were found
to be important by the home-visit nurses and paid caregivers: the
anticipation of risk, the manner of handling an emergency situation, and
the observation of a patient's breathing. The Delphi technique was used to
obtain consensus between the home-visit nurses and the paid caregivers
regarding the essential knowledge, skills, and attitudes.(34)
Zhongguo Wei Zhong Bing Ji Jiu Yi Xue. (2007) The Chinese
Society of Critical Care Medicine (Chinese Medical Association) held a
consensus conference to draft a guideline for the recommendation of
mechanical ventilation to categorize all the information gathered from the
literature into five grades from A to E, with A being the highest, according
to a modified Delphi criteria, which were adopted by the International
35
Sepsis Forum held in 2001. After further nationwide inquiries and
conscientious discussions, this guideline has been drafted pending further
addition and correction. This guideline chiefly covers the following
aspects: the choice of mechanical ventilation for critically ill patients, the
aim and indication of mechanical ventilation, non invasive positive
pressure ventilation, regulation of modes and settings of the ventilator, etc.
With the implementation of the guideline, it is hoped that the clinical use
of mechanical ventilation in the critically ill patients will be more or less
standardized.(35)
Galvano (2006) Unintended consequences, such as limited
ability to think beyond algorithms, may exist when protocols are used
extensively. In Journal of American Medical Association, Prasad et al
studied the relationship between critical care training under high and
lowintensity institutional mechanical ventilation protocols and subsequent
knowledge about ventilator management. Results showed 86% of all
respondents had protocols for ventilation liberation, 73% had protocols for
sedation management and 60% had protocols for lung-protective
strategies. The overall pass rate was 91%; there was no difference in the
mean scores on the mechanical ventilation questions between the high-
and low-intensity groups (high- intensity mean score, 497; 95% confidence
interval, 486-507; low-intensity mean score, 497; 95% confidence interval
485-509). These results suggest that trainees from hospitals with high-
intensity ventilation protocols do not demonstrate knowledge deficits
36
regarding mechanical ventilation as compared to trainees from hospitals
with low-intensity protocols. Potential limitations to this work include the
use of examination questions to test knowledge exclusively about
mechanical ventilation and the fact that the study population consisted of
examinees trained in internal medicine, not surgery, anesthesiology or
emergency medicine. Nevertheless, this study has important implications
for physician-educators, because the unintended consequences of
protocols on education have not been evaluated broadly. Clinical
protocols, which are designed to enhance and standardize patient care,
may have an impact on medical education.(36)
Russell.c (2005) conducted a study on providing the nurse with a
guide to tracheostomy care and management. The study revealed that
Tracheostomy care and management is more and more necessary in both
the intensive care setting and the general ward. The trained nurses are
equipped with the appropriate skills and knowledge. It support to meet the
unique needs of each patient safely and competently.(37)
C Wiesenack et. al (2005) conducted a study on ‘’assessment of
fluid responsiveness in mechanically ventilator cardiac surgical patients’’
with 20 samples. The study was designed to evaluate the accuracy of
stroke volume variations and pulse pressure variations. It surrogate pulse
pressure variations derived from pulse contour analysis by using an
improved algorithm. It can serve as a indication of fluid responsiveness in
normal ventilator cardiac surgical patients.(38)
37
Myers S.T., (2004) conducted a study on Emergency ventilation
of the tracheotomy patient, Part I: Knowledge assessment of healthcare
professionals. A convenience sample and comparative descriptive design
was used for this study. The sample size was 587. Three item
questionnaire was used to assess the specific knowledge. Findings
revealed that less than half of nurses and physicians were able to answer
correctly all 3 questions asked to regard emergency strategies.
Recommendation address that knowledge deficit.(39)
Carolyn et al (2003) conducted a study on nurse’s
implementation of guidelines for ventilator–associated pneumonia. 29 item
questionnaires were completed by twelve hundred nurses. The study
concluded that there was a significant reduction in rates of ventilator
associated pneumonia. It may be achieved by broader implementation of
oral care protocols.(40)
Health care bench marks and quality improvement (2003)
conducted a multimodal education programme to teach nursing and
respiratory therapy to the nursing staff about improved techniques. This
led to a significant reduction in the incidence of ventilator associated
pneumonia. The effectiveness of the educational program was evaluated
by 20-questionnares to test the staff VAP prevention knowledge. The
average pre intervention test score was 79.6, and the average post
interventional score was 90.9.(41)
38
Lübeck, G., (2006) Weaning from mechanical ventilation are a
complex process requiring assessment and interpretation of both objective
and subjective clinical parameters. For many years, computerized
systems are used respiratory management. That have been proposed to
optimize decision-making and reduce variation amongst clinicians in
Smart Care, available since 2003 as a software application for the Evita
XL ventilator (Dragger Medical Ag), is one of the first such ventilator
systems to be made commercially available. Smart Care can be described
as a knowledge-based weaning system, which adjusts pressure support
based on measurement of the patient's respiratory status, specifically the
spontaneous respiratory rate, tidal volume and end-tidal carbon dioxide
with the aim of optimizing the weaning process. The primary proposed
advantage of this system is an ability to provide management of
ventilatory weaning through continuous physiological monitoring and real-
time interventions. The relatively small number of available clinical studies
indicates the system is able to deliver appropriate ventilation during
pressure support weaning from both short-term and prolonged ventilation.
Of potential clinical note, a recent study suggested that use of Smart Care
might be associated with useful reductions in the duration of weaning
compared to existing clinical practice using weaning protocols.(42)
Mary J O., et.al. (2003) Conducted a study on a collaborative
practice: development implementation and evaluation of a weaning
protocol for patients receiving mechanical ventilation. The findings
39
revealed that implementation of the protocol significantly reduced the
duration of mechanical ventilation. Finally they concluded that need to
provide efficient care requires the collaboration of all discipline involved in
providing patients care. The weaning protocols introduced in their study to
demonstrate the benefit of using a collaborative team.(43)
Keisuke M., et.al, (2003) conducted a study on ‘’ continuous
monitoring of oxygen consumption in patients undergoing weaning from
mechanical ventilation’’ 20 adult patients meeting the criteria. Findings
revealed that 208 weaning trails including 145 successful trails &
63 focused trails from 20 patients. Finally they concluded that measuring
the oxygen was clinically beneficial in avoiding the induction of an
excessive movement load on the respiratory muscles. The patients treated
with mechanical ventilation, have continuous monitoring of oxygen. It
useful to predict success or failure of trials attempting to reduce
mechanical ventilation support.(44)
Esteban A., et.al., (2004) conducted a prospective cohort study
“On to determine the threshold of age that best discriminate the survival of
mechanically ventilator patient and to estimate the outcome of
mechanically ventilator older patient.’’ The survival in hospital 45% for the
elderly group and 55% for the middle age. They concluded that older
mechanically ventilator patients(age >70years) had a lower Intensive Care
Unit and hospital survival, by the duration of mechanical ventilation
Intensive Care Unit and hospital stay were similar to younger patients.
40
The highest risk of mortality in patients of older. The complications are
renal failure and shock.(45)
Giorgio R et.al., (2003) conducted a study on ‘’criteria for
success for ventilator weaning in the long term acute care hospital: is one
week free from ventilator support as good as for a week free. They
concluded that, although derived on winnable in the acute care hospital
many patients referred to LTCAV program have been successfully
weaned.(46)
Zack je et al (2002) conducted a study pre and post intervention
observational study on effect of an education program aimed at reducing
the occurrence of ventilator associated pneumonia in five Intensive Care
Unit units are setting, participants were patients requiring mechanical
ventilation who developed Ventilator Associated Pneumonia. Interventions
include that an education program directed toward respiratory care
practitioners and Intensive Care Unit nurses. The findings revealed that a
focused education intervention can dramatically decrease the incidence of
Ventilator Associated Pneumonia. Education programs should be more
widely employed for infection control in the Intensive Care Unit. It can lead
to substantial decreases in the cost. The patient morbidity attributed to
hospital-acquired infections.(47)
Farnell.S et.al (2002) conducted a study on Tracheal suctioning:
an exploration of nurses' knowledge and competence in acute and high
dependency ward areas. Twenty-eight nurses were observed using
41
nonparticipant observation and a structured observation schedule. Each
subject was interviewed and questioned about their tracheal suctioning
practices, and subsequently completed a knowledge-based questionnaire.
The findings demonstrated a poor level of knowledge for many subjects.
This was also reflected in practice. The study raised concern about all
aspects of tracheal suctioning. It has highlighted the need for changes in
practice, clinical guidelines and focused practice-based education.(48)
Duane T M., et. al., (2002) conducted a study on ‘’protocol –
driven ventilator management in a trauma Intensive Care Unit population’’
with the sample of 328 they concluded that use of weaning and sedation
protocol did not affect the measured out come in this study. These findings
may reflect their utilization.(49)
Wainwright S.P, Day.T, Wilson Barnett.J (2001) conducted a
study on an evaluation of a teaching intervention to improve the practice of
endotracheal suctioning in intensive care units. This study was designed
to examine to what extent Intensive Care Nurses' knowledge and practice
of endotracheal suctioning are based on research evidence, to investigate
the relationships between knowledge and practice. This quasi
experimental study was a randomized, controlled, single-blinded
comparison of two research-based teaching program, with 16 intensive
care nurses, using non participant observation and a self-report
questionnaire. Initial baseline data revealed a low level of knowledge for
many participants, which was also reflected in practice, as suctioning was
42
performed against many of the research recommendations. The significant
improvements were seen in both knowledge and practice.(50)
Esteban A ,. (2000) conducted two randomized studies have
evaluated the usefulness of non-invasive ventilation as a weaning
technique. In the study by Nava et al ., 50 Chronic Obstructive Pulmonary
Dissese patients who failed a T-tube trial after 36-48 h of mechanical
ventilation were randomized to either immediate extubation with non
invasive pressure support via a face mask and a standard ventilator, or
continued pressure support via an endotracheal tube. Both groups
underwent trials of spontaneous breathing at least twice a day. There
were reductions in the pressure support level of 2-4 cmH2O/day.
Compared with patients who were weaned while intubated, the group that
was weaned with Non invasive Ventilation had a lower rate of nosocomial
pneumonia (0% versus 28%), a significantly higher weaning rate at 60
days (88% versus 68%), and a significantly lower 60-day mortality rate
(8% versus 28%). A study by Girault et al 33 patients with chronic
respiratory failure who failed a 2-h T-piece weaning trial of spontaneous
breathing were randomized to either extubation and Non Invasive
Ventilation (n = 17) or conventional invasive Presure Support Ventilation
(n = 17). No differences were observed between the two groups with
respect to clinical and functional characteristics, either at admission to the
intensive care unit or at randomization. In the conventional invasive
ventilation protocol, 75% of patients were successfully weaned and
43
extubated versus 76.5% in the Non Invasive Ventilation group. As
expected by the study design, the duration of endotracheal intubation was
significantly shorter in the Non Invasive Ventilation group than in the
control group (4.6 ± 1.5days versus 7.7 ± 3.8 days; P = 0.004). The total
duration of ventilatory support related to weaning, however, was
significantly higher in the Non Invasive Ventilation group (11.5 ± 5.2 days
versus 3.5 ± 1.4 days; P <0.001). The durations of intensive care unit and
hospital stay and the 3-month survival were similar in the two groups. The
use of Non Invasive Ventilation to facilitate weaning has not been
evaluated in postoperative patients or those with altered neurologic status,
hemodynamic instability, or any of a number of severe concomitant
diseases. Nonetheless, Non Invasive Ventilation may become an
important weaning mode in selected patients if its success is replicated in
other trials. (51)
Brook et.al.(1999) conducted a study on ‘’effect of a nursing
implemented sedation protocol on the duration of mechanical ventilation
by using descriptive study with a sample of 132 at critical care unit
questionnaire by random sampling. Use of protocol-directed sedation can
reduce the duration of mechanical ventilation.(52)
Dojat MBrochard LLemaire F Harf A., 1992 Conducted a study
on knowledge-based system for assisted ventilation of patients in
intensive care units. The procedure for weaning a patient with respiratory
insufficiency from mechanical ventilation may be complex and requires
44
expertise obtained by long clinical practice. They designed a knowledge-
based system for the management of patients receiving respiratory
support and implemented a weaning procedure. The system is intended
for patients whose spontaneous respiratory activity is assisted by a
Hamilton Vs Clinical protocols are associated with improved patient
outcomes; however, they may negatively affect medical education by
removing trainees from clinical decision making. To study multi mode
ventilator delivering a positive pressure plateau during inspiration
(Pressure Support Ventilation mode). The closed-loop real-time system
running on a Personal Computer continuously adapts the assistance
provided by the ventilator to the patient's evolution, and indicates when the
patient can be withdrawn from the ventilator. Three parameters are used
to appreciate the 'respiratory comfort' of the patient: breathing frequency,
which we considered the most informative index, tidal volume and end-
tidal CO2 pressure. A preliminary study of 19 patients was performed to
evaluate the ability of their system to adapt the assistance to the patient's
needs, with the main objective of facilitating weaning by gradually lowering
the level of assistance. In 10 of these patients, considered as good
candidates for weaning on the strength of objective criteria, the system
maintained the breathing pattern in a zone of comfort for 95% of the
period of assisted ventilation and stated that they were 'wean able'. This
was consistent with the clinical evolution of all 10 patients. These results
45
showed the system can provide effective management for mechanically
ventilated patients.(53)
Darnetta MBA et.al,(1997) conducted a study “On impact of
passive humidification on clinical outcomes of mechanical ventilated
patients’’. 13 randomized controlled trial studying 2580 patients were
included. They concluded that the available evidence does not support the
preferential performance either passive or active humidification in
mechanical ventilated patients.(54)
(b) Nurses Practice On Nursing Care Of The Patients With
Mechanical Ventilator
King ML.et.al (2010) conducted a study to determine current
practice and differences in practices between registered nurses and
respiratory therapists in managing patients receiving mechanical
ventilation. A descriptive comparative design was used. A convenience
sample of 41 registered nurses and 25 respiratory therapists who manage
critical care patients treated with mechanical ventilation, completed a
survey on suctioning techniques and airway management practices.
Descriptive and inferential statistics were used to analyze the data.
Results show that Significant differences existed between nurses and
respiratory therapists for hyper oxygenation before suctioning (P =.03). In
the 2 groups, nurses used the ventilator for hyper-oxygenation
more often, and respiratory therapists used a bag-valve device more often
46
(P =.03). Respiratory therapists instilled saline (P <.001) and rinsed the
closed system with saline after suctioning (P =.003) more often than
nurses did. Nurses suctioned oral secretions (P <.001) and the nose of
orally intubated patients (P =.01), brushed patients' teeth with a toothbrush
(P<.001), and used oral swabs to clean the mouth (P <.001) more
frequently than respiratory therapists did. The study concludes that nurses
and respiratory therapists differed significantly in the management of
patients receiving mechanical ventilation. To reduce the risk of ventilator-
associated pneumonia, both nurses and respiratory therapists must be
consistent in using best practices.(55)
Marx G. et.al (2009) conducted a prospective cohort study to
determine the effects of staff training on the care of mechanically
ventilated patients. This study was performed on a 50-bed intensive care
unit of a tertiary care university hospital. Application of a ventilator bundle
consisting of semi recumbent positioning, lung protective ventilation in
patients with acute lung injury, ulcer prophylaxis, and deep vein
thrombosis prophylaxis was assessed before and after staff training in
post-surgical patients requiring mechanical ventilation for at least 24
hours. Study results shows that a total of 133 patients before and 141
patients after staff training were included. Overall bundle adherence
increased from 15 to 33.8% (P<0.001). Semi recumbent position was
achieved in 24.9% of patient days before and 46.9% of patient days after
staff training (P<0.001). Administration of increased from 89.5 to 91.5%
47
(P=0.048). Ulcer prophylaxis of >90% was achieved in both groups.
Median tidal volume in patients with remained unaltered. Days on
mechanical ventilation were reduced from 6 (inter quartile range 2.0-15.0)
to 4 (2.0-9.0) (P=0.017). Rate of Ventilator-Associated Pneumonia,
Intensive Care Unit length of stay, and Intensive Care Unit mortality
remained unaffected. In patients with Ventilator-Associated Pneumonia,
the median Intensive Care Unit length of stay was reduced by 9 days
(P=0.04). He concludes that Staff training by an Intensive Care Unit
change team improved compliance to a pre-defined ventilator bundle. That
led to a reduction in the days spent on mechanical ventilation.(56)
Lorraine.b fields (2009) conducted a study on oral care
intervention to reduce the incidence of ventilated associated pneumonia.
In ventilated patients on a 24 bed-stroke, neurological, medical Intensive
Care Unit patient’s. Patient was randomized into a control group that
performed usual oral care and an interventional group. The results were
immediate and start as the Ventilator-Associated Pneumonia rate dropped
to zero within a week.(57)
Laura. A(2009) : Evidence-based guidelines can serve as a
catalyst for knowledge translation to the clinical arena. In addition to
reducing the overall length of time that patients are intubated, strategies to
prevent Ventilator-Associated Pneumonia arise directly from the 3
mechanisms believed to cause Ventilator-Associated Pneumonia: micro
aspiration of colonized secretions, colonization of the digestive tract, and
48
exposure to contaminated hands or equipment. The risk of Ventilator-
Associated Pneumonia increases with each day the patient is intubated.
The best and most obvious way to prevent pneumonia in critically ill
patients are to avoid intubation altogether and implement noninvasive
ventilation whenever possible.(58)
Reeve J.C (2009) conducted a study on instillation of normal
saline before suctioning reduces the incidence of pneumonia intubated
and ventilated adults. Randomized controlled trial was used in medical,
surgical, Intensive Care Unit and participants expected to require at least
72 hours of mechanical ventilation via endotracheal or tracheostomy
.Randomization of 262 participants allotted 130 to the intervention group
and 132 to a control group. The results conclude that instillation of normal
saline before tracheal suctioning decreases the incidence of Ventilator
Associated Pneumonia in mechanically ventilated adults.(59)
Krein et al (2008) conducted a study on preventing ventilated
associated pneumonia in the United States, a multi center mixed methods
study.14 hospitals were selected for an in-depth qualitative investigation.
The reports indicated that semi recumbent positioning is commonly used
to prevent VAP; subglottic secretion drainage is used for less often.(60)
Kelleher.S, (2008) conducted a study on an observational study
on the open-system endotracheal suctioning practices of critical care
nurses. A structured observational study was conducted using a piloted
20-item observational schedule on two adult intensive-care units. The
49
result shows that the findings suggest that critical care nurses do not
adhere to best practice recommendations when performing ETS and need
to be developed and/or reviewed and teaching interventions developed to
improve nurses' ETS practices, particularly in regard to auscultation skills,
hyper oxygenation practices, suctioning pressures and infection control
measures.(61)
Lau G.et al, (2008) conducted a study on Ventilator-associated
pneumonia bundled strategies: an evidence-based practice. The aims of
the study are (1) to provide a review of the literature on Ventilator-
associated pneumonia bundle practices. (2) To describe the etiology and
risk factors and define bundled practices. (3) To discuss an explanatory
framework that promotes knowledge translation of Ventilator-Associated
Pneumonia Bundle into clinical settings. (4) To identify areas for further
research and implications for practice to decrease the incidence of
Ventilator-Associated Pneumonia. Evidence shows that Ventilator-
Associated Pneumonia Bundle practices decrease Ventilator-Associated
Pneumonia rates. Bundled practices result in decreased ventilator days,
intensive care unit length of stay, and mortality rates. A strong association
was seen, with an increased clinician compliance with Ventilator-
Associated Pneumonia Bundle protocols with decreased Ventilator-
Associated Pneumonia rates.(62)
Cason CL., et al., (2007) had done a study to evaluate the extent
to which nurses working in intensive care units implement best practices
50
when managing adult patients receiving mechanical ventilation. Nurses
attending education seminars in the United States completed a 29-item
questionnaire about the type and frequency of care provided. Twelve
hundred nurses completed the questionnaire. Most (82%) reported
compliance with hand washing guidelines, 75% reported wearing gloves,
half reported elevating the head of the bed, a third reported performing
subglottic suctioning, and half reported having an oral care protocol in
their hospital. The study concluded that the guidelines for the prevention
of ventilator-associated pneumonia from the Centers for Disease Control
and Prevention are not consistently or uniformly implemented. Practices of
nurses employed in hospitals with oral care protocols are more often
congruent with the guidelines than are practices of nurses employed in
hospitals without such protocols. Significant reductions achieved by
implementation of oral care protocols.(63)
Jeffrey J. (2007): Conducted a study on Responsibilities of
critical care nurses for management of mechanical ventilation among
nurses and other paramedical in Royal Melbourne Hospital, Australia.
Organizational interventions, including weaning protocols, may have a
variable impact in settings that differ in nursing autonomy and
interdisciplinary collaboration. A 3-month, prospective cohort study was
performed in all clinical decisions related to mechanical ventilation in a 24-
bed, combined medical-surgical adult intensive care unit. Of 474 patients
admitted during the 81-day study period, 319 (67%) received mechanical
51
ventilation. Death occurred in 12.5% (40/319) of patients. Median
durations of mechanical ventilation and intensive care stay were 0.9 and
1.9 days, respectively. A total of 3986 ventilation and weaning decisions
(defined as any adjustment to ventilator settings, including mode change;
rate or pressure support adjustment; and titration of tidal volume, positive
end-expiratory pressure, or fraction of inspired oxygen) were made. Of
these, 2538 decisions (64%) were made by nurses alone, 693 (17%) by
medical staff, and 755 (19%) by nurses and staff in collaboration.
Decisions made exclusively by nurses were less common for patients with
predominantly respiratory disease or multiple organ dysfunctions than for
other patients. In this unit, critical care nurses have high levels of
responsibility for, and autonomy in, the management of mechanical
ventilation and weaning.(64)
Ross A, (2007) conducted a study on the impact of an evidence-
based practice education program on the role of oral care in the
prevention of ventilator-associated pneumonia. The aim of the study was
to determine if an Evidence-Based Practice educational programme would
improve the quality of oral care delivered to mechanically ventilated
patients; thereby, reducing the Ventilator-Associated Pneumonia rate.
Results show that the improvement in oral health was demonstrated by a
decrease in median scores on the Oral Assessment Guide (pre (11.0),
post (9.0)). A t-test analysis revealed a statistically significant difference
(p=0.0002). The frequency of oral care documentation is demonstrated by
52
a positive shift. The Ventilator-Associated Pneumonia rates have
decreased by 50% following the Ventilator-Associated Pneumonia
education intervention. The study concludes that the implementation of an
evidence-based practice educational programme focused on patient
outcome performed the quality of oral care delivered by the nursing
staff.(65)
Shiao SY.et.al,(2007) had done a study on Evidence-based
practice: use of the ventilator bundle to prevent ventilator-associated
pneumonia. This study was carried out to examine critical care nurses'
knowledge about the use of the ventilator bundle to prevent ventilator-
associated pneumonia. Education sessions were held to present the
findings to 61 nurses in coronary care and surgical intensive care units.
Changes in the nurses' knowledge were evaluated by using a 10-item test,
given both before and after the sessions. Results showed that , after the
education sessions, the nurses performed better on 8 of the 10 items
tested (P from .03 to <.001). The areas of most significant improvement
were elevation of the head of the bed (P < .001), Charting of the elevation
of the head of the bed (P= .009), Oral care (P= .009), checking of the
nasogastric tube for residual volume (P = .008), Washing of hands before
contact with patients (P < .001), and limiting the wearing of rings (P <
.001) and Nail Polish (P = .04). Even after the education sessions, the
nurses' compliance with hand-washing recommendations before contact
with patients was low, though statistically some improvement was
53
apparent. Contraindications to elevation of the head of the bed did not
appear to affect the nurses' practices (P= .38). Study concludes that, the
education sessions designed to inform nurses about the ventilator bundle
and its use to prevent ventilator-associated pneumonia. There was a
significant effect on participants knowledge and subsequent clinical
practice.(66)
Ania gonzalen.N et.al (2004) conducted a study on Assessment
of practice competence and scientific knowledge of Intensive Care Unit
nurses in the tracheal suctioning. This descriptive study, performed in 34
nurses, analyzed the performance of tracheal suctioning by direct
observation, using the data collection of a structured grid that included 19
aspects to evaluate, grouped into 6 categories. The results were
concluded that the study nurses have scientific knowledge of the
suctioning procedure that are better than their practice competence.
Discrepancies between practice and knowledge were also found in
several aspects evaluated. That orient towards the specific needs of
training in this procedure.(67)
University of Washington, USA. 2004: New data on the efficacy
of low tidal volume ventilation for acute lung injury, noninvasive ventilation
for chronic obstructive pulmonary disease exacerbation, weaning from
mechanical ventilation, and prevention of ventilator-associated pneumonia
provide, for perhaps the first time in respiratory care, compelling evidence
for clinicians to change practice. However, experience from every other
54
field in medicine suggests that there will be significant barriers to changing
clinical practice at the bedside. Studies on implementation of effective
practice in medicine show that a multifaceted, team oriented approach
incorporating reminders, efficient use of non physician personnel,
protocols, and education are required to change clinical practice. Limited
data on current practice of mechanical ventilation suggest that it deviates
from recommended practice. Unfortunately, there are no studies exploring
community based implementation of mechanical ventilation guidelines and
only a few studies to inform clinicians as to why ventilator practice may be
difficult to change. As the evidence base grows for effective critical care
practice, that improve outcome from research journals to patients
bedsides.(68)
Daedal us Enterprises 2003: Ventilator circuits should not be
changed routinely for infection control purposes. The maximum duration of
time that circuits can be used safely is unknown. Evidence is lacking
related to Ventilator-Associated Pneumonia and issues of heated versus
unheated circuits. Were type of heated humidifier, method for filling the
humidifier, and technique for clearing condensate from the ventilator
circuit. Although the available evidence suggests a lower Ventilator-
Associated Pneumonia rate with passive humidification than with active
humidification, other issues related to the use of passive humidifiers
(resistance, dead space volume, airway occlusion risk) preclude a
recommendation for the general use of passive humidifiers. Passive
55
humidifiers do not need to be changed daily for reasons of infection
control or technical performance. They can be safely used for at least 48
hours. The use of closed suction catheters should be considered part of a
Ventilator-Associated Pneumonia prevention strategy, and they do not
need to be changed daily for infection control purposes. The maximum
duration of time that closed suction catheters can be used safely is
unknown. Clinicians caring for mechanically ventilated patients should be
aware of risk factors for Ventilator-Associated Pneumonia (eg, nebulizer
therapy, manual ventilation, and patient transport).(69)
Fern Malila 2002: Long-term acute care (LTAC) hospitals and
units are becoming increasingly important to the management of patients
who have serious, complex critical illnesses. There required mechanical
ventilation for extended periods of time. Kindred Healthcare, INC., a nation
wide system of hospitals embarked on a quality initiative to establish a
Ventilator Management and Weaning Best Practice. The process steps
included: measurement of performance of all hospitals in the system using
a risk adjusted methodology to evaluate clinical outcomes. Identification of
facilities with superior outcomes; structured evaluation of the
characteristics, practices, and protocols of these Best Practice hospitals;
and utilization of the information gleaned from these hospitals to establish
evidence-based best practice ventilator management guidelines. Key
characteristics of the Best Practice hospitals were: hospital wide
philosophy, collaborative multidisciplinary plans of care, daily
56
communication; mutual respect for the contributions of all disciplines to the
weaning process; and early, aggressive nutrition support and intervention
by rehabilitation services. (70)
Marelich GP(2000) conducted a study on Protocol weaning of
mechanical ventilation in medical and surgical patients by respiratory care
practitioners and nurses: effect on weaning time and incidence of
ventilator-associated pneumonia. The study design was Prospective,
randomized, controlled study. the samples were Three hundred eighty-five
patients receiving mechanical ventilation. The study concluded that a
ventilator management protocol designed for multidisciplinary use was
effective in reducing the duration of mechanical ventilatory support without
any adverse effects on patient outcome. The ventilator management
protocal was also associated with a decrease in incidence of ventilator-
associated pneumonia in trauma patients. These results, in conjunction
with prior studies, suggest that ventilator management protocal s are
highly effective means of improving care.(71)
(c) Outcome Of Knowledge & Practice Regarding Ventilator Care Of
The Patients
Thomas P. Bleck, 2012: In this study the Burns Wean Assessment
Program is a 26-factor weaning assessment worksheet and scoring
instrument used to reduce practice variability in the clinical management
of patients receiving mechanical ventilation. The instrument has been
57
tested in patients in a medical-surgical Intensive Care Unit. To determine
the relationship between Burns Wean Assessment Program scores and
outcomes of weaning trials in patients treated with mechanical ventilation
for 3 or more days. For 5 years in 5 adult critical care units (surgical,
medical, neurological, thoracic-cardiovascular, and coronary care),
advanced practice nurses collected scores within 24hours of a weaning
attempt. All patients were managed similarly by using a multidisciplinary
pathway, the Burns Wean Assessment Program checklist, protocols for
weaning trials, and sedation guidelines. Of 1889 weaning attempts, 1669
(88%) were successful, and 220 (12%) were unsuccessful. Weaning
outcomes did not differ according to sex, but significantly more trials were
successful in younger patients. Than in older patients (P = .002) And in
patients in different units (P = .01). Regardless of unit, patients with Burns
Wean Assessment Program scores greater than 50 were significantly
more likely to be weaned successfully (P = .001) than were patients with
lower scores. Systematic tracking of the factors and scores on the Burns
Wean Assessment Program may be helpful in care planning and
management and in determining weaning potential. (72)
Halloran P. et. al 2010 conducted a research on Protocolized
versus non-protocolized weaning for reducing the duration of mechanical
ventilation in critically ill adult patients. Reducing weaning time is
desirable in minimizing potential complications from mechanical
ventilation. Standardized weaning protocols are purported to reduce time
58
spent on mechanical ventilation. However, evidence supporting their use
in clinical practice is inconsistent. To assess the effects of protocol
weaning from mechanical ventilation for critically ill adults; ascertain.
Differences between protocol and non protocol weaning in terms of
mortality, adverse events, quality of life, weaning duration, Intensive Care
Unit and hospital length of stay. and explore variation in outcomes by type
of Intensive Care Unit, type of protocol and approach to delivering the
protocol. We included randomized and quasi-randomized controlled trials
of protocol weaning versus non protocol weaning from mechanical
ventilation in critically ill adults. Three authors independently assessed trial
quality and extracted data. A prior subgroup and sensitivity analyses were
performed. Eleven trials that included 1971 patients met the inclusion
criteria. The total duration of mechanical ventilation geometric mean in the
protocol weaning group was on average reduced by 25% compared with
the usual care group (N = 10 trials, 95% CI 9% to 39%, P = 0.006);
weaning duration was reduced by 78% (N = 6 trials, 95% Confident
intervel 31% to 93%, P = 0.009); and Intensive Care Unit by 10% (N = 8
trials, 95% CI 2% to 19%, P = 0.02). There was significant heterogeneity
among studies for a total duration of mechanical ventilation (I(2) = 76%, P
< 0.01) and weaning duration (I(2) = 97%, P < 0.01), which could not be
explained by subgroup analyses based on the type of unit or type of
approach. There is some evidence of a reduction in the duration of
mechanical ventilation, weaning duration and Intensive Care Unit with the
59
use of standardized protocols. But there is significant heterogeneity
among studies. An insufficient number of studies to investigate the source
of this heterogeneity. Although some study authors suggest that
organizational context may influence outcomes. These factors were not
considered in all included studies.(73)
Stefano Nava (2011) conducted a study on Nursing specialty
certification and nursing-sensitive patient outcomes in the Intensive Care
Unit. The objective of the study is to determine whether the proportion of
certified nurses on a unit is associated with the rate of nurse-sensitive
patient outcomes. A non experimental, co relational, descriptive design
was used to anonymously survey 866 nurses were working in 25 intensive
care units in Southeast Michigan. The Conditions for Work Effectiveness
Questionnaire-II were used to measure workplace empowerment, and an
additional question was asked about certification status. Outcome data
were simultaneously collected on 3 nurse-sensitive patient outcomes: (1)
rate of central line catheter-associated blood stream infection, (2) rate of
ventilator-associated pneumonia, and (3) prevalence of pressure ulcers.
Results show that there was no significant relationship was found between
the proportion of certified nurses’ on a unit and patients' outcomes. The
association between nurses' perception of overall work-place
empowerment and certification, however, was positive and statistically
significant (r=.397, P=.05). They concluded that, the association between
workplace empowerment and the proportion of certified nurses on a unit
60
underscores the importance of organizational factors in the promotion of
nursing certification.(74)
S. Hartl 2010: Conducted a study on Incidence and outcome of
weaning from mechanical ventilation according to new categories. They
screened 510 patients who were admitted to the Intensive Care Unit
requiring mechanical ventilation. 79 (15%) patients received noninvasive
ventilation and did not require subsequent intubation. The remaining 431
(85%) patients were intubated. Of the intubated patients, 170 (39%) did
not start weaning because of death (33%), transfer to another Intensive
Care Unit (6%) or unplanned extubation (0.2%). The remaining 261 (51%
of the initial cohort or 61% of the intubated patients) patients started
weaning according to the recommendations. Four (1% of all intubated
patients) patients experienced unplanned extubation during weaning and
were excluded from the analysis. Therefore, 257 patients were included in
the final analysis. The cumulative incidences of simple, difficult and
prolonged weaning were 152 (59%), 68 (26%) and 37 (14%), were
respectively. The baseline characteristics of the 257 patients were
stratified by weaning category. Age and SAPS II score at the time of
admission did not differ between the groups. Co morbidity of chronic
respiratory failure a respiratory cause of admission were more common in
patients with prolonged weaning. (75)
Lavelle C, (2011) conducted a study on the importance of knowing
the patient in weaning from mechanical ventilation. The aim of the
61
research was to understand how nurses used technology to wean patients
from mechanical ventilation. An ethnographic approach was used to
understand how nurses used technology to wean patients from
mechanical ventilation. Data was gathered by participant observation and
interviewing over a 6-month period. In total, 250 h of field notes were
recorded. Three sub themes were identified: ways of knowing,
continuity of care and the role of the patient in the weaning trajectory.
'Knowing patients' was implied during the interviews as essential to the
delivery of patient centred care. There were two main factors that needed
to be present in order for nurses to know their patients: continuity of care
and expertise. 'Ways of knowing' was reliant on gaining information about
the patient. The role of the patient was a passive recipient of treatment.
Knowing the patient has been defined as a characteristic of expert
nursing. To be truly patient centred nursing needs to prevent nurses from
getting to 'know' their patients.(76)
Rose L., et al., (2009) done a study to categorizes the current
practice of mechanical ventilation and weaning in Australian and New
Zealand intensive care units. During 2005, a by national one-day survey of
55 intensive care units found the point-prevalence of mechanical
ventilation to be 284/491(58%). Common modes used were synchronized
intermittent mandatory ventilation with pressure support, pressure support
ventilation (each 116/284, 41%) and pressure-control modes (48/284,
17%). Pressure-control was more frequently used for patients with
62
respiratory disease. (odds ratio 4.7, 95% confidence interval 2.4 to 9.2, P
<0.001) or greater severity of illness (odds ratio 1.7, 95% confidence
interval 1.1 to 2.6, P = 0.01. Excluding cardiothoracic surgery patients, the
Kaplan-Meier estimated median total ventilation duration was 1.9 days
(inter quartile range 0.8 to 6.8 days). Apart from 24/255 (9.4%) patients
who received only pressure support ventilation, weaning methods
(attempted in 255 patients, 29 prior deaths) included: change to pressure
support ventilation (186/255, 73%), T-piece (31/255, 12%) or other
methods (14/255, 5.5%). The point prevalence of mechanical ventilation
was greater than comparable international studies. Australian and New
Zealand intensive care unit ventilatory practices were similar. Prominent
use of pressure-control modes and a preference for pressure support
ventilation weaning as opposed to T-piece.(77)
Hansen BS, (2007) done a study to identify intensive care
nurses' perceptions of protocol-directed weaning, by means of focus group
interviews and qualitative content analysis. The results showed that the
nurses perceived the protocol as useful. When prescribed, it represented
inter professional agreement that allowed them to act in the absence of a
physician. It focused on weaning, saved time, was easy to use and led to
a feeling of safety and continuity in the weaning process. Barriers to its
use were related to lack of instructions from physicians. Nurses reported
three ways of handling the situation in the absence of a weaning plan:
taking action, waiting, and giving weaning low priority, which could lead to
63
undesired variations. Nurses reported that they would like an
interdisciplinary approach to weaning and expressed the need for a
shared "language" or knowledge base in order to improve communication.
It is important that different disciplines meet to share each others
knowledge. Contact is vital in order to learn and respect different types of
professional knowledge.(78)
Isis Montalvo, 2007: The National Database of Nursing Quality
Indicators is the only national nursing database that provides quarterly and
annual reporting of structure, process, and outcome indicators to evaluate
nursing care at the unit level. Linkages between nurse staffing levels and
patient outcomes have already been demonstrated through the use of this
database. Currently over 1100 facilities in the United States contribute to
this growing database which can now be used to show the economic
implications of various levels of nurse staffing. The purpose of this article
is to describe the work and accomplishments related to the National
Database of Nursing Quality Indicators as researchers utilize its nursing
sensitive outcomes measures to demonstrate the value of nurses in
promoting quality patient care. After reviewing the history of evaluating
nursing care quality, this article will explain the purpose of the National
Database of Nursing Quality Indicators and describe how the database
has been operationalized. Accomplishments and future plans of the
National Database of Nursing Quality Indicators will also be discussed.
The National Database of Nursing Quality Indicators has made
64
considerable progress since the American Nursing Association Board of
Directors asked American Nursing Association staff to investigate the
impact of workforce restructuring and redesign on patient care and to
quantify the relationship between nurse staffing and patient outcomes.
Today's national spotlights on patient safety and public reporting have
increased the need for nursing to collect and monitor data related to
patient outcomes. Nursing has the appropriate workforce to render the
care necessary to optimize patient outcomes at the unit level. National
Database of Nursing Quality Indicators studies have demonstrated the
value of nursing care and the significance of nursing's contribution to
positive patient outcomes. National Database of Nursing Quality Indicators
data now has the validity and reliability to be used to evaluate nursing
care, improve patient outcomes, and identify the linkages between nurse
staffing and patient outcomes at the unit level. National Database of
Nursing Quality Indicators has indeed become the seminal nursing
database that is used to influence nursing policy and improve nursing
care. (79)
Davidson P.M. 2011 described nurses' attitudes to providing oral
care and their knowledge of the mode of transmission of ventilator-
associated pneumonia. Oral care is an important nursing intervention in
the intensive care unit to reduce dental plaque. Dental plaque provides
respiratory pathogens contributing to ventilator associated pneumonia in
the critically ill patients. This study used both survey and observational
65
methods. The observational study was conducted by a nurse, trained in
the study protocol. The observation period a selected shift over three
weeks. Intensive care unit nurses (n = 284) participated in the survey.
Respondents had a positive attitude towards providing oral care. On a 10-
point Likert scale, aspiration of contaminated secretions from the
oropharynx was identified by nurses as the highest risk factor for
ventilator-associated pneumonia (mean response 6.8, SD 2.0). The
majority of nurses used cotton and forceps for oral care. Toothbrushes
were not used in any of the study sites. Although nurses had a positive
attitude to oral hygiene, this study found no intensive care units
incorporated a soft toothbrush in oral care protocols which is
recommended in best practice guidelines. A review of strategies to
implement evidence-based practice in the intensive care unit is warranted.
This study has identified a failure to adhere with evidence-based practice.
Implementing and evaluating protocols for oral hygiene in the intensive
care unit improved patient outcomes.(80)
Gordon D. 2006: Revealed that An increased volume of patients
is associated with improved survival in numerous high-risk medical and
surgical conditions. The relationship between the number of patients
admitted (hospital volume) and outcome among patients with critical
illnesses is unknown. They analyzed data from 20,241 nonsurgical
patients receiving mechanical ventilation at 37 acute care hospitals. In the
Acute Physiology and Chronic Health Evaluation clinical information
66
system from 2002 through 2003. Multivariate analyses were performed to
adjust for the severity of illness and other differences in the case mix. An
increase in hospital volume was associated with improved survival among
patients receiving mechanical ventilation in the intensive care unitand in
the hospital. Admission to a hospital in the highest quartile according to
volume associated with a 37 percent reduction in the adjusted odds of
death in the Intensive Care Unit. As compared with admission to hospitals
in the lowest quartile (≤150 patients receiving mechanical ventilation per
year, P<0.001). In-hospital mortality was similarly reduced. A typical
patient in a hospital in a low-volume quartile would have an adjusted in-
hospital mortality of 34.2 percent as compared with 25.5 percent in a
hospital in a high-volume quartile. Among survivors, there were no
significant trends in the length of stay in the Intensive Care Unit or the
hospital. Mechanical ventilation of patients in a hospital with a high case
volume is associated with reduced mortality. Further research is needed to
determine the outcome among patients with a critical illness.(81)
Barry .E. 2005, reported the Intervention outcome measures
included ventilator-associated pneumonia frequency and the number of
days between ventilator-associated pneumonia incidence. The monthly
ventilator-associated pneumonia rate is calculated using the number of
ventilator-associated pneumonia cases as the numerator and the number
of ventilator days as the denominator. Days between incidences of
ventilator-associated pneumonia also were measured and reported along
67
with the monthly rate. At baseline, the incidence rate for ventilator-
associated pneumonia was 6%. Significant improvement in the ventilator-
associated pneumonia rate was noted within 4 months of implementation
of the ventilator bundle. The MICU achieved an 88% reduction in
ventilator-associated pneumonia over 2.6 years, with only three confirmed
cases of diagnosed ventilator-associated pneumonia over 738 days. By
tracking the data over time, we observed a continued and sustained
reduction in ventilator-associated pneumonia rate and a proportionate
increase in days between episodes. Other notable improvements: a 1.4
day decrease in monthly average length of stay, a 3% reduction in
mortality, and an overall 22% reduction in sedation days. A lesser
reduction in mortality rate was seen, although this was likely the result of a
10% increase in the number of patients requiring mechanical ventilation
each year since January 2003. In addition, a palliative care consultation
team became actively involved in the care of patients in the MICU.
Examination of data involving deaths in the MICU revealed that greater
than 93% of deaths occurred after end-of-life issues were addressed.
Founded in 1991 and based in Cambridge, Mass., the Institute for
Healthcare Improvement (IHI) is a not-for-profit organization, cultivating
innovative concepts for improving patient care and implementing
programs for putting these ideas into action. The 100,000 Lives Campaign
is a nationwide initiative of the IHI to radically reduce morbidity and
mortality in American healthcare. Building on the successful work of
68
healthcare providers all over the world, the Institute introduced proven
best practices across the country to extend or save as many as 100,000
lives. The IHI and its partners in this work believe it is possible to achieve
this goal by June 2006. (82)
Respiratory Care 1999: Results and observations related to
suctioning should be recorded to inform and alert other caregivers. The
suctioning procedure can be considered successful and the need for
suctioning affirmed by one or more of the following. Removal of secretions
improvement in breath sounds. Decreased peak inspiratory pressure
during volume cycled mechanical ventilation. Increased tidal volume
delivery during pressure cycled mechanical ventilation. Clearing of cough.
Improvement in Oxyhemoglobin Saturation as reflected by pulse oximetry.
Subjective improvement as reported by the patient. A decrease in
respiratory and heart rate and decreased shortness of breath.(83)
Saramma PP, Krishnakumar K, Dash PK, Sarma PS. Alcohol-
based hand rub and ventilator-associated pneumonia after elective
neurosurgery: An interventional study. Indian Journal of Critical Care Med
2011;15:203-8,studied on the effect of alcohol-based hand rub on
ventilator-associated pneumonia among neurosurgical patients are scarce
with aim to observe the effect of alcohol-based hand rub on
tracheobronchial colonization and ventilator-associated pneumonia after
elective neurosurgical procedures. Materials and Methods used was an
interventional study using a "before-after" design in a tertiary care center
69
in Kerala. Two 9-month study periods were compared; between these
periods, an infection control protocol incorporating an alcohol-based hand
rub was implemented for a period of 3 months and continued thereafter.
Consecutive patients who required mechanical ventilation after
neurosurgery between January and September 2006 and 2007,
respectively, were included. Outcome measures included ventilator-
associated pneumonia rate, tracheobronchial colonization rate, profile of
microorganisms and patient survival. Results was a total of 352 patients
were on mechanical ventilator for a varying period of 1-125 days. The
patients in the control and intervention groups were similar with regard to
sex, age and type of neurosurgery. Tracheobronchial colonization was
seen in 86 (48.6%) of 177 in the control group and 73 (41.7%) of 175
among the intervention group (P = 0.195). The ventilator-associated
pneumonia rates in the control and intervention groups were 14.03 and
6.48 per 1000 ventilator days (P = 0.08). The predominant organisms
causing ventilator-associated pneumonia and tracheobronchial
colonization were Klebsiella and Pseudomonas aeruginosa, respectively,
in both groups. Patient survival rates were 87.6% (control) and 92%
(intervention). Clinical results indicated a better outcome, showing a
reduction in tracheobronchial colonization rate and ventilator-associated
pneumonia rate, although this was not statistically significant.
Deven Juneja et.al Prevention and management of ventilator-
associated pneumonia: A survey on current practices by intensivists
70
practicing in the Indian subcontinent, , Department of Critical Care
Medicine, Max Super Speciality Hospital, Saket, New Delhi, India,
conducted a survey on implementation of evidence-based guidelines to
prevent and manage ventilator-associated pneumonia in the clinical
setting may not be adequate. He aimed to assess the implementation of
selected ventilator-associated pneumonia prevention strategies, and to
learn how ventilator-associated pneumonia is managed by the intensivists
practicing in the Indian Subcontinent. Three hundred 10-point
questionnaires were distributed during an International Critical Care
Conference held at New Delhi in 2009. A total of 126 (42%)
questionnaires distributed among delegates from India, Nepal and Sri
Lanka were analyzed. Majority (96.8%) reported using ventilator-
associated pneumonia bundles with a high proportion including head
elevation (98.4%), chlorhexidine mouth care (83.3%), stress ulcer
prophylaxis (96.8%), heat and moisture exchangers (92.9%), early
weaning (94.4%), and hand washing (97.6%) as part of their ventilator-
associated pneumonia bundle. Use of subglottic secretion drainage
(45.2%) and closed suction systems (74.6%) was also reported by many
intensivists, whereas use of selective gut decontamination was reported
by only 22.2%. There was good concordance regarding ventilator-
associated pneumonia prophylaxis among the intensivists with a majority
adhering to evidence-based guidelines.
71
Shiva B. N. Prasad, et.al studied the role of noninvasive ventilation
in weaning from mechanical ventilation in patients of chronic obstructive
pulmonary disease. Endotracheal intubation and Mechanical Ventilation
are often needed in patients of Chronic Obstructive Pulmonary Disease
with acute hypercapnic respiratory failure. The rate of weaning failure is
high and prolonged Mechanical Ventilation increases intubation
associated complications. The study aimed to evaluate the role of Non
Invasive Ventilation in weaning patients of chronic obstructive pulmonary
disease from Mechanical Ventilation, after T piece trial failure. The method
used was a prospective, randomized, controlled study was conducted in a
tertiary care centre. 30 patients of acute exacerbation of Chronic
Obstructive Pulmonary Disease with acute on chronic hypercapnic
respiratory failure, who were mechanically ventilated, were included in the
study. A T-piece weaning trial was attempted once the patients achieved
satisfactory clinical and biochemical parameters. After T-piece failure,
defined as pH < 7.35, PaCO2 >50 mmHg, PaO2 <50 mmHg, HR >100/min,
RR >35, patients were randomized to receive either Non Invasive
Ventilation or PSV. The result was the demography, severity of disease
and clinical profiles were similar in both groups. No significant difference
between the two groups in duration of Mechanical Ventilator (6.20 ± 5.20
days vs. 7.47 ± 6.38 days, P > 0.05), duration of weaning (35.17 ± 16.98
and 47.05 ± 20.98 hours, P > 0.05) or duration of Intensive Care Unit stay
(8.47 ± 4.79 and 10.80 ± 5.28 days, P > 0.05) in Gp I and Gp II,
72
respectively. Five patients developed VAP in the PSV group, where as
only one patient had pneumonia in the Non Invasive Ventilation group.
Lesser number of deaths in the Non Invasive Ventilation group at
discharge from Intensive Care Unit (3 vs. 5 patients, respectively) and at
30 days (5 vs. 9 patients, respectively), it did not achieve statistical
significance (P > 0.05). Non Invasive Ventilation is as useful as Presure
Support Ventilation in weaning and can be better in weaning failure
especially in Chronic Obstructive Pulmonary Disease for earlier weaning,
decrease Intensive Care Unit stay, complications and mortality.
73
2.2 PART-II
CONCEPTUAL FRAME WORK
The conceptual frame work for this study was derived from
modified GENERAL SYSTEM THEORY Ludwig von bertalanffy
1968.According to the general system theory ,the system is a set of
interacting parts within a boundary which make the system work well to
achieve its overall objective. The system is categorized as open or close.
Open system is that in which relatively free movements of information,
matter and energy in and out of the system exits.
The four major aspects of this system were,
INPUT:
Input is any type of information, energy and material that enters the
system from the environment through its boundaries. In this study the
input is structured teaching programme on Nursing care of patient with
Mechanical ventilator.
THROUGHPUT:
Through put is a process that allows the input to be changed, so that is
useful to the system. In this study, through put is a process of change
assimilation of knowledge and improving the level of practice on nursing
care of the patients with mechanical ventilator.
OUTPUT:
It is any information energy or material that leaves the system and enters
the environment through the system boundaries.
74
FEEDBACK:
It allows the system to monitor its internal function so, that it can either
restrict or encourage its input and output. In this study, the improved score
gained by the nurses indicate moderately adequate knowledge regarding
nursing care of the patients with mechanical ventilator.
INPUT:
Input is structured teaching programme on nursing care of patients with
mechanical ventilator.
THROUGHPUT:
It is a process of change assimilation of knowledge and improving the
level of practice on nursing care of patient with Mechanical Ventilator.
OUT PUT:
Output is improved level of knowledge, practice and outcome of patient
care.
1. Level of knowledge is evaluated like adequate, moderately adequate
and inadequate.
2. Practice is evaluated like poor, average and good after the structured
teaching programme on nursing care of patients with ventilator.
3. Outcome refers to whether ventilator care is good or poor.
4. In this study the outcome is assessed by the post test conducted
among the nurses after structured teaching programme.
75
CONCEPTUAL FRAME WORK BASED ON MODIFIED GENERAL SYSTEM MODEL
LUDWIG VON BERTANLANFFY (1968)
FIG: 01
76
CHAPTER- III
3. METHODOLOGY
3.1 Research Approach:
The methodology of research indicates the general and pattern of
organizing the procedure for collecting valid and reliable data for the problem
under investigation. The word research is composed of two syllables, Re and
search. Re is a prefix meaning again, anew or again, search is a verb meaning
to examine closely and carefully, to test and try, or to probe. Together they form
a noun describing a careful, systematic, patient study and investigation in some
field of knowledge, undertaken to establish facts or principles. Quasi-
experimental research approach is like true experiments, involve the
manipulation of an independent variable, which is an intervention. However,
Quasi-experimental design lack in true control group or randomization. But, in
this study, quasi experimental design was adopted with randomization and
manipulation with compromised control group.
3.2 Research Design:
The researcher’s overall plan for obtaining answers to the research
questions or for testing the research hypotheses is referred to as the research
design. The research design incorporates some often most important
methodological decisions that the researchers make in conducting a research
study. The research design stipulates the fundamental form that the research
will take. It has three phases: 1. Orientation and overview 2. Focused
77
exploration 3. Confirmation and closure. Quasi-experimental design is the non
equivalent control group pretest-posttest design, which involves an experiment
treatment and randomized two groups of subjects observed before and after its
implementation. In this study also Structured Teaching Program was the
intervention (Manipulation), pretest, posttest was performed for both control and
experimental groups.
3.3 Setting Of The Study: The study was conducted in Narayana Medical
College and Hospital, Nellore, A.P. It is located in Narayana Medical College
Campus at Nellore. Narayana General Hospital has 1030 beds with excellent
infrastructure and high end equipment, providing primary, secondary and tertiary
healthcare. Hospital is supported by ultra modern laboratory and around the
clock running blood bank. It has unique emergency medicine department
managed by qualified professionals to provide the quality care.
Narayana Super Specialty Hospital consists of 220 beds with state of the art
infrastructure with 18 modular operation theaters, well equipped different
Intensive Care Unit. Skilled professionals, nurses and Para medical staff provide
the quality health care around the clock. The clinical outcomes are excellent.
Narayana Hospital and Super Specialty are managed by a team of dedicated
medical professionals of Narayana with rich teaching, clinical and research
experience in reputed Medical Colleges and Hospitals in the Country. Narayana
hospital has totally 118 beds of intensive care units in various specialties like
Medical Intensive Care Unit, Surgical Intensive Care Unit, Obstetric and
78
Gynnaecology Intensive Care Unit, Neonatal Intensive Care Unit, Peadiatric
Intensive Care Unit, Renal Intensive Care Unit, and Hemo Dialysis Unit etc.
Whereas the Narayana superspeciality hospital has 78 beds of intensive care
beds which inclusive of organ transplants units, immediate post operative wards,
Neuro Intensive Care Unit, Neuro surgical Intensive Care Unit, Burns Intensive
Care Unit, Coronary Care Unit, Surgical Gastro Intensive Care Unit, Cardio
Thoracic Post Operative Intensive Care Unit. As the patient, Staff ratio is 1:1 for
each shift it was convenient to the investigator to get the samples as required to
study.
3.4 Population:. The population for this present study is registered nurses who
are working in critical care units.
Target Population: The Registered nurses those who are working in selected
hospitals at Nellore, A.P.
Accessible Population: The registered nurses those who are working in
Narayana Group of hospitals.
3.5 Sample: Total samples of 500 nurses were selected from the Narayana
Group of Hospitals.
3.6 Sampling Technique:
Probability sampling technique was used. The nurses who were working
in all the Intensive Care Unit listed with serial number. Totally 500 nurses were
selected as per inclusion criteria. All odd numbered staff was selected for the
79
experimental group. All even numbered staff was selected for control group.
Simple random sampling technique was used.
3.7 Sample Size:
Sample size of the study was 500 registered nurses who were working in
Intensive Care Unit of the Narayana Group of Hospitals.
3.8 Criteria For Sample Selection:
3.9 Inclusion Criteria:
1. Registered Nurses who were working in the Narayana group of
Hospitals. Age group between 20-40 years.
2. This study included both male and female nurses.
3. Those who were willing to participate in this study.
4. Those who were present at the time of data collection.
3.10 Exclusion Criteria:
1. Registered nurses who were working as in charge nurses.
2. Registered nurses who were working as nurse educators.
3. Registered nurses who were selected for Pilot Study.
4. Registered nurses who were not in the age group of 40 years and above.
5. Those who were not present during the time of data collection.
80
3.11 Variables Of The Study:
Independent Variable:
A structured teaching programme on nursing care of patients with
ventilator was considered as independent variable.
Dependent Variables:
1. Knowledge level of the nurses on ventilator care
2. Practicing skill of the nurses on Oral hygiene to patients on ventilator.
3. Practicing skill of the nurses on Endotracheal suction to patients’ on
ventilator.
4. Practicing skill of the nurses on Tracheostomy to patients’ on ventilator.
5. Practicing skill of the nurses on Weaning process to patients’ on
ventilator.
6. Outcome of the patients who were on Ventilator.
3.12 Content Validity:
Content validity concerns the degree to which an instrument has an
appropriate sample of items for the construct being measured.
The content validity for the tool was obtained from 3 nursing experts, 2
medical experts and one statistician.
Reliability:
The reliability of the instrument was analyzed by using test retest
method, which measured the coefficient of internal consistency. The obtained
value for the instrument score was r = 0.82. Thus the tool was considered
reliable.
81
3.13 Ethical Consideration:
The ethical principles followed in the study were
I. Beneficence
1. Freedom from harm and discomfort participants were not subject to
unnecessary risks for hard or discomfort during the study period.
2. Protection from exploitation of Participants they were assured that the
information they provided would be kept confidential.
II. Respect for human dignity
Participants were given full rights to ask questions, refuse to give
information and also to with draw from the study.
A written consent was obtained from the participants.
III. Justice:
The selection of study participants was completely based on research
requirements
Full privacy was maintained throughout the process of data collection.
3.14 Description Of The Tool:
The investigator developed a tool based on the review of literature and advice
from nursing and medical exports.
The tool was divided into three parts:
Part – I: Demographic Data: Age, Sex, Education, ward and Experience.
Part-II : It consists of,
a) Structured questionnaire:
82
The Structured questionnaire (multiple choice questions) was used to
assess the knowledge of nurses regarding mechanical ventilator care. A score
of one mark was given for every correct answer & a score of zero was given to
every wrong answer.
The total score was calculated as follows:
>75% - Adequate knowledge
51 – 74% - Moderate knowledge
<50% - Inadequate knowledge
b) Structured Observational check lists.
1. Structured Observational check list for oral hygiene to patients on
Mechanical ventilator care.
2. Structured Observational check list for endotracheal suctioning to
patients on Mechanical ventilator care.
3. Structured Observational check list for tracheostomy care to patients on
Mechanical ventilator care.
4. Structured Observational check list for weaning process to patients on
Mechanical ventilator care.
5. Structured Observational check list for the outcome of ventilator care.
The score was given according to the performance of the nurse. The total
score was calculated as follows:
>75% - Good
51 – 74% - Average
<50% - Poor performance.
83
3.15 Pilot Study:
The ethical clearance was obtained from ethical clearance committee.
After getting the content validity from the medical and nursing experts, the pilot
study was conducted in Narayana general hospital and superspeciality
hospitals, Nellore for the period of six months. The purpose of the pilot study
was to determine the feasibility of the main study and to refine the instrument.
Accordingly 30 nurses who fulfilled the inclusion criteria were selected for the
pilot study. In these 15 nurses were in the control group and 15 nurses were in
the experimental group. By using a structured questionnaire and structured
observational check lists pre test was conducted for both experimental and
control groups. Then the investigator performed the structured teaching
programme on nursing care of patients with mechanical ventilator among the
experimental group. On 30th day of the study post test was conducted for both
the groups by using the same questionnaire and check lists. The study was
feasible/, and the reliability of the tool was established by using the spearman’s
formula which was +1.
84
3.16 Data Collection Procedure:
The data collection procedure was done for a period of 6 months.
Permission to conduct the study was obtained from the medical superintendent
and nursing superintendent of Narayana general hospital and superspeciality
hospitals. The samples were informed by the investigator about the nature and
purpose of the study and consent was obtained. A total number of 500
registered nurses who met the inclusion criteria was selected by simple random
technique. Structured questionnaire and check list were used to assess the pre
test level of knowledge and practice. It took 30mins to administer questionnaire.
Each check list took minimum of 20 to 30 minutes. The structured teaching
programme was conducted for the experimental group. The registered nurses at
experimental group was divided into 5 sub groups with 50 members at each
group. The nurses are requested to attend class room teaching for 30
hours(3hrs x 10 days). The class room teaching was done by using Power Point
projections, charts and white board. The method of teaching was lecture,
discussion and question and answer. The practical training was given in their
work area itself. The investigator went to the work area in all three shifts and
demonstrated and requested the nurses to redemonstrate. So it took 1 hour time
approximately to complete each procedure. Totally the investigator conducted
the teaching program for 3 months. After thirty days of interval the same
structured questionnaire and check list were used to assess the post test level of
knowledge and practice among the experimental and the control groups. The
outcome of patient care with ventilator was measured by means of infection rate,
days of hospital stay, skin integrity, ventilator assisted pneumonia and tube
patency accordingly.
85
CHAPTER IV
4. DATA ANALYSIS AND INTERPRETATION
This chapter deals with the statistical analysis, a method of rendering
quantitative information in a meaningful and intelligible manner. The data can be
presented in the form of diagrams, graphs and tabular form. Often this enables
relationships, trends and comparisons to be grasped more readily. The data
was analyzed by using central tendency, percentage and inferential statistics.
The demographic variables are presented in percentage for comparing control
and experimental groups, comparison of knowledge and practice level among
the control group and the experimental group also done with percentage.
Comparison of post test knowledge and practice among the control group and
the experimental group was done with independent “Z” test. Correlation of
knowledge and practice in different variables was done by using Karl Pearson’s
correlation ‘r’ test. The association with demographic variables and dependent
variables were analyzed by Chi – square test.
This chapter was mainly classified into six sections for analyzing the data
according to the hypotheses:
86
SECTION-I : Frequency and percentage distribution of demographic variables.
SECTION-II :
1. Comparison of pre test and post test level of knowledge in the experimental
group and control group.
2. Comparison of pre test and post test level of practice in the
experimental group and control group.
SECTION-III : Comparison of pre and post test level of knowledge and practice
among the experimental group.
SECTION – IV: To correlate the post test knowledge levels with the post test
practice in experimental and control group.
SECTION-V: To find an association between post test results of experimental
and control group with the selected demographic variables.
SECTION –VI: To compare the outcome of the patient care with ventilator.
87
SECTION – I: FREQUENCY AND PERCENTAGE DISTRIBUTION OF
DEMOGRAPHIC VARIABLES.
TABLE – 1 a): FREQUENCY AND PERCENTAGE DISTRIBUTION OF AGE:
N = 500
FIG: 1 a) DISTRIBUTION OF FREQUENCY AND PERCENTAGE OF SAMPLES
BASED ON AGE N = 500
S.NO DEMOGRAPHIC
VARIABLE
EXPERIMENTAL
GROUP
CONTROL
GROUP
F % F %
1. AGE:
20-30 YEARS
31-40 YEARS
250
0
100%
0%
250
0
100%
0%
88
The above Figures and table I (a) showed, 500 samples were in the age group
of 20-30 years [250 experimental group, 250 control group].
TABLE – 1b. : FREQUENCY AND PERCENTAGE DISTRIBUTION OF SEX:
N = 500
FIG:1 b) DISTRIBUTION OF FREQUENCY AND PERCENTAGE OF SAMPLES BASED ON SEX N = 500
The above Figures and table I (b) showed, regarding sex 12.8% (32) samples
were male in experimental group, 22.4% (56) samples were in
S.NO DEMOGRAPHIC
VARIABLE
EXPERIMENTAL
GROUP
CONTROL
GROUP
F % F %
1 SEX:
MALE
FEMALE
32
218
12.8%
87.2%
56
194
22.4%
77.6%
SEX
89
control group. 87.2% (218) samples were female in
experimental group, 77.6% (194) samples were in control group.
TABLE – 1 c) : FREQUENCY AND PERCENTAGE DISTRIBUTION OF
EDUCATION: N = 500
FIG:1 C) DISTRIBUTION OF FREQUENCY AND PERCENTAGE OF SAMPLES BASED ON EDUCATION N = 500
S.NO DEMOGRAPHIC
VARIABLE
EXPERIMENTAL
GROUP
CONTROL
GROUP
F % F %
1. EDUCATION:
GNM
B.Sc. [N]
112
138
44.8%
55.2%
184
66
73.6%
26.4%
90
The above Figures and table I (c) showed, regarding education 44.8% (112)
were studied GNM in experimental group, 73.6% (184) were studied GNM in
control group. 55.2% (138) samples were studied B.Sc. [N] in experimental
group, 26.4% (66) samples in control group.
TABLE – 1 d) : FREQUENCY AND PERCENTAGE DISTRIBUTION OF
WARD: N = 500
FIG:1 D) DISTRIBUTION OF FREQUENCY AND PERCENTAGE OF SAMPLES BASED ON WARD N = 500
The above table I (d) showed, regarding ward 6.4% (16) samples were from
emergency, 16.8% (42) samples were from post operative ward, and 76.8%
S.NO DEMOGRAPHIC
VARIABLE
EXPERIMENTAL
GROUP
CONTROL
GROUP
F % F %
1.
WARD:
EMERGENCY
POST-OPERATIVE WARD
INTENSIVE CARE UNIT
16
42
192
6.4%
16.8%
76.8%
16
42
192
6.4%
16.8%
76.8%
91
(192) samples were from ICU in experimental group. Regarding working area
6.4% (16) samples from emergency, 16.8% (42) samples from post operative
ward, 76.8% (192) samples from ICU in control group.
TABLE – 1 e) : FREQUENCY AND PERCENTAGE DISTRIBUTION OF
EXPERIENCE: N = 500
FIG:1 E) DISTRIBUTION OF FREQUENCY AND PERCENTAGE OF SAMPLES BASED ON EXPERIENCE N = 500
S.NO DEMOGRAPHIC
VARIABLE
EXPERIMENTAL
GROUP
CONTROL
GROUP
F % F %
1. EXPERIENCE:
1-3 YEARS
4-6 YEARS
242
8
96.8%
3.2%
250
0
100%
0%
92
The above table I e) showed, regarding experience 96.8% (242) were having 1-
3 years of experience only 3.2% (8) samples were having 4-6 years of
experience in experimental group. 100% (250) samples were having 1-
3 years of experience in control group.
SECTION-II: 1. COMPARISON OF PRE TEST AND POST TEST LEVEL OF
KNOWLEDGE IN EXPERIMENTAL AND CONTROL GROUP.
1. COMPARISON OF PRETEST AND POSTTEST LEVEL OF PRACTICE IN
EXPERIMENTAL AND CONTROL GROUP.
TABLE - 2:
I) . COMPARISON OF PRE TEST AND POST TEST LEVEL OF KNOWLEDGE IN
EXPERIMENTAL GROUP AND CONTROL GROUP
N = 500
S.NO CRITERIA LEVEL OF KNOWLEDGE
INADEQUETEKNOWLEDGE
MODERATELY ADEQUATE
KNO WLEDGE
ADEQUATE KNOWLEDGE
F % F % F %
1.
PRE
TEST
EXPERIMENTAL
GROUP
152
60.8 96
38.4 2
0.8
CONTROL
GROUP
144
57.6 106
42.4 -
-
2. POST
TEST
EXPERIMENTAL
GROUP
-
- 48
19.2 202
80.8
93
FIG: 2(I): COMPARISON OF PRETEST AND POST TEST LEVEL OF KNOWLEDGE
IN EXPERIMENTAL GROUP AND CONTROL GROUP. N = 500
The above figure and table: 2 (I) shows that in pre test experimental group
out of 250 nurses, 60.8% (152) had inadequate knowledge,38.4%(96) had
moderately adequate knowledge and 0.8% (2) had adequate knowledge in
experimental group. In pre test control group 57.6% (144) had inadequate
knowledge, 42.4% (106) had moderately adequate knowledge. In the post test
experimental group, nobody had inadequate knowledge, 19.2% (48) had
moderately adequate knowledge 80.8% (202) had adequate knowledge. In the
CONTROL
GROUP
144
57.6 106
42.4 -
-
94
Post test control group 57.6% (144) had inadequate knowledge, 42.04% (106)
had moderately adequate knowledge and nobody had adequate knowledge. So
it is proved the effectiveness of Structured Teaching Program. The hypothesis –
I is accepted.
II). COMPARISON OF PRETEST AND POSTTEST LEVEL OF PRACTICE IN
EXPERIMENTAL AND CONTROL GROUP.
This section dealt with practices of a) oral hygiene, b) tracheostomy care, c)
endotracheal tube suctioning and d) weaning process practices.
TABLE – 2 (II):
a) COMPARISON OF PRETEST AND POST TEST LEVEL OF ORAL HYGIENE PRACTICE AMONG EXPERIMENTAL AND CONTROL GROUP N = 500
S.NO CRITERIA LEVEL OF PRACTICE
POOR AVERAGE GOOD
F % F % F %
1. PRE TEST EXPERIMENTAL
GROUP
183 73.2 67 26.8 - -
CONTROL GROUP 183 73.2 64 25.6 3 1.2
2. POST TEST EXPERIMENTAL
GROUP
8 3.2 50 20 192 76.8
95
CONTROL GROUP 217 86.8 31 12.4 2 0.8
FIG: 2(II) a.
COMPARISON OF PRETEST AND POST TEST LEVEL OF ORAL HYGIENE
PRACTICE AMONG EXPERIMENTAL AND CONTROL GROUP
The above figure and table: 2 (II) a. showed oral hygiene practice.
Out of 250 nurses 73.2% (183) had poor practice, 26.8% (67) had average and
there is no good in oral hygiene practice in the pretest experimental group. In
Pre test control group 73.2% (183) had poor practice, 25.6% (64) had average
and 1.2% (3) had good in oral hygiene practice. In post test experimental group,
3.2% (8) had poor, 20% (50) average and 76.8% (192) had good in practice. But
96
in post test control group 86.8% (217) had poor performance, 12.4% (31) had
average performance and 0.8% (2) were good in oral hygiene practice. It
showed that the structured teaching program was effective. The hypothesis – I is
accepted.
TABLE – 2(II) (b) :
COMPARISON OF PRETEST AND POST TEST LEVEL OF TRACHEOSTOMY
CARE PRACTICE AMONG EXPERIMENTAL AND CONTROL GROUP. N = 500
S.NO CRITERIA LEVEL OF PRACTICE
POOR AVERAGE GOOD
F % F % F %
1.
PRE TEST
EXPERIMENTAL
GROUP
83
33.2 167
66.8 - -
CONTROL GROUP108 43.2 142 56.8 - -
2. POST TEST EXPERIMENTAL
GROUP
-
- 42 16.8 208 83.2
CONTROL GROUP 125 50 125 50 - -
97
FIG: 2(II) (b): COMPARISION OF PRETEST AND POST TESTLEVEL OF
TRACHEOSTOMY CARE PRACTICE AMONG EXPERIMENTAL
ANDCONTROL GROUP. N = 500
The above figure and table: 2(II) (b) showed out of 250 nurses 33.2% (83)
had poor practice, 66.8% (167) had average and nobody good in tracheostomy
care practice in pretest experimental group. In pre test control group 43.2%
98
(108) had poor practice, 56.8% (142) had average and nobody had good in
tracheostomy care. In post test experimental group nobody had poor practice,
16.8% (42) had average and 83.2% (208) had good in tracheostomy care
practice. In post test control group 50% (125) had poor practice, 50% (125) had
average in their performance of tracheostomy care. It reflected the significant
difference of practice after structured teaching program. This hypothesis – I is
accepted.
TABLE – 2(II) (c):
COMPARISION OF PRETEST AND POST TEST LEVEL OF ENDOTRACHEAL
TUBE SUCTIONING PRACTICE AMONG EXPERIMENTAL AND CONTROL
GROUP.
N = 500
S.NO CRITERIA LEVEL OF PRACTICE
POOR AVERAGE GOOD
F % F % F %
1.
PRE TEST
EXPERIMENTAL
GROUP
100 40 142 56.8 8 3.2
CONTROL GROUP 83 33.2 167 66.8 - -
2.
POST TEST
EXPERIMENTAL
GROUP
- - 75 30 175 70
CONTROL GROUP 83 33.2 167 66.8 - -
99
FIG: 2(II) (c)
COMPARISION OF PRETEST AND POST TEST LEVEL OF ENDOTRACHEAL
TUBE SUCTIONING PRACTICE AMONG EXPERIMENTAL AND CONTROL GROUP
The above figure and table: 2(II) (c) showed regarding the
endotracheal tube suctioning practice, out of 250 nurses in pre test experimental
100
group 40% (100) had poor practice, 56.8% (142) had average and 3.2% (8) had
good in practice. In pre test control group 33.2% (83) had poor practice, 66.8%
(167) had average and nobody had good in practice. In post test experimental
group nobody in poor practice, 30% (75) had average and 70% (175) had good
in practice. In post test control group 33.2% (83) had poor practice, 66.8% (167)
had average and nobody had good in endotracheal tube suctioning practice. It
showed the structure teaching programme had good effect to improve the
quality care for the patients, and hypothesis – I is accepted.
TABLE – 2(II) (d):
COMPARISION OF PRETEST AND POST TEST WEANING PROCESS PRACTICE
N = 500
S.NO CRITERIA LEVEL OF PRACTICE
POOR AVERAGE GOOD
F % F % F %
1. PRE TEST EXPERIMENTAL GROUP
98 39.2 144
57.6 8 3.2
CONTROL GROUP 81 32.4 169 67.6 - -
2. POST TEST
EXPERIMENTAL GROUP
- - 75 30 175 70
CONTROL GROUP 75 30 175 70 - -
101
FIG: 2(II) (d)
COMPARISION OF PRETEST AND POST TEST WEANING PROCESS PRACTICE
The above figure and table: 2(II) (d) showed the weaning process practice, out
of 250 nurses in pre test experimental group, 39.2% (98) had poor practice,
57.6% (144) had average practice and 3.2% (8) had good in weaning process
practice. In pre test control group 32.4% (81) had poor, 67.6% (169) had
102
average and nobody had good in weaning process practice. In post test
experimental group nobody had poor, 30% (75) had average and 70% (175) had
good in weaning process practice. In post test control group, 30% (75) had poor
practice, 70% (175) had average practice and nobody had good in weaning
process practice. It showed the effectiveness of structured teaching program,
the hypothesis – I is accepted.
SECTION-III: COMPARISON OF POST TEST LEVEL OF KNOWLEDGE AND
PRACTICE IN EXPERIMENTAL AND CONTROL GROUP.
I. COMPARISON OF POST LEVEL OF KNOWLEDGE IN EXPERIMENTAL AND
CONTROL GROUP.
II. COMPARISON OF POST TEST LEVEL OF PRACTICE IN EXPERIMENTAL AND
CONTROL GROUP.
a) Oral hygiene, b) Tracheostomy care, c) endotracheal tube suctioning and d)
weaning process.
TABLE – 3 (I) :
I. COMPARISON OF POST TEST LEVEL OF KNOWLEDGE IN
EXPERIMENTAL AND CONTROL GROUP - INDEPENDENT “Z” TEST
N = 500
S.NO CRITERIA MEAN S.D Z- VALUE
1. Post test level of knowledge in
experimental group on nursing care
of the patients with mechanical
31.8 3.18
34.67
103
ventilator
2. Post test level of knowledge in
control group on nursing care of the
patients with mechanical ventilator
20.7 3.940
* = significant at 0.05 level (P<0.05) = Z Tab Value = 1.96
The above table: 3 (I) showed the post test level of knowledge in
experimental group on nursing care of the patients with ventilator the mean
value is 31.8, and S.D value is 3.18. The post test level of knowledge in control
group on nursing care of the patients with ventilator mean value is 20.7 and S.D
value is 3.940.The Z value is 34.67 which is greater than the Z-tab value, so it
is significant at the level of 0.05. There was highly significant difference between
the experimental group and the control group regarding knowledge of ventilator
care after structured teaching programme. Since the hypothesis –II is accepted.
104
TABLE – 3(II) a. :
COMPARISION OF POST – TEST ORAL HYGIENE PRACTICE LEVELS IN
EXPERIMENTAL AND CONTROL GROUP- INDEPENDENT “Z” TEST
N = 500
S.NO CRITERIA MEAN S.D “Z “ VALUE
1.
2.
Post test level of oral hygiene practice in
experimental group on nursing care of
the patients with mechanical ventilator
Post test level of oral hygiene practice in
control group on nursing care of the
patients with mechanical ventilator
10.8
5.6
1.107
0.906
635.6 *
* = significant at 0.05 level (P<0.05) = 1.96
The above table: 3 (II) a. showed the post test level of oral hygiene
practice in experimental group on nursing care of the patients with ventilator
105
mean value is 10.8 the post test level of oral hygiene practice in control group on
nursing care of the patients with ventilator mean value is 5.6 and S.D value is
0.906 and Z value is 635.6 which is greater than the Z-tab value, It was
significant at the level of 0.05. There is highly significant difference between the
experimental and control group regarding oral hygiene practice. Since the
hypothesis –II is accepted.
TABLE – 3 (II) b. :
COMPARISION OF POST – TEST TRACHEOSTOMY CARE PRACTICE
LEVELS IN EXPERIMENTAL AND CONTROL GROUP - INDEPENDENT
“Z” TEST N = 500
* = significant at 0.05 level (P<0.05) = 1.96
S.NO CRITERIA MEAN S.D “Z “
VALUE
1.
2.
Post test level of tracheostomy care
practice in experimental group on
nursing care of the patients with
mechanical ventilator
Post test level of tracheostomy care
practice in control group on nursing
care of the patients with mechanical
ventilator
11.1
6.6
1.3
1.08
42.09896
*
106
The above table: 3 (II) b. showed the post test level of tracheostomy
care practice in experimental group on nursing care of the patient with ventilator
mean is 11.1 and S.D value is 1.3 the post test level of tracheostomy patient in
control group on nursing care of the patient with ventilator mean value is 6.6 and
S.D value is 1.08. The Z value is 42.098 which is greater than the Z-tab value. It
is significant at the level of 0.05. There was highly significant difference between
the experimental group and the control group regarding tracheostomy care
practice after structured teaching programme. So the hypothesis II was
accepted.
TABLE – 3 (II) c.:
COMPARISION OF POST – TEST ENDOTRACHEAL TUBE SUCTIONING
PRACTICE LEVELS IN EXPERIMENTAL AND CONTROL GROUP -
INDEPENDENT “ Z ” TEST N = 500
S.NO CRITERIA MEA
N
S.D Z-VALUE
1. Post test level of endotracheal
suctioning practice in experimental
group on nursing care of the patients
with mechanical ventilator.
7.8 0.55
34.27 * 2. Post test level of endotracheal
suctioning practice in control group on
nursing care of the patients with
mechanical ventilator
4.9 1.22
0
* = significant at 0.05 level (P<0.05) = 1.96
107
The above table: 3 (II) c. showed post test level of endotracheal tube
suctioning practice in experimental group on nursing care of the patients, the
mean value is 7.8 and S.D value is 0.55. Post test level of endotracheal tube
suctioning practice in control group on nursing care of the patients with
mechanical ventilator the mean value is 4.9 and the S.D value is 1.220. This
showed the Z-cal value 34.27 which is greater than the Z-tab value. It was
significant at the level of 0.05. There is highly significant difference between the
experimental group and control group regarding endotracheal tube suctioning
practice after structured teaching programme. So the hypothesis II was
accepted.
TABLE – 3 (II) d.:
COMPARISION OF POST – TEST WEANING PROCESS PRACTICE LEVELS
IN EXPERIMENTAL AND CONTROL GROUP - INDEPENDENT “Z” TEST
N = 500
* = significant at 0.05 level (P<0.05) = 1.96
S.NO CRITERIA MEAN S.D Z-
VALUE
108
1.
2.
Post test level of Weaning practice in
experimental group on nursing care of
the patients with mechanical ventilator.
Post test level of Weaning practice in
control group on nursing care of the
patients with mechanical ventilator.
7.9
4.8
0.54
1.230
34.27
*
The above table 3 (II) d. revealed the Post test level of Weaning process
practice in experimental group on nursing care of the patients, the mean value is
7.9 and S.D value is 0.54. Post test level of Weaning process practice in control
group on nursing care of the patients with mechanical ventilator the mean value
is 4.8 and the S.D value is 1.230. This showed Z-cal value 34.27 which is
greater than the Z-tab value. It is significant at the level of 0.05 ed. There was
highly significant difference between the experimental group and control group
regarding Weaning process practice after structure teaching programme. So the
hypothesis II was accepted.
SECTION-IV: CORRELATION OF POST TEST KNOWLEDGE AND
PRACTICE:
I. CORRELATION OF POST TEST KNOWLEDGE AND PRACTICE IN EXPERIMENTAL
GROUP:
a) Oral hygiene, b) Tracheostomy care, c) endotracheal tube suctioning and d)
weaning process.
TABLE – 4 (I) (a):
CORRELATION OF POST TEST KNOWLEDGE AND PRACTICE OF ORAL
HYGIENE IN EXPERIMENTAL GROUP: N = 500
109
S.NO CRITERIA MEAN “r”
VALUE
1 Posttest knowledge of nurses on nursing care of
the patients with mechanical ventilator in
experimental group
31.8
+0.33
2 Post-test practice of oral hygiene on patients
with mechanical ventilator in experimental
group.
10.8
The above table: 4 (I) (a) showed the Posttest knowledge of nurses on
nursing care of the patients with mechanical ventilator in experimental group the
mean value is 31.8. The post-test practice of oral hygiene on patients with
mechanical ventilator in experimental group the mean value is 10.8. The r value
is +0.33. There is a positive correlation between the post test knowledge and
practice of oral hygiene in experimental group. Thus the hypothesis III was
accepted.
TABLE – 4 (I) b:
CORRELATION OF POST TEST KNOWLEDGE AND PRACTICE OF
TRACHEOSTOMY CARE IN EXPERIMENTAL GROUP: N = 500
S.NO CRITERIA MEAN “r”
VALUE
110
1 Post-test knowledge of nurses on nursing care
of the patients with mechanical ventilator in
experimental group
31.8
+0.96
2 Post-test practice of tracheostomy care on
patients with mechanical ventilator in
experimental group
11.1
The above table: 4 (I) b revealed the Post-test knowledge of nurses on
nursing care of the patients with mechanical ventilator in experimental group the
mean value is 31.8. The post-test practice of tracheostomy care on patients with
mechanical ventilator in experimental group the mean value is 11.1. The “r”
value is +0.96. There is a positive correlation was existed between the post test
knowledge and practice of tracheostomy care in experimental group. Hence the
hypothesis III was accepted.
TABLE – 4 (I) c:
CORRELATION OF POST TEST KNOWLEDGE AND PRACTICE OF
ENDOTRACHEAL TUBE SUCTIONING IN EXPERIMENTAL GROUP
N = 500
S.NO CRITERIA MEAN “r”
111
The above table: 4 (I) c. found the post-test knowledge of nurses on
nursing care of the patients with mechanical ventilator in experimental group the
mean value is 31.8. The post-test practice of endotracheal tube suctioning on
mechanical ventilator in experimental group the mean value is 7.8. The “r” value
is +0.14. There was a positive correlation of post test knowledge and practice of
endotracheal tube suctioning in experimental group. Thus the hypothesis III was
accepted.
TABLE – 4 (I) d:
CORRELATION OF POST TEST KNOWLEDGE AND PRACTICE OF
WEANING PROCESS PRACTICE IN EXPERIMENTAL GROUP: N = 500
VALUE
1 Post-test knowledge of nurses on nursing care
of the patients with mechanical ventilator in
experimental group
31.8
+0.14
2 Post-test practice of endotracheal suctioning on
mechanical ventilator in experimental group 7.8
S.NO CRITERIA MEAN “r”
112
The above table: 4 (I) d informed the post-test knowledge of nurses on
nursing care of the patients with mechanical ventilator in experimental group the
mean value is 31.7. The post-test practice of Weaning process practice on
mechanical ventilator in experimental group the mean value is 7.9. The r value is
+0.14. There is a positive correlation of post test knowledge and weaning
practice of experimental group. Hence the hypothesis III was accepted.
SECTION- V: ASSOCIATION BETWEEN PRE TEST RESULTS OF
EXPERIMENTAL AND CONTROL GROUP WITH THE SELECTED
DEMOGRAPHIC VARIABLES.
VALUE
1 Post-test knowledge of nurses on nursing care
of the patients with mechanical ventilator in
experimental group
31.7
+0.14
2 Post-test practice of Weaning practice on
mechanical ventilator in experimental group 7.9
113
I. Association between pre test and post test knowledge level and practice of
oral hygiene, tracheostomy care, endotracheal tube suctioning and weaning
process with demographic variables of age, sex, education, ward and
experience in experimental group.
II. Association between pre test and post test knowledge level and practice
of oral hygiene, tracheostomy care, endotracheal tube suctioning and weaning
process with demographic variables of age, sex, education, ward and
experience in control group.
The data were analyzed by using chi square inferential method for significant
level with degree of freedom and p<0.05 level. The data were tabulated and
assigned with serial numbers as 5.1 and alphabetic a to e for association of
variables like knowledge, practice of oral hygiene, tracheostomy care,
endotracheal tube suctioning and weaning process with demographic variables
of experimental group in pretest.
For control group in pretest the tables were serial as 5.II and alphabetic a to e
for association of variables like knowledge, practice of oral hygiene,
tracheostomy care, endotracheal tube suctioning and weaning process with
demographic variables. Whereas for post test analysis 5.I and 5.II and
alphabetic f to j were assigned for both experimental and control group
TABLE 5. I. a. ASSOCIATION OF PRE TEST KNOWLEDGE WITH
DEMOGRAPHIC VARIABLES IN EXPERIMENTAL GROUP. N=250
S.NO DEMOGRAPHIC VARIABLES
KNOWLEDGE Chi-square
Table ValueInadequate Moderately Adequate
114
knowledge Adequate knowledge
knowledge
1 AGE 20-30 YEARS 31-40YEARS
144
-
106
-
- -
0
D.f=1
3.86 N.S
2 SEX:
MALE
FEMALE
22
122
10
96
-
-
2.156
D.f=1
3.86
N.S
3 EDUCATION:
GNM
B.Sc. [N]
90
54
22
84
-
-
42.05
D.f=1
3.86
S
4
WARD:
EMERGENCY
POSTPERATIVE
ICU
10
42
92
6
-
100
-
-
-
36.39
D.f=1
3.86
S
5 EXPERIENCE:
1-3 YEARS
4-6 YEARS
142
2
100
6
-
-
5.534
D.f=1
3.86
S
NS indicates: Non significant D.f = degree of freedom
The Above Table: 5. I. (a). showed the association between pretest knowledge
with demographic variables in experimental group. The calculated chi-square
values were greater in education 42.05 with d.f.1,ward 36.39 d.f.1 and experience
5.534 d.f.1. So the education, ward and experience had significant association at p
0.05 level. Other demographic variables age and sex had no significant
association with pre test knowledge level. The hypothesis – IV is accepted.
5 I. b.)ASSOCIATION OF PRE TEST ORAL HYGINE LEVEL WITH DEMOGRAPHIC VARIABLES IN EXPERIMENTAL GROUP. N=250
S.NO DEMOGRAPHIC
VARIABLES
ORAL HYGINE Chi-
square
Table
Value Poor Average Good
115
1 AGE
20-30 YEARS
31-40YEARS
183
-
64
-
3
-
0
D.f=1
3.86
N.S
2 SEX:
MALE
FEMALE
23
160
9
55
-
3
2.4
D.f=1
5.99
N.S
3 EDUCATION:
GNM
B.Sc.[N]
90
93
22
42
-
3
6
D.f=2
5.99
S
4
WARD
EMERGENCY
POSTOPERATIVE
ICU
6
39
138
10
3
51
-
-
3
20.52
D.f=2
5.99
S
5 EXPERIENCE:
1-3 YEARS
4-6 YEARS
181
2
61
3
-
3
13.665
D.f=12
5.99
S
NS indicates: Non significant D.f = degree of freedom
The Above Table: 5. I. (b). showed the association between pretest practice of
oral hygiene with demographic variables in experimental group. The calculated
chi-square values were greater in education 6 with d.f.2, ward 20.52, d.f.1 and
experience 13.665, d.f.2. So the education, ward and experience had significant
association at p 0.05 level. Other demographic variables age and sex had no
significant association with pre test oral hygiene practice. The hypothesis – IV is
accepted.
5 I.c). ASSOCIATION OF PRE TEST TRACHESTOMY CARE LEVEL WITH
DEMOGRAPHIC VARIABLES IN EXPERIMENTAL GROUP. N=250
S.NO DEMOGRAPHIC
VARIABLES
TRACHESTOMY CARE Chi-
square
Table
ValuePoor Average Good
116
1 AGE
20-30 YEARS
31-40YEARS
108
-
142
-
-
-
0
D.f=1
3.84
N.S
2 SEX:
MALE
FEMALE
11
97
21
121
-
-
93
D.f=1
3.84
S
3 EDUCATION:
GNM
B.Sc.[N]
64
44
48
94
-
-
16
D.f=1
3.84
S
4
WARD:
EMERGENCY
POSTOPERATIVE
ICU
8
34
66
8
8
126
-
-
-
352
D.f=1
3.84
S
5 EXPERIENCE:
1-3 YEARS
4-6 YEARS
108
-
134
8
-
-
7.218
D.f=1
3.84
S
NS indicates: Non significant D.f = degree of freedom
The Above Table: 5. I. (c). revealed the association between pretest
tracheostomy care with demographic variables in experimental group. The
calculated chi-square values were greater in sex 93, d.f. 1, education 16 with
d.f.1, ward 352, d.f.1 and experience 7.218, d.f.1. So the sex, education, ward
and experience had significant association at p 0.05 level. Other demographic
variable age had no significant association with pre test tracheostomy care
practice. The hypothesis – IV is accepted.
5 I d). ASSOCIATION OF PRE TEST ENDOTRACHEAL TUBE SUCTIONING
LEVEL WITH DEMOGRAPHIC VARIABLES IN EXPERIMENTAL GROUP.
N=250
S.NO DEMOGRAPHIC ENDOTRACHEAL TUBE Chi- Table
117
VARIABLES SUCTIONING square value Poor Average Good
1 AGE 20-30 YEARS 31-40YEARS
83 -
167
-
- -
0 D.f=1
3.84 N.S
2 SEX: MALE FEMALE
27 56
5 162
- -
119.07 D.f=1
3.84 S
3 EDUCATION: GNM B.Sc.[N]
41 42
71 96
- -
1.06 D.f=1
5.99 N.S
4
WARD: EMERGENCY POSTOPERATIVE ICU
7 31 44
9 11 147
- - -
40.58 D.f=1
3.84 S
5 EXPERIENCE: 1-3 YEARS 4-6 YEARS
81 2
161 6
- -
6.718 D.f=1
3.84 S
NS indicates: Non significant D.f = degree of freedom The
Above Table: 5. I. (d). stated the association between pretest endotracheal tube
suctioning with demographic variables in experimental group. The chi-square
values calculated were greater in sex 119.07 d.f.1, ward 40.58, d.f.1 and
experience 6.718, d.f.1. So the sex, ward and experience had significant
association at p 0.05 level. Other demographic variables age and education had
no significant association with pre test endotracheal tube suctioning practice.
The hypothesis – IV is accepted.
5 I e). ASSOCIATION OF PRE TEST WEANING PROCESS LEVEL WITH
DEMOGRAPHIC VARIABLES IN EXPERIMENTAL GROUP.
N=250
S.NO DEMOGRAPHIC WEANING PROCESS Chi- Table
118
VARIABLES Poor Average Good square value 1 AGE
20-30 YEARS 31-40YEARS
81 -
169
-
- -
0 D.f=1
3.84 N.S
2 SEX: MALE FEMALE
20 61
12 157
- -
18.3 D.f=1
3.84 S
3 EDUCATION: GNM B.Sc.[N]
58 23
54 115
- -
35.76 D.f-=1
3.84 H.S
4
WARD: EMERGENCY POSTPERATIVE ICU
8
21 52
8
21 140
- - -
10.23 D.f=1
3.84 S
5 EXPERIENCE: 1-3 YEARS 4-6 YEARS
79 2
163
6
- -
6.0468 D.f=1
3.84 S
NS indicates: Non significant D.f = degree of freedom
The Above Table: 5. I. (e). stated the association between pretest weaning
process with demographic variables in experimental group. The chi-square
values calculated were greater in sex 18.3, d.f.1, education 35.76, d.f 1, ward
10.23, d.f.1 and experience 6.046, d.f.1. So the sex, education, ward and
experience had significant association at p 0.05 level. Other demographic
variables age had no significant association with pre test weaning process
practice. The hypothesis – IV is accepted.
TABLE – 5. II (a):
ASSOCIATION OF PRE TEST KNOWLEDGE LEVEL WITH DEMOGRAPHIC
VARIABLES IN CONTROL GROUP
119
N = 250 S.NO DEMOGRAPHIC
VARIABLES
KNOWLEDGE Chi-square
Table Value Inadequate
knowledge Moderately Adequate
knowledge
Adequate knowledge
1 AGE 20-30 YEARS 31-40YEARS
144
-
106
-
- -
0
D.f = 1
3.86 N.S
2 SEX: MALE FEMALE
43 101
13 93
- -
10.87 D.f = 2
3.86
S
3 EDUCATION: GNM B.Sc. [N]
99 45
85 21
- -
4.11
D.f = 2
3.86 N.S
4
WARD:
EMERGENCY POSTPERATIVE ICU
11 29 104
5 13 88
- - -
3.99 D.f = 4
N.S
5 EXPERIENCE: 1-3 YEARS 4-6 YEARS
144
-
106
-
- -
NS indicates: Non significant D.f = degree of freedom
The Above Table: 5 I (a). showed the association between pretest knowledge with
demographic variables in control group. The calculated chi-square values were
greater in sex 10.87with d.f.2. So the sex had significant association at p 0.05 level.
Other demographic variables had no significant association with pre test knowledge
level. The hypothesis – IV had accepted.
TABLE – 5 II (b):
ASSOCIATION OF PRE TEST PRACTICE OF ORAL HYGIENE WITH DEMOGRAPHIC VARIABLES IN CONTROL GROUP. N = 250
S.N DEMOGRAPHIC ORAL HYGINE Chi- Table
120
O VARIABLES Poor Average Good square Value
1 AGE
20-30 YEARS
31-40YEARS
183
-
64
-
3
-
0
D.f = 1
3.86
N.S
2 SEX:
MALE
FEMALE
45
138
11
53
-
3
2.37
D.f = 2
N.S
3 EDUCATION:
GNM
B.Sc.[N]
135
48
47
17
2
1
.077
D.f = 2
N.S
4
WARD
EMERGENCY
POSTOPERATIVE
ICU
11
27
145
5
14
45
-
1
2
2.89
D.f = 4
N.S
5 EXPERIENCE:
1-3 YEARS
4-6 YEARS
183
-
64
-
3
-
NS - Non significant S – Significant D.f – Degree of freedom
The Above Table: 5. II (b). showed the association between pretest practice of oral
hygiene with demographic variables in control group. The calculated chi-square
values were lesser than the tabulated value in all demographic variables. So there
was no significant association with demographic variables at p 0.05 level with pre test
practice of oral hygiene. The hypothesis – IV had accepted.
TABLE – 5.II. (c) :
ASSOCIATION OF PRE TEST PRACTICE OF TRACHEOSTOMY CARE WITH DEMOGRAPHIC VARIABLES IN CONTROL GROUP. N = 250
S.NO DEMOGRAPHIC TRACHESTOMY CARE Chi- Table
121
VARIABLES Poor Average Good square Value1 AGE
20-30 YEARS 31-40YEARS
108
-
142
-
- -
0 D.f = 1
N.S
2 SEX: MALE FEMALE
41 67
15 127
- -
26.49 D.f = 2
S
3 EDUCATION: GNM B.Sc.[N]
83 25
101 41
- -
1.03 D.f = 2
N.S
4
WARD: EMERGENCY POSTOPERATIVE ICU
5
13 90
11 29 102
- - -
4.55
D.f = 4
N.S
5 EXPERIENCE: 1-3 YEARS 4-6 YEARS
108
-
142
-
- -
0 D.f = 1
N.S
NS - Non significant S – Significant D.f – Degree of freedom
The Above Table: 5. II. (C). showed the association between pretest practice of
tracheostomy care with demographic variables in control group. The calculated
chi-square values were greater in sex 26.49 with d.f.2. So the sex had significant
association at p 0.05 level. Other demographic variable age education, ward and
experience had no significant association with pre test practice of tracheostomy
care. The hypothesis – IV had accepted.
TABLE – 5. II (d) : ASSOCIATION OF PRE TEST PRACTICE OF ENDOTRACHEAL TUBE
SUCTIONING WITH DEMOGRAPHIC VARIABLES IN CONTROL GROUP N = 250
122
S.NO DEMOGRAPHIC
VARIABLES
ENDOTRACHEAL TUBE SUCTIONING
Chi-squar
e
Table Value
Poor Average Good 1 AGE
20-30 YEARS 31-40YEARS
83 -
167
-
- -
2 SEX: MALE FEMALE
14 69
42 125
- -
2.18
D.f = 2
N.S
3 EDUCATION: GNM B.Sc.[N]
62 21
122 45
- -
0.07
D.f = 2
N.S
4
WARD: EMERGENCY POSTOPERATIVE ICU
5
12 66
11 30 126
- - -
0.558 D.f = 4
N.S
5 EXPERIENCE: 1-3 YEARS 4-6 YEARS
83
167
- -
NS - Non significant S – Significant D.f – Degree of freedom
The Above Table: 5. II. (d). showed the association between pretest practice of
endotracheal tube suctioning with demographic variables in control group. The
calculated chi-square values were lesser than the tabulated values at p0.05
level. It revealed no significant association with pre test practice of endotracheal
tube suctioning with demographic variables. The hypothesis – IV had accepted.
TABLE – 5 II (e) :
ASSOCIATION OF PRE TEST PRACTICE OF WEANING PROCESS WITH DEMOGRAPHIC VARIABLES IN CONTROL GROUP. N = 250
123
S.NO DEMOGRAPHIC VARIABLES
WEANING PROCESS Chi-square
Table Value Poor Average Good
1 AGE 20-30 YEARS 31-40YEARS
81 -
169
-
- -
0 D.f = 1
N.S
2 SEX: MALE FEMALE
14 67
42 127
- -
1.80 D.f = 2
N.S
3 EDUCATION: GNM B.Sc.[N]
58 23
126 43
- -
0.24 D.f = 2
N.S
4
WARD: EMERGENCY POSTPERATIVE ICU
5
13 63
11 29 129
- - -
0.06 D.f = 4
N.S
5 EXPERIENCE: 1-3 YEARS 4-6 YEARS
81 -
169
-
- -
0 D.f = 1
N.S
NS - Non significant S – Significant D.f – Degree of freedom
The Above Table: 5. II. (e). showed the association between pretest practice of
weaning process with demographic variables in control group. The calculated
chi-square values were lesser than the tabulated values at p0.05 level. It
revealed no significant association with pre test practice of weaning with
demographic variables. The hypothesis –IV had accepted.
TABLE – 5 I (f) :
ASSOCIATION OF POST TEST KNOWLEDE LEVEL WITH DEMOGRAPHIC VARIABLES IN EXPERIMENTAL GROUP N = 250
124
S.NO
DEMOGRAPHIC VARIABLES
KNOWLEDGE Chi-square
Table
Value
Inadequate
knowledge
Moderately Adequate
knowledge
Adequate
knowledge
1 AGE
20-30 YEARS
31-40YEARS
-
-
48
-
202
-
0
D.f = 1
N.S
2 SEX:
MALE
FEMALE
-
-
15
33
17
185
18.11
D.f = 2
S
3 EDUCATION:
GNM
B.Sc. [N]
-
-
30
18
82
120
7.52
D.f = 2
S
4
WARD:
EMERGENCY
POSTOPERATIVE
ICU
-
-
-
5
22
21
11
20
171
39.75
D.f = 4
S
5 EXPERIENCE:
1-3 YEARS
4-6 YEARS
-
-
48
-
194
8
0
D.f = 1
N.S
NS indicates: Non significant D.f = degree of freedom
The Above Table: 5 I (f). showed the association between post test
knowledge level with demographic variables in experimental group. The calculated
chi-square values were greater than the tabulated values at p0.05 level. Therefore
sex 18.11, education 7.52, ward 39.75. It revealed significant association with post
test knowledge with demographic variables. The hypothesis – IV had accepted.
TABLE – 5 I (g):
125
ASSOCIATION OF POST TEST PRACTICE OF ORAL HYGIENE WITH
DEMOGRAPHIC VARIABLES IN EXPERIMENTAL GROUP. N = 250
S.NO DEMOGRAPHIC VARIABLES
ORAL HYGINE Chi-square
Table Value Poor Average Good
1 AGE 20-30 YEARS 31-40YEARS
8 -
50 -
192
-
0 D.f = 1
N.S
2 SEX: MALE FEMALE
2 6
10 40
20 172
4.36 D.f = 2
N.S
3 EDUCATION: GNM B.Sc.[N]
6 2
30 20
76 116
9.73 D.f = 2
S
4
WARD: EMERGENCY POSTPERATIVE ICU
5 2 1
8
10 32
3
30 159
52.54 D.f = 4
S
5 EXPERIENCE: 1-3 YEARS 4-6 YEARS
7 1
48 2
187 5
2.56 D.f = 6
NS
NS - Non significant S – Significant D.f – Degree of freedom
The table 5. I (g). showed that association of experimental group post
test practice of oral hygiene with demographic variables. It found the chi square
calculated values of education 9.73, ward 52.54 which were greater than the
tabulated values at p0.05 level with d.f.2 and 4. Thus there was significant
association between practice of oral hygiene with education and ward. There
was no association with age, sex and experience. The hypothesis – IV had
accepted.
TABLE – 5. I. (h) :
126
ASSOCIATION OF POST TEST PRACTICE OF TRACHEOSTOMY CARE WITH DEMOGRAPHIC VARIABLES IN EXPERIMENTAL GROUP. N = 250
S.NO DEMOGRAPHIC VARIABLES
TRACHESTOMY CARE Chi-square
Table ValuePoor Average Good
1 AGE
20-30 YEARS
31-40YEARS
-
-
42
-
208
-
0
D.f = 1
N.S
2 SEX:
MALE
FEMALE
-
-
17
25
15
193
34.64
D.f = 2
S
3 EDUCATION:
GNM
B.Sc.[N]
-
-
27
15
85
125
8.03
D.f = 2
S
4
WARD:
EMERGENCY
POSTPERATIVE
ICU
-
-
-
9
10
23
7
32
169
22.48
D.f = 4
S
5 EXPERIENCE:
1-3 YEARS
4-6 YEARS
-
-
40
2
202
6
0.397
D.f = 6
N.S
NS - Non significant S – Significant D.f – Degree of freedom The table 5 I (h). showed that association of experimental group post test
practice of tracheostomy care with demographic variables. It found the chi square calculated values of sex 34.6, d.f.2, education 8.03, d.f.2, ward 22.48, d.f.4 which were greater than the tabulated values at p0.05 level. It revealed the significant association between practice of tracheostomy care with sex, education and ward. There was no association with age, and experience. The hypothesis – IV had accepted. TABLE – 5 I (i) :
127
ASSOCIATION OF POST TEST PRACTICE OF ENDOTRACHEAL TUBE SUCTIONING WITH DEMOGRAPHIC VARIABLES IN EXPERIMENTAL GROUP N = 250 S.NO DEMOGRAPHIC
VARIABLES
ENDOTRACHEAL TUBE SUCTIONING
Chi-square
Table Value
Poor Average
Good
1 AGE 20-30 YEARS 31-40YEARS
- -
75 -
175
-
0 D.f = 1
N.S
2 SEX: MALE FEMALE
- -
19 56
13 162
15.07 D.f = 2
S
3 EDUCATION: GNM B.Sc.[N]
- -
26 49
86 89
4.44
D.f = 2
N.S
4
WARD: EMERGENCY POSTOPERATIVE ICU
- - -
22 42 11
20 150 5
27.49 D.f = 4
S
5 EXPERIENCE: 1-3 YEARS 4-6 YEARS
- -
69 6
173 2
7.97
D.f = 6
N.S
The table 5 I (i). showed that association of experimental group post test
practice of endotracheal tube suctioning with demographic variables. The chi
square calculated values of sex 15.07, d.f.2, and ward 27.49, d.f.4 which were
greater than the tabulated values at p0.05 level. It revealed the significant
association between practice of endotracheal tube suctioning with sex and ward.
There was no significant association with age, education and experience. The
hypothesis – IV had accepted
128
TABLE – 5. I. (j):
ASSOCIATION OF POST TEST PRACTICE OF WEANING PROCESS WITH DEMOGRAPHIC VARIABLES IN EXPERIMENTAL GROUP. N = 250
S.NO DEMOGRAPHIC VARIABLES
WEANING PROCESS Chi-square
Table Value Poor Average Good
1 AGE 20-30 YEARS 31-40YEARS
- -
75 -
175
-
0 D.f = 1
N.S
2 SEX: MALE FEMALE
- -
22 53
10 165
26.23963 D.f = 2
S
3 EDUCATION: GNM B.Sc.[N]
- -
30 45
82 93
0.998225 D.f = 2
N.S
4
WARD EMERGENCY POSTPERATIVE ICU
- - -
11 25 39
5
17 153
0.998225 D.f = 2
N.S
5 EXPERIENCE: 1-3 YEARS 4-6 YEARS
- -
69 6
173
2
7.969 D.f = 6
N.S
NS - Non significant S – Significant D.f – Degree of freedom
The table 5 I (j).showed that association of experimental group post test practice
of weaning process with demographic variables. It showed the chi square
calculated values of sex 26.23, d.f.2, and ward 37.45, d.f.4 which were greater
than the tabulated values at p0.05 level. It revealed the significant association
between practice of weaning process with sex and ward. There was no
significant association with age, education and experience. The hypothesis – IV
had accepted.
129
TABLE 5 II (f).
ASSOCIATION BETWEEN PRE AND POST TEST KNOWLEDGE LEVEL
WITH DEMOGRAPHIC VARIABLES IN CONTROL GROUP. N = 250
S.NO
DEMOGRAPHIC VARIABLES
KNOWLEDGE CHISQUARE VALUE Inadequate
knowledgeModeratelyAdequate
knowledge
Adequate knowledge
1 AGE: 20 – 30 YEARS 31 – 40 YEARS
144
-
106
-
- -
0 Df = 1 NS
2 SEX: MALE FEMALE
33 111
23 83
- -
0.052 Df = 1 NS
3 EDUCATION: GNM B.Sc.[N]
112
32
72 34
- -
3.05 Df = 1 NS
4
WARD EMERGENCY POSTPERATIVE ICU
11 31 102
5 11 90
- - -
6.907 Df = 2 S
5 EXPERIENCE: 1-3 YEARS 4-6 YEARS
144
0
106
0
- -
0 Df = 1 NS
NS indicates: No significant d.f = degree of freedom
There was no change between the pretest and post test knowledge level among
control group. Association of knowledge was established with ward only by chi
square value 6.907 which was significant at 2 d. f with p value of 0.05. Other
demographic variables had no association. The hypothesis – IV had accepted.
130
TABLE 5 II (g).
ASSOCIATION BETWEEN POST TEST PRACTICE OF ORAL HYGIENE
WITH DEMOGRAPHIC VARIABLES IN CONTROL GROUP. N = 250
S.NO DEMOGRAPHIC VARIABLES
ORAL HYGIENE CHISQUARE VALUE Poor Average Good
1 AGE: 20 – 30 YEARS 31 – 40 YEARS
217
-
31 -
2 -
0 Df = 0 NS
2 SEX: MALE FEMALE
33 184
23 8
- 2
56.92 Df = 2 S
3 EDUCATION: GNM B.Sc.[N]
174
43
8 23
2 -
45.9 Df = 2 S
4
WARD EMERGENCY POSTPERATIVE ICU
11 31 175
5 11 15
- 2 -
16.72 Df = 4 S
5 EXPERIENCE: 1-3 YEARS 4-6 YEARS
217 0
31 0
2 -
0 Df = 0 NS
NS indicates: No significant d.f = degree of freedom
Table 5. II (g) showed significant association of Practice of oral hygiene with
sex, education, and ward. The chi square values were 56.92, d.f 2, 45.9, d.f.2
which were greater than the tabulated value at p 0.05 level. Other demographic
variables had no significant association with practice of oral hygiene. The
hypothesis – IV had accepted.
131
TABLE 5 II (h).
ASSOCIATION BETWEEN POST TEST PRACTICE OF TRACHOSTOMY
CARE WITH DEMOGRAPHIC VARIABLES IN CONTROL GROUP. N = 250
S.NO DEMOGRAPHIC VARIABLES
TRACHEOSTOMY CARE CHI -SQUARE VALUE Poor Average Good
1 AGE: 20 – 30 YEARS 31 – 40 YEARS
125
-
125
-
- -
0 NS
Df = 0
2 SEX: MALE FEMALE
30 95
26 99
- -
0.37 N.S d.f.2
3 EDUCATION: GNM B.Sc.[N]
91
34 93 32
- -
0.8 N.S d.f.2
4
WARD EMERGENCY POSTPERATIVE ICU
11 22 92
5 20 100
- - -
2.68 N.S d.f.4
5 EXPERIENCE: 1-3 YEARS 4-6 YEARS
125 0
125 0
- -
0 NS
Df = 0 NS indicates: No significant d.f = degree of freedom
Table 5. II (h) showed no significant association of Practice of tracheostomy
care with all demographic variables on tabulated value at p 0.05 level. It was
the evidence that the demographic variables had no significant association with
practice of tracheostomy care. The hypothesis – IV had accepted.
132
TABLE 5 II (I). ASSOCIATION BETWEEN POST TEST PRACTICE OF ENDOTRACHEAL TUBE SUCTIONING WITH DEMOGRAPHIC VARIABLES IN CONTROL GROUP N = 250 S.NO
DEMOGRAPHIC VARIABLES
ENDOTRACHEAL TUBE SUCTIONING
CHI -SQUARE VALUE Poor Average Good
1 AGE: 20 – 30 YEARS 31 – 40 YEARS
83 -
167
-
- -
0 NS
Df = 0
2 SEX: MALE FEMALE
27 56
29 138
- -
7.34 d.f.2
S
3 EDUCATION: GNM B.Sc.[N]
34 49
160 17
- -
95.94 d.f.1
S
4
WARD EMERGENCY POSTPERATIVE ICU
11 23 49
5 19 143
- - -
23.03 d.f.2
S
5 EXPERIENCE: 1-3 YEARS 4-6 YEARS
83 0
167
0
- -
0 NS
Df = 0 NS indicates: No significant d.f = degree of freedom
Table 5. II (i) showed significant association between Practice of endotracheal
tube suctioning with sex 13.50 d.f.1, education 95.94 d.f.1and ward 23.03 d.f.2
which were more than the tabulated value at p 0.05 level. It was the evidence
that the said demographic variables had a significant association with practice of
endotracheal tube suctioning practice. No significant association between age
and experience. The hypothesis – IV had accepted.
133
TABLE 5 II (j).
ASSOCIATION BETWEEN POST TEST PRACTICE OF WEANING PROCESS
WITH DEMOGRAPHIC VARIABLES IN CONTROL GROUP
N = 250
S.NO DEMOGRAPHIC
VARIABLES
WEANING PROCESS PRACTICE
CHI -SQUARE VALUE Poor Average Good
1 AGE: 20 – 30 YEARS 31 – 40 YEARS
75 -
175
-
- -
0 Df = 0
NS
2 SEX: MALE FEMALE
26 49
30 145
- -
9.275 Df = 1 S
3 EDUCATION: GNM B.Sc.[N]
51 24
133 42
- -
1.729 Df = 1 NS
4
WARD EMERGENCY POSTPERATIVE ICU
11 22 42
5
20 150
- - -
27.494 Df = 2 S
5 EXPERIENCE: 1-3 YEARS 4-6 YEARS
75 0
175
0
- -
0 Df = 0 NS
NS indicates: No significant d.f = degree of freedom
Table 5. II (j) showed significant association between Practice of the weaning
process with sex 9.27 d.f.1, and ward 27.494 d.f.2 which were more than the
tabulated value at p 0.05 level. It was the evidence that the said demographic
variables had significant association with practice of weaning process. No
significant association between age, education and experience. The hypothesis
– IV had accepted.
134
SECTION-VI
OUTCOME OF VENTILATOR CARE
The investigator observed the patient out come for the period of 6 months
as pre test and post test model. She collected the data at the time of discharge
of the patient from 200 patients. 100 patients were observed during pre test and
100 patients were observed during post test period.
TABLE – 6.a: PRE AND POST TEST VALUE OF THE OUTCOME OF THE
PATIENT CARE WITH MECHANICAL VENTILATOR
S.No. Criteria of out come
Pre test
value
N=100
Post test
value
N=100
F % F %
1 Infection rate 15 15 8 8
2 Days of hospital stay 10 10 6 6
3 Impaired skin integrity 15 15 Nil Nil
4 VAP 10 10 Nil Nil
5 Tube patency 8 8 Nil Nil
The table : 6 a. showed that the infection rate in the pre test frequency was 15
and it is reduced to 8 in the post test. Outcome of the patient care with
mechanic ventilator was beneficent. Days of the hospital stay in the pre test
frequency are 10 days and it is reduced in to 6 days in the post test. Impaired
skin integrity in the pre test the frequency is 15 and in the post test nobody had
impaired skin integrity. Regarding ventilator assisted pneumonia in the pre test
the frequency is 10 and there is no sample found that ventilator assisted
pneumonia. In pre test the tube patency was poor in 8 samples, and there was
no sample found to have tube block, tube patency is good. Hence the
hypothesis- V is accepted.
135
CHAPTER – V
5. DISCUSSION
Quasi experimental design was used for the present study. There were two
group pre and post test design. Randomization was selected to evaluate the
effectiveness of structured teaching program on ventilator care for nurses. It also
analyzed the outcome of patient on a mechanical ventilator.
This chapter dealt about the discussion of the findings based on the objectives
of the study. The objectives are as follows:
1. To assess the knowledge and practice regarding ventilator care among the
nurses, working in the selected hospitals at Nellore, A.P.
2. To compare the pre and post test knowledge and practice regarding
ventilator care among the nurses, working in the selected hospitals at
Nellore, A.P.
3. To correlate the post test knowledge and practice regarding ventilator care
among nurses, working in the selected hospitals at Nellore, A.P.
4. To find out the outcome of the ventilator care in the selected hospitals at
Nellore, A.P.
5. To determine the association between knowledge and practice regarding
ventilator care with the selected demographic variables among nurses,
working in the selected hospitals at Nellore, A.P.
136
In this study, the demographic variables discussed are included age, sex,
education, ward and experience.
The samples of 500 registered working nurses were divided into control and
experimental groups equally by randomization. All the samples were within the
age group of 20 to 30 years, and no one had 30 to 40 years or more than 40
years.
The samples selected for this study had male and female sex. In the
experimental group the males were 12.8% (32) and in the control group the same
was 22.4% (56). But, the female samples were 87.2% (218) in the experimental
group and 77.6% (194) in the control group. In this study also it is noted that the
females are dominant in nursing.
The samples again categorized according to education wise also. In that, in
experimental group 44.8% (112) and in control group 73.6% (184) had completed
GNM course and in the experimental group 55.2% (138) and in the control group
26.4% (66) had completed B.Sc (N) course. It denotes that still diploma nurses
are more in clinical than the degree nurses.
For this study purposes, the samples were selected from emergency, post
operative ward and intensive care units, because, the nurses, who were working
in these areas need more knowledge and practice in mechanical ventilator care.
In the experimental group, the samples selected were working in an emergency
was 6.4% (16), in post operative ward was 16.8% (42) and in Intensive care
Units was 76.8% (192). In the Control group, it was equally distributed.
137
The samples also grouped according to their experience to facilitate analyzing of
their knowledge and practice. The samples had 1 to 3 years of experience in the
experimental group been 96.8% (242), and 4 to 6 years of experience was 3.2%
(8). But in the control group all the samples had only 1 to 3 years of experience
and no one had 4 to 6 years of experience.
The knowledge level on ventilator care was studied in three levels as inadequate
knowledge, moderate adequate knowledge and adequate knowledge both in
experimental group and control group as pretest and post test level after
administration of structured teaching program. The results are as follows:
In pre test out of 250 nurses in experimental group, 60.8% (152) had inadequate
knowledge, 38.4% (96) had moderately adequate knowledge and 0.8% (2) had
adequate knowledge. But in post test after Structured teaching program the
result changed to nobody had inadequate knowledge, 19.2 (48) had moderately
adequate knowledge and 80.8% (202) had adequate knowledge. In pre test
control group 57.6% (144) had inadequate knowledge, 42.4% (106) had
moderately adequate knowledge. In the Post test control group there was no
change in the knowledge level. Comparison of post test knowledge by
‘Independent Z test’ was 34.67 which was significant at 0.05 level. Thus the first
objective of assessing the knowledge on ventilator.
The nursing practice taught and analyzed in this study limited to a) oral
hygiene, b) tracheostomy care, c) endotracheal tube suctioning and d) weaning
process practice. In the practice of oral hygiene, among the experimental group
138
out of 250 nurses, in pretest 73.2% (183) had poor practice, 26.8%(.67) had
average practice and no one had a good practice. But after structured teaching
program the practice was enhanced to 3.2% (8) had poor practice, 20% (50) had
average practice and 76.8% (192) had a good practice. Whereas, in the control
group out of 250 nurses, in pretest 73.2% (183) had poor practice, 25.6% (64)
had average practice and 1.2% (3) had a good practice. But after study period
86.8% (217) had poor practice, 12.4% (31) had average practice and 0.8% (2)
had a good practice. The second objective was to compare the pre test and post
test level of knowledge and practice. There was no change. Comparison of post
test practice of oral hygiene by ‘Independent Z test’ was 635.6 which was
significant at 0.05 level. Regarding tracheostomy care practice, in pretest out of
250 nurses in the experimental group, 33.2% (83) had poor practice 66.8% (167)
had average and nobody had a good practice. In post test nobody had poor
practice, 16.8% (42) had average practice and 83.2% (208) had a good practice.
Whereas in pre test control group 43.2% (108) had poor practice, 56.8% (142)
had average and nobody had a good practice. But in post test 50% (125) had
poor practice, 50% (125) had average practice and nobody had a good practice,
comparison of post test practice of tracheostomy care by ‘Independent Z test’
was 42.09 which was significant at 0.05 level. Regarding endotracheal suctioning
practice, in pretest out of 250 nurses in the experimental group, 40% (100) had
poor practice 56.8% (142) had average and 3.2% (8) had a good practice. In post
test nobody had poor practice, 30% (75) had average practice and 70% (175)
139
had a good practice. Whereas in pre test control group 33.2% (83) had poor
practice, 66.8% (167) had average and nobody had a good practice. But in post
test there was no changes in practice. Comparison of post test practice of
endotracheal suctioning by ‘Independent Z test’ was 34.27 which was significant
at 0.05 level. Regarding weaning process practice, in pretest out of 250 nurses in
the experimental group, 39.2% (98) had poor practice, 57.6% (144) had average
and 3.2% (8) had a good practice. In post test nobody had poor practice, 30%
(75) had average practice and 70% (175) had good practice. Whereas in pre test
control group 32.4% (81) had poor practice, 67.6% (169) had average and
nobody had a good practice. But in post test 30% (75) had poor practice, 70%
(175) had average practice and nobody had a good practice. Comparison of post
test practice of the weaning process by ‘Independent Z test’ was 34.27 which
was significant at 0.05 level. It shows that the structured teaching programme
had a good effect on nurses to improve the quality care of patients. Thus the first
and second objectives of assess the knowledge level and practice in both
groups among registered working nurses and comparison of both groups in
pretest and post test were obtained, analyzed by using independent Z test
stating that the structured teaching program was beneficial.
The third objective was to correlate the post test knowledge and practice
regarding ventilator care. For analyzes ‘r’ test was used. The post test knowledge
and practice of oral hygiene in the experimental group had a positive correlation.
140
The ‘r’ value was +0.33. The post test knowledge and practice of tracheostomy
care in experimental group had a positive correlation. The ‘r’ value was +0.96.
The post test knowledge and practice of endotracheal tube suctioning in the
experimental group had a positive correlation. The ‘r’ value was +0.14. The post
test knowledge and practice of weaning in the experimental group had a positive
correlation. The ‘r’ value was +0.14. The post test knowledge and practice of oral
hygiene in the control group had a positive correlation. The ‘r’ value was +0.06.
The post test knowledge and practice of tracheostomy care in the control group
had a positive correlation. The ‘r’ value was +0.185. The post test knowledge and
practice of endotracheal tube suctioning in the control group had a negative
correlation. The ‘r’ value was -0.06. The post test knowledge and practice of the
weaning process practice in the control group had a positive correlation. The ‘r’
value was +0.33. As discussed above all the groups showed a positive
correlation, the objective three was achieved.
The fourth objective was to find out the outcome of ventilator care among
patients. The data was analyzed by using a percentage. The outcome was
discussed under the following criteria. a) The infection rate had come down from
15% to 8%, b) the days of hospital stay had reduced to 10% to 6%, c) the skin
integrity was maintained, the risk was reduced from 15% to nil d) the VAP
reduced from 10% to nil and e) the endotracheal tube patency was maintained
141
and reduced 8% to nil. So it is proved that the Structured teaching program was
effective and helped to provide quality nursing care.
The fifth objective was to determine the association between knowledge
and practice with selected demographic variables of experimental and control
group. The association was calculated by using chi – square.
In pretest experimental group the association between with demographic
variables of education, ward and experience had a significant association with
pretest knowledge. But in practice of oral hygiene there was significant with
education, ward and experience. Next in tracheostomy care, sex, education,
ward and experience were significant. With endotracheal tube suctioning, sex,
ward and experience were significant. The association with weaning process the
sex, education, ward and experience were significant at p 0.05 level. It evidenced
the demographical variables had influence on dependent variables.
In pretest control group the association between with demographic
variable of sex had a significant association with pretest knowledge. But in
practice of oral hygiene there was no significant with demographic variables.
Next in tracheostomy care, sex had significant. With endotracheal tube
suctioning had no significant. The association with the weaning process also had
142
no significant at p 0.05 level. It showed the demographical variables may not
influence on dependent variables.
In post test experimental group the association between with
demographic variables of sex, education, and ward had a significant association
with post test knowledge. But in practice of oral hygiene there was significant
with education, and ward. Next in tracheostomy care, sex, education, and ward
were significant. With endotracheal tube suctioning, sex and ward had
significant. The association with the weaning process the sex was significant at p
0.05 level. It evidenced the demographical variables had influence on dependent
variables only in the experimental group.
In post test control group the association between with demographic
variable of ward had a significant association at d.f.1 with post test knowledge.
But in practice of oral hygiene there was significant with sex, education and ward.
Next in tracheostomy care ward had significant. With endotracheal tube
suctioning, sex, education and ward were significant. The association with
weaning process the sex and ward were significant at p 0.05 level. It evidenced
the demographical variables had influence on dependent variables. As evidenced
by the above discussion and data it was proved that the structured teaching
program was effective for nurses on care of patients with ventilator and the
outcome of ventilator care was beneficial in the selected hospitals at Nellore.
143
CHAPTER-VI
6. SUMMARY, IMPLICATIONS, LIMITATIONS AND RECOMMENDATIONS
6.1 Summary Of The Study:
A quasi experimental study was undertaken from Jan 2005 – 2012 at
Narayana Group of hospitals in Nellore. The hospitals have 196 beds in various
Intensive Care Unit and Superspeciality hospital. Data was collected from 500
registered nurses working in the hospitals and involved in mechanical ventilator
care. Structured teaching program was developed and conducted to assess the
effectiveness of the ventilator care on knowledge and practice. The collected
data were analyzed by using descriptive and inferential statistics. The findings of
the summary are as follows: the knowledge and practice regarding ventilator
care among the nurses was highly significant between pre and post test. In the
post test experimental group nobody had inadequate knowledge, 19.2% (48)
had moderately adequate knowledge and 80.8% (202) had adequate
knowledge. There was highly significant difference between the experimental
group and the control group regarding knowledge of ventilator care after
structured teaching programme. The calculated ‘Independent Z’ value 34.67 was
greater than the Z-tab value. Structured teaching programme had improved
knowledge of registered nurses regarding nursing care of patients with
mechanical ventilator. In the practice of oral hygiene, post test experimental
group, 3.2% (8) had poor, 20% (50) had average and 76.8% (192) had a good
144
practice. In post test experimental group, in tracheostomy care, there was no
body had poor practice, 16.8% (42) had average and 83.2% (208) had a good
practice. Regarding endotracheal tube suctioning, post experimental group
nobody had poor practice, 30% (75) had average and 70% (175) had a good
practice. About the weaning process, in post test experimental group nobody
had poor weaning practice, 30% (75) had average and 70% (175) had a good
weaning process practice. There were statistically significant difference in
practice of oral hygiene 635.6, tracheostomy care 42.09, endotracheal tube
suctioning 34.27 and weaning process practice 34.27, which was proved by
‘Independent Z test’. The knowledge and practice had a positive correlation on
ventilator care among nurses. The ‘r’ values were as follows: oral hygiene +0.33,
tracheostomy care +0.96, endotracheal tube suctioning +0.14 and weaning
process practice +0.14. Thus there was positive correlation existing with
knowledge and practice.
In pretest experimental group the association between with demographic
variables of education, ward and experience had a significant association with
pretest knowledge, oral hygiene, tracheostomy care, endotracheal tube
suctioning and weaning process practice was established at p 0.05 level .
In pretest control group the association between with demographic
variable of sex had a significant association with pretest knowledge and
tracheostomy care. There was no significant association with demographic
145
variables and practices of oral hygiene, endotracheal tube suctioning and
weaning process.
In post test experimental group the association between with
demographic variables of sex, education, and ward had a significant association
with post test knowledge, and other dependent variables of practice.
In post test control group the association between with demographic
variable of ward had a significant association at d.f.1 with post test knowledge.
But in practice of oral hygiene there was a significant association with sex,
education and ward of demographic variables. In tracheostomy care, among
demographic variables ward only had significant association with practice. With
endotracheal tube suctioning, the demographic variables like sex, education and
ward were significant association. The association with weaning process the sex
and ward were significant at p 0.05 level. It evidenced the demographical
variables had influence on dependent variables.
6.2 Implications Of The Study:
According to the Tolsma (1995) the section of the research report that
focuses on nursing implications usually include specific suggestions for nursing
practice ,education, administration and nursing research.
146
6.3 Nursing Practice:
o The assessment of knowledge and practice on nursing care of the patients with
mechanical ventilator will help the clinical nurse to improve the quality of nursing
care.
o The present study indicated that improving the knowledge is essential on nursing
care of the patients with mechanical ventilator to develop best practice in critical
care units.
o The study indicated the need for continuing nursing education and workshops on
ventilator care to update the knowledge and evidence based practice.
o The study also found out the enhancement of knowledge and practice in turn
improves the outcome of patient care. So the informatics may be developed to
provide quality care.
6.4 Nursing Education:
Nursing curriculum has to focus on nursing care in critical units.
Student nurses have to update their knowledge on nursing care of patients with
mechanical ventilator to practice evidence based nursing in Intensive Care Unit.
Special courses can be planned.
More hours may be allotted for practice in intensive care areas.
Nurse managed home care practices may be encouraged.
Standardized evaluation tools and protocols may be developed.
147
6.5 Nursing Administration:
The present study proposed to help the hospital administrator to plan for
continuing education programme for nurses.
Nursing journals may be published which are concentrating problem solving
approach on ventilator care.
Must develop critical analysis path way for mechanical ventilator care.
Data base may be developed for further references.
6.6 Nursing Research :
More research studies in India are needed to develop knowledgeable nurses to
practice in clinical settings.
Cross sectional studies may be encouraged.
Meta analysis may be done in this field.
Nursing theories may be formulated for nursing care on a mechanical ventilator.
6.7 Limitations:
In this study, the samples cannot be matched both in experimental and control
group.
Age and experience of samples were in the same category. So the associations
with demographic variables were limited.
6.8 Recommendations:
The ventilator care module may be included in nursing curriculum.
The same study can be conducted as true experimental study.
148
6.9 BIBLIOGRAPHY:
TEXT BOOK:
1. Barbara A. Erickson, (1996) ”Text book of critical care nursing”1st edition,
Spinghouse publications, Pennsylvania, page no:138.
2. Barbara K. Timby and nancy e.smith (2003), ”Text book of introductory
medical surgical nursing”, 8th edition, Lippincott publications, USA, page
no: 346-348.
3. Brunner & Suddarth (2004),” Text book of medical & surgical nursing”, 10th
edition, Lippincott William’s publications, India, page no: 613-626.
4. David W. Chang (2006) ”Clinical application of mechanical ventilator”3rd
edition, Delmar cengage publications, New Delhi, page no: 232-233.
5. Donna D. Ignatavicius (1995), ”Text book of medical surgical nursing”2nd
edition, Saunders publications, Pennsylvania, page no760-762.
6. Flynn and Bruce (1993), ”Introduction to critical care skills”,1st edition, Mosby
publications, USA, page no:72-97.
7. Harkness Dincher (1996), ”Text book of medical surgical nursing total
patient care”9th edition, Mosby publications, Moussouri, page no:554.
8. Indukhurana. Arushi (2009),” Anatomy and physiology for nurses”, 1st
edition, CBS publications, India, page no: 217-244.
9. Joyce M. Black (2005), “Text book of introductory medical surgical nursing”
7th edition, Elsevier publications, Pennsylvania, page no:1886.
149
10. Kozier and Erb’s (2008),”Fundamentals of nursing,”8th edition, Pearson
publications, India, page no: 1390-1392.
11. Leiwis (2007),”Text book of medical & surgical nursing”, 7th edition, Elsevier
publication, Moussouri, page no: 1763-1769.
12. Lois White (2002),” Text book of medical surgical nursing”2nd edition,
Delman publications, Moussouri , page no:386.
13. Luckmann’s (1996), ”Medical surgical nursing”1st edition, Saunders
publication, Pennsylvania, page no: 533-542.
14. Phipps, (1995) ” text book of introductory medical surgical nursing” 5th
edition, Mosby publication, Canada, page no: 1165-1168.
15. Priscilla lemone (2008),”Text book of medical surgical nursing”4th edition,
Pearson publications, India, page no:1358-1364.
16. Ross and Wilson (2006), “Anatomy and physiology”10th edition, Evolve
publications, USA, page no: 237-360.
17. Thelan’s (2006),”Text book of critical care nursing”5th edition, Mosby
publications, Missouri, page no: 670-680.
JOURNALS:
18. Ann M. Price (June 2001), ”Nurse-led weaning from mechanical
ventilation”, volume 17,issue3, published by Elsevier.
19. J. Mancebo, (1996) ”weaning from mechanical ventilation”, European
respiratory journal, volume-9.
150
20. Hampton, Debrac (July1, 2005), ”Evidence-based clinical improvement for
Mechanically ventilated patients,
21. Inmaculata Alía and Andrés Esteban (18 February 2000), ”Weaning”
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CENTRAL OBJECTIVE
After attending this structured teaching programme, the staff nurses at
Narayana Medical College Hospital, Chinthareddypalem, Nellore, will acquire
knowledge and develop desirable attitude and practicing skill on care of patients
with ventilator.
Sl. No.
Contribution Objectives Time in Hrs
1 Review of anatomy and physiology of respiratory system 2 2 Review of psychology 2 3 Review of Sociology 2 4 Review of microbiology 2 5 Review of pharmacology 2 6 Introduction
Mechanical ventilators Definition Ventilation Concepts of ventilation Principles of ventilator care Standards of care to patients with mechanical ventilator
2
7 Mechanical ventilators Definition of mechanical ventilation Historical review of mechanical ventilators? Classification of ventilators Mechanical ventilation with in conventional gases Ventilator troubleshoot Modes of ventilators Disinfection of ventilators
4
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8 Care of patients on mechanical ventilator Indications for mechanical ventilation Air way management
a. Acid base management b. Nutritional management
Comfort and sleep management c. Communication d. Mobilization of patients e. Skin integrity f. Protection and safety g. Psychological/social self determination h. Stress management i. Suctioning procedures j. Weaning modules k. Discharge planning l. Expected outcomes
14
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Structure Teaching Programme Lesson Plan :
Subject : VENTILATOR CARE
Group : Registered Nurses
Method of Teaching : 1) Lecture
2) Discussion
3) Review
4) Demonstration
5) Re-Demonstration
6) Explanations
Teaching aids : 1) LCD Projection
2) Charts
3) Models
4) Live Demonstrations
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Content
Respiratory System :-
ORGANS OF THE RESPIRATORY:- Nose Pharynx
Larynx
Trachea
Two bronchi
Bronchioles and smaller air passage
Two lungs and their coverings, the pleura
Muscles of respiration the intercostals muscles with the diaphragm
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NOSE AND NASAL CAVITY :-
Position and Structure
The nasal cavity is the first of the respiratory organs with consists of a large irregular cavity divided into 2 equal passages by a septum.
The posterior bony part of the septum is formed by the perpendicular plate of the ethmoid bone with the vomer.
Anteriorly it consist o hyaline cartilage.
Respiratory Functions of the Nose
The air is warmed, moistened, and filtered
PHARYNX :-
Position
The pharynx is a tube 12 to 14cm long that extends from the base of the skill to the level of the 6th cervical vertebra.
It lies behind the nose, mouth and larynx and is wider at its upper end.
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Structures Associated with the Pharynx Superiorly - The inferior surfaced of the base of the skill Inferiorly - It is continuous with the esophagus Anteriorly - The wall is incomplete because of the openings into the nose, mouth and larynx Posteriorly - Areolar tissue, involuntary muscle and the bodies of the first 6 cervical vertebral Pharynx is Divide into,
Nasopharynx Oropharynx
Laryngopharynx Blood and Nerve Supply
. Blood is supplied to the pharynx by several branches of the facial artery.
. The venous return is into the facial and internal jugular veins.
. The nerve supply is from the pharyngeal plexus, formed by parasympathetic and sympathetic nerves Parasympathetic supply - Vagus and glossopharyngeal Sympathetic supply - Superior cervical ganglia FUNCTIONS OF PHARYNX:- 1. Passage Way for Air and Food 2. Warning and Humidifying 3. Taste 4. Hearing 5. Protection 6. Speech LARYNX :- Position
The larynx (or) voice bone extends from the root of the tongue and the hyoid bone to the trachea. It lies in front of the Laryngopharynx at the level of the 3rd, 4th, 5th, 6th cervical vertebrae.
There is little difference in the size of the larynx between the senses. It grows larger in the male, which explains the prominence of the ADAM’S
APPLE generally deeper voice.
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STRUCTURE
Cartilages
The larynx is composed of several irregularly shaped cartilages attached to each other by ligaments and membranes.
Thyroid Cartilage
This is the most prominent and consist of 2 flat pieces of hyaline cartilage (or) laminae, fused Anteriorly, forming the laryngeal prominence (Adam apple).
Immediately above the laryngeal prominence the laminae are separated, forming V-shaped notch known as the “Thyroid notch”.
The upper part of the thyroid car is lined with stratified sqnamous epithelium. Cricoid Cartilage
This lies below the thyroid cartilage and is also composed of hyaline cartilage.
It is shaped like SIGNET RING, Completely encircling the larynx with the
1. Thyroid cartilage 2. Cricoid cartilage 3. Arytenoids cartilage 4. Epiglottis
Hyaline cartilage
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narrow part anteriorly and the broad part posteriorly. Arytenoids Cartilages
These are 2 roughly pyramid-shaped hyaline situated on top of the broad part of the Cricoid cartilage forming part of the posterior wall of the larynx. Epiglottis
This is a leaf-shaped fibro elastic cartilage attached to the inner surface of the anterior wall of the thyroid cartilage. Blood and Nerve Supply
Blood is supplied to the larynx by the superior and inferior laryngeal arteries and drained by the thyroid veins, which join the internal jugular vein. TRACHEA :-
Position
The trachea (or) windpipe is a continuation of the larynx andextends downwards to about the level of the 5th thoracic vertebra where it divides at the carina into the right and left bronchi, one bronchus going to each lung.
It is approximately 10 to 11cm long and lies mainly in the median plane in front of the esophagus
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STRUCTURE
The trachea is composed of from 16 to 20 incomplete (c-shaped) rings hyaline cartilages lying one above the other.
The cartilages are incomplete posteriorly there are 3 layers of tissue which clothe the cartilages of the trachea. 1. Outer Layer
This consists of fibrous and elastic tissue and encloses the cartilages. 2. Middle Layer
This consists of cartilages and bands of smooth muscle that wind round the trachea in helical arrangement. 3. Inner Lining
This consists of ciliated columnar epithelium containing mucus-secreting goblet cells. BLOOD AND NERVE SUPPLY, LYMPH DRAINAGE
1. Arterial Blood Supply
This is mainly by the inferior thyroid and bronchial arteries and the venous return is by the inferior thyroid veins into the brachiocephalic veins.
Nerve Supply
This is by parasympathetic and sympathetic fibers
Parasympathetic - Laryngeal nerve
Sympathetic - Sympathetic ganglia
Lymph
Lymph from the respiratory passages passes through lymph nodes situated round the trachea and into 2 bronchi. FUNCTIONS
1. Support and Patency
2. Mucociliary Escalator
3. Cough Reflex
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BRONCHI AND BRONCHIOLES
Structure
These are lined with ciliated columnar epithelium. The bronchi progressively sub divide into branchides, terminal bronchioles,
respiratory bronchioles, alveolar ducts and finally, alveoli. Towards the distal end of the bronchi the cartilages become irregular in
shape. Ciliated columnar mucous membrane change gradually to non-ciliated
cuboidal shaped cells in the distal bronchioles.
BLOOD AND NERVE SUPPLY, LYMPH DRAINAGE
The Arterial Blood Supply
The supply to the walls of the bronchi and smaller air passages is trough branches of the right and left bronchial arteries and the venous return is mainly through the bronchial veins. Nerve Supply
Parasympathetic - Bronchconstriction
Sympathetic stimulation - Bronchodilatation
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Lymphatic Vessels and Lymph Nodes
Lymph nodes situated around the trachea and bronchial tree then into the thoracic duct on the left side and right lymphatic duct on the other. Function
Warming with humidifying Support with patency Removal of particulate matter Cough reflex
Lungs:-
There are 2 lungs, one laying an each side of the midline in the thoracic cavity.
They are cone-shaped and are described as having. . An apex . A base . Costal surface . Medial surface .
Apex
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This is rounded and rises into the root of the neck about 25mm above the level of the middle third of the clavicle. Base
This is concave with semi lunar in shape and is closely associated with the thoracic surface of the diaphragm.
Costal Surface
This surface is convex with and closely associated with the costal cartilages the vibes and the intercostals muscles. Medial Surface
This surface is concave and has roughly triangular shaped area, called the helium. At the level of the 5th, 6th, and 7th thoracic vertebral.
Structures which form the root of the lung enter and leave at the helium. These include the primary bronchus, the pulmonary artery supplying the
lung with the two pulmonary veins draining it, the bronchial artery and veins with the lymphatic with nerve supply. The area between the lungs is the mediastinum. It is occupied by the heart, great vessels, trachea, right and oesophagus, lymph nodes, lymph vessels with nerves.
Respiration:-
Inflation and deflation of the lungs occurring with each breath ensures that regular exchange of gases takes place between the alveoli and the external air. Types
External respiration Internal respiration
External Respiration
Exchange of gases between the blood with the lungs is called external respiration. Internal Respiration
Gases between the bloods with the cells internal respiration
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Cycle of Respiration
This occurs 12 to 15 times per minute and consists of 3 phases. . Inspiration . Expiration . Pause
Inspiration
When the capacity of the thoracic cavity is increased by simultaneous contraction of the intercostals muscles without the diaphragm, the parietal pleura moves with the walls of the thorax with the diaphragm.
Expiration
Relaxation of the intercostals muscles and the diaphragm results in downward and inward movement of the rib cage and elastic recoil of the lungs.
Pressure inside the lungs exceed that in the atmosphere and therefore air is expelled from the respiratory tract.
The lungs still contains some air and are prevented from complete collapse by the intact pleura.
This process is passive as it does not require the expenditure of energy. After expiration, there is a ‘Pause’ before the next cycle begins.
PHYSIOLOGICAL VARIABLES AFFECTING
Respiration
Elasticity: The ability of the lung to return to its normal shape after each breath.
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Loss of elasticity of the connective tissue in the lungs necessitates forced expiration and increased effort on inspiration. Compliance
This measure of the dispensability of the lungs that is the effort required to inflate the alveoli.
When compliance is low the effort needed to inflate the lungs is greater than normal. Airflow Resistance
When this is increased in broncho constriction, more respiratory effort is required to inflate the lungs. Lung Volumes with Capacities
In normal quiet breathing there are about 15 complete respiratory cycles per minute.
The lungs with the air passages are never empty with as the exchange of gases take place only across the walls of the alveolar ducts with alveoli.
The remaining capacity of the respiratory passages is called the anatomical dead space (about 150ml).
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Tidal Volume (IV):-
This is the amount of air which passes into and out of the lungs during each cycle of quiet breathing (about 500ml).
Inspiratrory Reserve Volume (IRV)
This is the extra volume of air that can be inhaled into the lungs during nominal inspiration.
Inspiratory Capacity (IC)
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This is the amount of air that can be inspired with maximum effort. It consists of the tidal volume (500ml) plus the Inspiratory reserve volume.
Functional Residual Capacity (FRC)
This is the amount of air remaining in the air passages and alveoli at the end of quiet expiration.
The functional residual volume also prevents collapse of the alveoli on expiration. Expiratory Reserve Volume (ERV)
This is the largest volume of air which can be expelled from the lungs during maximal expiration.
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Residual Volume (RV)
This cannot be directly measured but is the volume of air remaining in the lungs after forced expiration. Vital Capacity (VC)
This is the maximum volume of air which can be moved into and out of the lungs. VC = Tidal volume +IRV+ERV
Alveolar Ventilation
This is the volume of air that moves into and out of the alveoli per minute. It is equal to the tidal volume minus the anatomical dead space, multiplied
by the respiratory rate. Alveolar ventilation = IX – Anatomical dead space X respiratory rate
= 500 – 150ml X per/min
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= 5.23 liters per min
HUMAN BEHAVIOR AND NEEDS IN CRISIS
DEFINITION:
Crisis is a perception of an event or situation as an intolerable difficulty that exceeds the person's resources and coping mechanisms.
STEPS IN CRISIS INTERVENTION;
Make Psychological Contact and Establish the Relationship. Establish rapport by conveying genuine respect and acceptance of the client. The client also needs assurance and reinforcement that he or she may receive help. If this step is omitted, the client will not feel respected and will be resistant to counseling.
Examine the Dimensions of the Problem to Define the Problem. Identify the precipitating event, previous coping methods, and lethality. Focus on the now and how, rather than the then and why. Use open-ended questions
Explore Feelings and Emotions.
It is therapeutic for the client to vent and express feelings and emotions in an accepting, supportive, private, and non-judgmental setting. The crisis
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intervener must actively listen.
Explore and Assess Past Coping Attempts.
Identify and modify the client’s coping behaviors at both the preconscious and conscious levels. Coping responses must be brought to the conscious level and to educate the client in modifying maladaptive coping behaviors. Explore how certain situations are handled: intense anger, loss of a loved one, disappointment, failure, etc. Help the client understand how they have been coping and why it has not worked. If this step is omitted, the client may continue using maladaptive coping behaviors that continue not to work
Generate and Explore Alternatives and Specific Solutions.
Clients need help conceptualizing more adaptive coping responses to the crisis. If the client has little introspection or personal insights, the clinician needs to take initiative and suggest coping methods.
Restore Cognitive Functioning Through Implementation of an Action Plan.
Help the client focus on why a specific event leads to a crisis state and, simultaneously, what the client can do to master the experience and be able to cope with future events. This is done in three stages:
. The client needs a realistic understanding of the crisis and what led to the event. Understand what happened, why it happened, who was involved, and the final outcome.
. Understand the specific meaning of the event, how it conflicts with expectations, life goals, and belief system. The clinician should note cognitive errors, distortions, irrational beliefs, and help the client discover them.
Reconstructing, rebuilding, and replacing irrational beliefs with new cognition. Provide new info through homework assignments or referrals to others who have lived through and mastered a similar crisis, such as a support group.
Follow-Up
Clinician should leave her door for client to come back for future sessions. Often, unforeseen events conjure up images and old feelings surrounding (i.e. the anniversary of the event).
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COUNSELLING:-
DEFINITION :
Counseling is a process that enables a person to sort out issues and reach decision affecting their life. Often counseling is sought out at times of changes or crisis it need not be so however as counseling can also help us at any time of our life.
Steps in the Counseling Process
1. Establish a safe, trusting environment
2. CLARIFY: Help the person put their concern into words.
3. Active listening: find out the client's agenda
a) paraphrase, summarize, reflect, interpret
b) focus on feelings, not events
4. Transform problem statements into goal statements.
5. Explore possible approaches to goal
6. Help person choose one way towards goal
DEVELOP A PLAN
7. Make a contract to fulfill the plan (or to take the next step)
8. Summarize what has occurred, clarify, get verification
EVALUATE PROGRESS
9. Get feedback and confirmation.
PHASES IN COUNSELLING:-
Phase 1. Developing A Relationship
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To develop solid relationships with youth, you need to create a safe environment where young people will feel comfortable enough to open up to you and talk to you about anything that is on their minds. You also need to help youth see that despite their circumstances they have strengths. In short, you should start things off from a strengths-based perspective.
Phase 2. Making An Informed Assessment
An informed assessment happens when both you and the youth gather information in order to figure out what’s “really” going on so that you can assess what needs to happen next in order to change the situation for the better or build up the youth’s coping skills to better deal with a problematic situation. The first step in making an assessment is to find out if change is necessary, and if it is what needs to happen for change to take place. If you have determined that change is necessary, then the next step is to figure out what needs to change. Is it a behavior? An attitude?
Phase 3. Establishing Mutually Agreed Upon Goals and Objectives
Because if a young person is in agreement with the goals then he/she is more likely to follow through on them. When a youth is actively involved in the goal setting process and is in agreement with the goals, then he/she is more inclined to take ownership of the goals. What are goals? Goals are broad statements that identify what you want to accomplish. Think of goals as the end result that you are trying to achieve
Phase 4. Implementation Plan
The implementation plan is a plan that you and the youth work on together. It is designed to prevent, intervene, or address unhealthy behaviors and practices. The implementation plan identifies who will perform the activities, where the activities will occur, how frequently they will occur, how they will be carried out and when they will be carried out. Implementation activities are designed to help individuals re-think risky behavior, work through problematic issues, address unhealthy lifestyles practices, learn new skills and build strengths. Implementation activities can include: counseling, crisis intervention, training and education, supportive services, concrete services and constructive use of free time.
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Attitudes and humanizing care:
According to tradition in social psychology, attitudes are precursors of behavior. An attitude is a predisposition to respond in a certain way. But this time one of the most widely used in all of psychology has developed diverse meanings. Some psychologist study attitudes only in terms of overt behavior. If a person persists in this text and by many psychologists today, is most broadly based. It states that an attitude has three basic components thinking feeling, and acting. The attitude is thus reflected in your overt behavior.
FAMILY AND FAMILY RELATIONSHIPS;
The family is a basic unit of society it consist of those individuals male or female, youth or adult, legally or not legally related, genetically or not genetically related who are considered by the others to represent their significant persons.
Families also have a structure and a way of functioning. Structure is based on the ongoing membership of the family and pattern of relationships. Relationships can be numerous and complex for example women’s relationships may include wife- husband, mothers- son, mother –daughter, employee- boss, each with different demands and rolls and expectations, patterns relationships from power and role structure within the family. These structures can be determined by observing family behavior and interactions.
Socio-cultural influences.
The following factors are included in socio-cultural values:
interpersonal relationships verbal and nonverbal communication value orientations religion social systems diet health Illness related to beliefs is affects directly or indirectly.
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Principals of asepsis:
All objects used in a sterile field must be sterile. Sterile objects become unsterile when touched by unsterile objects. Sterile items that are out of vision of below the waste or table level are
considered unsterile Sterile objects can become unsterile by prolonged exposure to air born
micro-organism Fluids flow in the direction of gravity. Moisture that passes through a sterile objects draws. Microorganisms from unsterile surfaces above or below to the sterile
surfaces by capillary action. The edge of the sterile field is considered unsterile. Biomedical waste management:
Bio medical or hospital waste means any waste generate during health care ,research testing or related procedures on human being or animals conducted in hospitals, clinics, and laboratories or similar establishment. This is far more dangerous and offensive than domestic waste.
The Gov. of India has promulgated medical waste rules, 1998 under which the person who are in charge of medical and other institutions where such waste are generated are held legally responsible for maintaining the condition prescribing the rules, which have come into effect from 1 January 2003.
Waste management:
A primary pre requisite for effective waste management is clean and tidy environment.
The hospital and its premises should be kept in a clean and hygienic condition.
The objectives of biowaste management are to prevent harm resulting from waste, minimize its volume, retrive reusable materials, ensure safe and economical disposal.
SEGREGATION OF WASTE:-
Segregation of waste means separating and placing the hospital waste/bio-medical waste and general waste
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COLOUR BINS FOR WASTE
1.Red bin:
Clearly demarcate plastic and non plastic waste. The plastic waste should be immersed at least for 30 minutes in the twin bin
for disinfection process. After disinfecting the plastic waste shift it to the specially designed pictured
red colour bag with big bio-hazard symbol inside the red bin.
2. Blue bin;
Bio medical waste such as sharps including ampoules ,vials, broken galasses,suture,slidsetc.should be placed in the blue bin
Needle and suture lancets should be managed by using needle destroyer.
3.Yellow bin;
Bio medical waste such as anatomical waste , placenta, tissues, body parts,etc.should be placed in the yellow bin.
4.Black bin:
In the black bin all expired drugs and cytoxic drugs etc. should be placed.5.Green bin;
General waste such as food items ,plastic covers, needle covers and non
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infected plaster of paris,etc should be placed in the green bins.
ROLE OF NURSE;
Segregate the waste as per colour code. Disinfect the segregation waste wherever essential. Avoid transferring sharp instruments directly from person to person. Do not recap the needles. Record the quantity of weighed bio-medical waste in the prescribed
register on daily basis.
Principles of drug administration :
Almost all drugs are harm products and are foreign materials that the body producing reactions.
Additional force of water towards the glass produces a downward curve called meniscus
The human tongue presents an irregular surface and so tablets powders and capsules produce friction and prevent easy swallowing.
The sense of taste is acute and an unpleasant taste may produce nausea and vomiting.
The taste buds of the tongue can be partially is desensitized by cold drinks. Well diluted drugs and empty stomach favor absorption of drugs. But certain drugs
are irritating to mucus membrane of the stomach. Medical record is a legal one and reference for future study and research. Using common medicine glasses promote cross infection.
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Volatile liquids when kept open or not tightly corked diffuse through a air and get decomposed.
Elements of error is a possibility in all human activity and commit ort omit a dose of medicine means the extents of the end of tile of the person.
Understanding of how the drugs benefits, how it is to be given and the side effects of the drug will help the patient to take drug regularly and report the physician concerned.
Administration of the medication is a therapeutic measure. It will be therapeutic only, if the patient gets the desired effect of the drug..
Role of nurse:
She should know the nature of drugs She should know the various factors that modified the action of the
drug. She should be familiar with the habit forming drugs and the measures
and means of restricting their use. She should know the factors which must be considered in determining
the method and time of administration. She should know the abbreviation and symbol used in writing orders
for administering e.g. tid bd. She should be familiar with the drugs which are continually appearing
in the market by reacting pamphlets journals etc.
Care of drug:
Drugs for external use should be kept separate. Bottles should be arranged alphabetically so that is easy to handle the
drugs if the bottles are equal in size. Poisonous drugs should be kept in a separate cupboard. A register should be maintained to keep the account of the poisonous
drugs Drugs that are unusual in colure, odor and consistency should be
returned to the pharmacy to be discarded. Emergency drugs such as stimulants should be kept in a box.
Mechanical ventilation is useful modality for patients who are unable to sustain the level of ventilation necessary to maintain the gas exchange functions (oxygenation and carbon dioxide elimination) indications for mechanical
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MINUTE VENTILATION = RATE × TIDAL VOLUME
Respiratory rates and tidal volume alone are unreliable indicators of adequate ventilation because both can vary widely from breath to breath. Together however the tidal volume and respiratory rates are important because the minute ventilation which is useful in detecting respiratory failure can be determine from them. Minute ventilation is the volume of air expired for minutes. It is equal to the product of the tidal volume and the respiratory rates or frequency.
COMPLICATIONS OF MECHANICAL VENTILATORE
Baro trauma Pneumothorax and pneumomediastinum Volume pressure trauma Alveolar hypoventilation Alveolar hyperventilation Ventilator associated pneumonia
PREVENTION:
Continuous positive- pressure ventilation increases the production of secretions regardless of the patient’s underlying condition.
The nurse assess for the presence of secretions by lung auscultation at least every 2 to 4 hours
Have patient cough and, if feasible, deep breathe every 2hrs to remove
ventilation vary greatly among patient. Mechanical ventilation may be indicated in conditions due to physiological changes, disease states, medical surgical procedures, as well as many other conditions leading to ventilator failure or oxygenation failure. Use of mechanical ventilation also various greatly from short term to long term and from acute care in the hospital to extended care at home. one of the frequent uses of mechanical ventilation is for the management of post operative patients recovering from anesthesia and medication. In one study post operative procedure accounted 35% of all patients who were placed on mechanical ventilation for more than 24hrs. Mechanical ventilation is a method for using machines to help patients breathe when they are unable to breathe sufficiently on their own.
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secretions and to prevent hypoventilation. Assess for adequate systemic hydration and provide supplemental
humidification of ventilator-delivered gases because these will assist with the thinning of secretions.
Suction oropharynx as needed to remove pooled secretions. Perform tracheobronchial suctioning to remove retained secretions and
improve oxygemtion. Perform postural drainage, vibration, and percussion maneuvers when indicated to prevent pooling of secretions in the lungs.
Change the patient's position every 2hrs Humidification of the airway via the ventilator is maintained to liquefy secretions
so they are more easily removed. Sputum is not produced continuously or every 1 to 2 hours but as a response to
pathologic condition. Therefore, there is no rationale for routine suctioning of all patients every 1 to 2
hours. Although suctioning is used to aid in the clearance of secretions. It can damage
the airway mucosa and impair cilia action Bronchodilators are administered to dilate the bronchioles and are classified as
adrenergic or anticholinergic.. Mucolytic agents such as acetylcysteine (Mucomyst) are administered as
prescribed to liquefy secretions so that they are more easily mobilized. Nursing management of patients receiving mucolytic therapy includes
assessment for an adequate cough reflex, sputum characteristics, and improvement in incentive spirometry. MECHANICAL VENTILATORS
Mechanical ventilation is a form of artificial respiration that uses a breathing machine (mechanical ventilator) to assist patients with breathing. It is used when the lungs are not functioning properly.
In the history of mechanical ventilation, it was first introduced by the ‘VESALIUS’, by inserting a reed or cane into the trachea of animals and then blowing into this tube. In 1908, GEORGE POE demonstrated his mechanical respiratory by asphyxiating dogs and seemingly boringly they back of life.
For centuries, medical pioneers have experimented with the idea of artificially mimicking the respiratory function of the lungs to sustain human life. Twenty eight centuries ago, reference to support ventilation appeared in the bible.
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HISTORICAL REVIEW OF MECHANICAL VENTILATORS;
PAST-EARLY HISTORY OF ANCIENT TIMES;
First recorded in the Bible – Old Testament (1600 BC) – the creation of man – God breathed into nostrils the breathe of life and man became a living soul (Gen 2:7)
800BC – mention of prophets Elijah and Elisha inducing pressure breathing from mouth to mouth to a dying child.
Roman Physicians Galen and Vesalius described mechanical ventilation by inserting reed or cane into trachea of animals. MODERN HISTORY;
DEVELOPMENT OF VENTILATORS;
1493-1541 – Paracelsus used “Fire Bellows” connected to a tube inserted into the patient’s mouth as a device for assisted ventilation. He also described anesthesia effects of ether
1543 – Andreas Vesalius – experimented on a pregnant sow – described the physiological effects produced when mechanical ventilation is applied after lung collapse.
1667 – Robert Hook performed experiments to demonstrate the need of continuous supply of air through two bellows to keep an animal alive.
1744 – John Farthergill reported a successful mouth to mouth resuscitation, but didn’t gain momentum till 2 centuries later.
1767 – Human Society in Amsterdam (Dutch Society for drowned patients) advocated principles of ventilation and resuscitating drowned patients as First Aid measure.
1770 – Tobacco resuscitator kit – used to revive patients by blowing air or smoke into lungs or up the rectum.
1775 – John Hunter developed double bellows - one to blow in good air, the other to draw out bad air.
1827 – Jean L D’etailles improved the design to prevent barotraumas (pressure) to the lungs.
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INHALATION AGENTS;
1796 – Johan Herholdt and Carl Rafn – Dutch Physicians were the first to propose the use of newly discovered gas Oxygen to improve resuscitation outcomes.
1907 – Marc Barthalomy & Leon Dufonc of Lyons developed equipment and performed first endotracheal anesthesia on human during facial surgery. NEGATIVE PRESSURE VENTILATORS;
1876 – Eugine Wailliz constructed the first whole body negative pressure device to eliminate the risk of barotraumas. This was called as “Spirophore” (Non- invasive). Thus negative pressure Ventilators were born
For long term home treatment “Chest cuirass” was developed. This covered only the chest of the patient. It was an improvement from whole body Ventilator.
1928-29 - Drinker & Shaw developed the “Iron Lung” – First negative pressure mechanical ventilator for long term ventilation.
20th CENTURY DEVELOPMENTS POSITIVE PRESSURE VENTILATORS;
1950 – Carl G Engstrom developed and refined positive pressure ventilators for polio victim on long term basis.
1952 – Scandinavian Polio Epidemic made Ventilators popular. Led to development of positive pressure ventilators to prevent death of polio patients on negative pressure ventilators.
1952 – Roger Manley of London developed a Gas driven ventilator. 1970-1980 – Beginning of electronic ventilators.
PRESENT ERA;
1971 – SERVO 900 Ventilator. 1991 – SERVO 300 series ventilator introduced 2001 –Modular concept ventilators.
FUTURE;
High Frequency Oscillatory Ventilation. Computer control of Mechanical Ventilation ( Operator and Patient Ventilator
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interface) The history of mechanical ventilator/ Ventilators extends over more than four
and a half centuries. CLASSIFICATION OF VENTILATORS
Once an artificial airway is successfully established, the cuff makes a seal between the patient and the ventilator. There are two main classifications.
Negative pressure ventilators Positive pressure ventilators
Pressure- cycled Time-cycled Volume- cycled
NEGATIVE PRESSURE VENTILATORS;
Negative pressure ventilators exert a negative pressure on the external chest. Negative pressure ventilators are simple to use and do not require intubation of the airway consequently they are especially adaptable for home use
POSITIVE PRESSURE VENTILATORS;
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Positive pressure ventilation can then be instituted. It forces air into the lungs, causes the lungs and chest wall to expand, and produces inspiration. When the flow of air stops, the chest and lungs recoil in expiration and return to normal airway pressure. Positive-pressure ventilators may be pressure-cycled, volume-cycled, or time-cycled ventilators. Newer computerized microprocessor-controlled ventilators are capable of multiple modes of ventilation. In addition, they are capable of computerized monitoring and are able to acquire, process, store, and retrieve data. Because of their reliability in delivering a preset tidal volume,
PRESSURE – CYCLED;
Deliver a volume of gas to the positive pressure is delivered until the preselected pressure has been reached. When the preset pressure is reached the machine cycles into exhalation. Pressure cycle ventilators are used in only a small portion of client who requires.
VOLUME- CYCLED ;
It allow for airflow into the lungs until a preset volume of gas is ejected from the ventilator. Once this tidal volume is reached, inspiration is terminated and exhalation is allowed. It must be remembered that some of the air ejected from the ventilator is distributed in the ventilator circuits, and the higher the pressure the more air remains in the tubing. Volume cycled ventilation is delivered in a variety
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of different modes which determine how patients receive breaths from the ventilator. Volume-cycled ventilation is generally used in the adult population.
TIME- CYCLED;
It terminated or control inspiration after a present time. The volume of air the patient receives is regulated by the length of inspiration and the flow rate of air. Most ventilators have a rate control that determines the respiratory rate but pure time cycling is rarely used for adults. These ventilators are used in new born and infants.
MECHANICAL VENTILATION WITH IN CONVENTIONAL GASES
Gas mixtures of air and oxygen are usually administered to produce the desired inspired oxygen concentration. How ever there may be clinical circumstances in which it is desirable to substitute helium for air. In this recent year there also has been increasing clinical interest in providing very low concentration of nitric oxide inspired gas of some patients.
HELIOX;
PHYSICS AND PHYSIOLOGY;
The physical properties of helium are different from those air or oxygen. The densities of helium air and oxygen are 0.18, 1.29 and 1.43kg\M3, respectively. The viscosities of helium, air, and oxygen are 201.8, 188.5, and 211.4 poise, respectively .the density and viscosity of heliox air 0.43kg/m3 and 203.6poise respectively. DELIVERY SYSTEM;
Heliox administration via mechanical ventilation can be problematic. Ventilators are designed to deliver a mixture of air and oxygen. The different density and viscosity of helium can affect the delivered tidal volume and the
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measurement of exhaled tidal volume The effect of heliox on the ability of the ventilator to correctly monitor
flow and tidal volume depends on the method that is used for this measurement. Monitoring device that are density dependent are inaccurate in the presence of heliox. .
The FiO2 requirement of the patient limits the helium concentration that can be administered. If an FiO2 greater than 0.49 is required the limited concentration of helium is unlikely to produce clinical benefits.
CLINICAL APPLICATION;
A common use of heliox is to reduce resistance with upper airway obstruction.
It is used for the treatment of asthma.
NITRIC OXIDE;
Nitric oxide is a ubiquitous highly reactive, gaseous, diatomic radical that is important physiologically at very low concentrations. Atmospheric concentrations of NO usually range between 10 and 100ppb and concentrations of 400 to 1000ppm routinely are inhaled by people who smoke cigarettes.
NO is an important messenger molecule and many cell types have shown the capacity to produce NO. The action of common nitrosovasodilators is a result of their release of NO.NO is present in low concentration in the hospital compressed gas supply and may produce physiologic effects in patient s breathing gas.
DELIVERY SYSTEM; Many articles have described systems to administer inhaled NO to adult
mechanically ventilated patients by premixing the NO with N2 and introducing the mixture proximal to the gas inlet of the ventilator. These systems typically add the O2 /N2/NO gas mixture to the low flow inlet of the servo 900c ventilator or the high pressure air or O2 inlet of a ventilator such as the NELLCOR PURITAN- BENNETT 7200.
CLINICAL APPLICATIONS;
It used for treatment of acute respiratory distress syndrome.
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It also used for treatment of hypoxemic respiratory failure of the newborn.
Troubleshooting
Assessment
The first priority in dealing with mechanical ventilation problems is to assess the patient.
How severe is the problem? Does the patient require immediate resuscitation?
Check
Is the chest moving and is it moving symmetrically? Is the patient cyanosed? What is the arterial saturation? Is the patient haemodynamically stable?
The next step is to diagnose the problem. Ventilator / circuit problems can be distinguished from endotracheal tube / patient problems by taking the patient off the ventilator and manually bagging the patient with a self inflating resuscitator.
High airway pressure
High airway pressure may cause barotraumas It signifies a deterioration in the patient's clinical state It may result in hypoventilation of the patient Many ventilators cycle from inspiration to expiration immediately if the upper
pressure alarm limit is reached. As a result inspiration is terminated early and the tidal volume is reduced.
Causes
Ventilator problems
inappropriate settings
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excessive tidal volume excessive flow or excessively short Inspiratory time high airway pressure alarm limit too low ventilator malfunction - rare
Circuit problems
fluid pooling in circuit fluid pooling in filter kinking of circuit
Endotracheal tube obstruction
E.g. due to sputum, kinking, biting
Increased airway resistance
E.g. bronchospasm
ET. Tube obstruction, biting the tube by the patient
Decreased respiratory system compliance
parenchyma disease pleural disease e.g. Pneumothorax decreased chest wall compliance e.g. due to patient "fighting" ventilator decreased ventilated lung volume sputum plugging lobar / lung collapse end bronchial intubation
Management
1. assess patient 2. Disconnect patient from ventilator and manually ventilate using self-inflating
resuscitator. Assess the "feel" of the lungs. Is the patient difficult to ventilate? If the patient is not difficult to ventilate the problem is a problem with the ventilator or the circuit. If the patient is difficult to ventilate it is a problem with the endotracheal tube or the respiratory system.
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3. For ventilator and circuit problems check ventilator settings and function, and check circuit for obstruction or kinking. For patient or ETT problems examine the patient looking particularly for wheeze, asymmetrical chest expansion and evidence of collapse. Pass a suction catheter through the ETT to check its patency.
4. Chest X-Ray
If the cause is still not clear measure Inspiratory pause pressure (approximates to alveolar pressure). If both airway and alveolar pressure are high the problem is due to poor compliance. If only the airway pressure is high the problem is one of high resistance
MODES OF VENTILATORS
A certain volume of gas in a set period of time the pressure generated in the lung will then be dependent on the resistance and compliance of the respiratory system known as volume control mode a certain level of pressure for a set period of time the tidal volume delivered will then be dependent on the resistance and compliance of the respiratory system pressure control and pressure regulated volume control modes in assist-control modes (volume control, pressure control, the ventilator guarantees that the patient will receive the set minimum number of breaths, although he/she is able to demand patient will receive the set minimum number of breaths, although he/she is able to demand [trigger] more in pressure support modes the patient only receives breaths when he/she triggers the ventilator
Conventional ventilation
The modes of ventilation can be thought of as classifications based on how to control the ventilator breath. Traditionally ventilators were classified based on how they determined when to stop giving a breath. The three traditional categories of ventilators are listed below. As microprocessor technology is incorporated into ventilator design, the distinction among these types has become less clear as ventilators may use combinations of all of these modes as well as flow-sensing, which controls the ventilator breath based on the flow-rate of gas versus a specific volume, pressure, or time.
Breath termination
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In a volume-cycled ventilator the ventilator delivers a pre-set volume of gas with each breath. Once the specified volume of breath is delivered, the positive pressure is terminated after a certain specified time period. Both pressure and volume modes of ventilation have their respective limitations. Many manufacturers provide a mode or modes that utilize some functions of each. These modes are flow-variable, volume-targeted, pressure-regulated, time-limited modes (for example, pressure-regulated volume control (PRVC). This means that instead of providing an exact tidal volume each breath, a target volume is set and the ventilator will vary the Inspiratory flow at each breath to achieve the target volume at the lowest possible peak pressure. The Inspiratory time limits the length of the Inspiratory cycle and therefore the I: E ratio. Pressure regulated modes such as PRVC or Auto-flow (Draeger) can most easily be thought of as turning a volume mode into a pressure mode with the added benefit of maintaining more control over tidal volume than with strictly pressure-control.
Breath initiation
The other method of classifying mechanical ventilation is based on how to determine when to start giving a breath. Similar to the termination classification noted above, microprocessor control has resulted in a myriad of hybrid modes that combine features of the traditional classifications. Note that most of the timing initiation classifications below can be combined with any of the termination classifications listed above.
Assist Control (AC). In this mode the ventilator provides a mechanical breath with either a pre-set tidal volume or peak pressure every time the patient initiates a breath. Traditional assist control used only a pre-set tidal volume--when a preset peak pressure is used this is also sometimes termed Intermittent Positive Pressure Ventilation or IPPV. However, the initiation timing is the same both provide a ventilator breath with every patient effort. In most ventilators a back-up minimum breath rate can be set in the event that the patient becomes apnoeic. Although a maximum rate is not usually set, an alarm can be set if the ventilator cycles too frequently. This can alert that the patient is tachypneic or that the ventilator may be auto-cycling (a problem that results when the ventilator interprets fluctuations in the circuit due to the last breathe termination as a new breath initiation attempt).
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Synchronized Intermittent Mandatory Ventilation (SIMV).
In this mode the ventilator provides a pre-set mechanical breath (pressure or volume limited) every specified number of seconds (determined by dividing the respiratory rate into 60 - thus a respiratory rate of 12 results in a 5 second cycle time). Within that cycle time the ventilator waits for the patient to initiate a breath using either a pressure or flow sensor. When the ventilator senses the first patient breathing attempt within the cycle, it delivers the preset ventilator breath. If the patient fails to initiate a breath, the ventilator delivers a mechanical breath at the end of the breath cycle. Additional spontaneous breaths after the first one within the breath cycle do not trigger another SIMV breath. However, SIMV may be combined with pressure support (see below). SIMV is frequently employed as a method of decreasing ventilators support (weaning) by turning down the rate, which requires the patient to take additional breaths beyond the SIMV triggered breath.
Controlled Mechanical Ventilation (CMV).
In this mode the ventilator provides a mechanical breath on a preset timing. Patient respiratory efforts are ignored. This is generally uncomfortable for children and adults who are conscious and is usually only used in an unconscious patient. It may also be used in infants who often quickly adapt their breathing pattern to the ventilator timing.
Pressure Support Ventilation (PSV).
When a patient attempts to breathe spontaneously through an endotracheal tube, the narrowed diameter of the airway results in higher resistance to airflow, and thus a higher work of breathing. PSV was developed as a method to decrease the work of breathing in-between ventilator mandated breaths by providing an elevated pressure triggered by spontaneous breathing that "supports" ventilation during inspiration. Thus, for example, SIMV might be combined with PSV so that additional breaths beyond the SIMV programmed breaths are supported. However, while the SIMV mandated breaths have a preset volume or peak pressure, the PSV breaths are designed to cut short when the Inspiratory flow reaches a percentage of the peak Inspiratory flow (e.g. 10-25%). New generation of ventilators provides user-adjustable inspiration cycling off threshold, and some even are equipped with automatic inspiration cycling off threshold function. This
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helps the patient ventilator synchrony. The peak pressure set for the PSV breaths is usually a lower pressure than that set for the full ventilator mandated breath. PSV can be also be used as an independent mode.
Continuous Positive Airway Pressure (CPAP).
A continuous level of elevated pressure is provided through the patient circuit to maintain adequate oxygenation, decrease the work of breathing, and decrease the work of the heart (such as in left-sided heart failure CHF). Note that no cycling of ventilator pressures occurs and the patient must initiate all breaths. In addition, no additional pressure above the CPAP pressure is provided during those breaths. CPAP may be used invasively through an endotracheal tube or tracheotomy or non-invasively with a face mask or nasal prongs.
Positive end expiratory pressure (PEEP).
It is functionally the same as CPAP, but refers to the use of an elevated pressure during the expiratory phase of the ventilatory cycle. After delivery of the set amount of breath by the ventilator, the patient then exhales passively. The volume of gas remaining in the lung after a normal expiration is termed the functional residual capacity (FRC). The FRC is primarily determined by the elastic qualities of the lung and the chest wall. In many lung diseases, the FRC is reduced due to collapse of the unstable alveoli, leading to a decreased surface area for gas exchange and intrapulmonary shunting (see above), with wasted oxygen inspired. Adding PEEP can reduce the work of breathing (at low levels) and help preserve FRC.
High Frequency Ventilation (HFV) High Frequency Ventilation refers to ventilation that occurs at rates
significantly above that found in natural breathing (as high as 300-900 "breaths" per minute). Within the category of high frequency ventilation, the two principal types are flow interruption and high frequency oscillatory ventilation (HFOV). The former operates similarly to a conventional ventilator, providing increased circuit pressure during the Inspiratory phase and dropping back to PEEP during the expiratory phase. In HFOV the pressure wave is driven by an electromagnetically controlled diaphragm similar to a loudspeaker. Because this can rapidly change
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the volume in the circuit, HFOV can produce a pressure that is lower than ambient pressure during the expiratory phase. This is sometimes called "active" expiration. In both types of high-frequency ventilation the pressure wave that is generated at the ventilator is markedly attenuated by passage down the endotracheal tube and the major conducting airways. This helps protect the alveoli from volutrauma that occurs with traditional positive pressure ventilation. Although the alveoli are kept at a relatively constant volume, similar to CPAP, other mechanisms of gas exchange allow ventilation (the removal of CO2) to occur without tidal volume exchange. Ventilation in HFV is a function of frequency, amplitude, and I: E ratio and is best described graphically as the area under the curve of an oscillatory cycle. Amplitude is analogous to tidal volume in conventional ventilation; larger amplitudes remove more CO2. Seemingly paradoxical, lower frequencies remove more CO2 in HFOV whereas in conventional ventilation the opposite is true. As frequency decreases, there is less attenuation of the pressure wave transmitted to the alveoli. This results in increased mixing of gas and thus ventilation. I-time is set as a percentage of total time (usually 33%). Amplitude is a function of power and is subject to variability due to changes in compliance or resistance. Therefore, power requirements may vary significantly during treatment and from patient to patient. Patient characteristics and ventilator settings determine whether PaCO2 changes may be more sensitive to amplitude or frequency manipulation. In HFOV, mean airway pressure (MAP) is delivered via a continuous flow through the patient circuit which passes through a variable restriction valve (mushroom valve) on the expiratory limb. Increasing the flow through the circuit and/or increasing the pressure in the mushroom valve increases MAP. The MAP in HFOV functions similarly to PEEP in conventional ventilation in that it provides the pressure for alveolar recruitment.
Non-invasive ventilation (Non-invasive Positive Pressure Ventilation or NIPPV)
This refers to all modalities that assist ventilation without the use of an endotracheal tube. Non-invasive ventilation is primarily aimed at minimizing patient discomfort and the complications associated with invasive ventilation. It is often used in cardiac disease, exacerbations of chronic pulmonary disease, sleep apnea, and neuromuscular diseases. Non-invasive ventilation refers only to the patient interface and not the mode of ventilation used; modes may include spontaneous or control modes and may be either pressure or volume modes.
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Some commonly used modes of NIPPV include
Continuous positive airway pressure (CPAP). Bi-level Positive Airway Pressure (BIPAP). Pressures alternate between
Inspiratory Positive Airway Pressure (IPAP) and a lower Expiratory Positive Airway Pressure (EPAP), triggered by patient effort. On many such devices, backup rates may be set, which deliver IPAP pressures even if patients fail to initiate a breath. (Wheatley 2000 et .al)
Intermittent positive pressure ventilation (IPPV) via mouthpiece or mask
Proportional Assist Ventilation (PAV).
It is a form of synchronized ventilator support based upon the Equation of Motion in which the ventilator generates pressure in proportion to the instantaneous patient effort. Unlike other modes of partial support, there is no target flow, tidal volume or pressure. PAV’s objective is to allow the patient to attain ventilation and breathing pattern his ventilatory control system desires. The main operational advantages of PAV are automatic synchrony with Inspiratory efforts, exhalation and adaptability to change in ventilatory demand.
Proportional Assist Ventilation Plus — PAV+ (Puritan Bennett – 840 ventilator range, Proportional Pressure Support — PPS (Drager Evita series) and Respironics BiPAP Vision PAV , are commercially available implementations of PAV which automatically amplify the patient's own spontaneous effort to breathe by increasing airway pressure during inspiration proportionally to a set amplification factor. In PAV+, the level of amplification, thus the level of work of breathing, is set through a single setting (%support) and the pressure applied is continuously and automatically adjusted based on measures (including automatic assessment of Elastance and Resistance) taken throughout the Inspiratory cycle to maintain an appropriate level of support.
Adaptive Support Ventilation (ASV)
Adaptive Support Ventilation (ASV) is a positive pressure mode of mechanical ventilation that is closed-loop controlled. In this mode, the frequency and tidal volume of breaths of a patient on the ventilator are automatically adjusted based on the patient’s requirements. The lung mechanics data are used to adjust the depth and rate of breaths to minimize the work rate of breathing. In
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the ASV mode, every breath is synchronized with patient effort if such an effort exists, and otherwise, full mechanical ventilation is provided to the patient.
ASV technology was originally described as one of the embodiments of US Patent No. 4986268. In this invention, a modified version of an equation derived in physiology in 1950 to minimize the work rate of breathing in man, was used for the first time to find the optimum frequency of mechanical ventilation. The rationale was to make the patient's breathing pattern comfortable and natural within safe limits, and thereby stimulate spontaneous breathing and reduce the weaning time. A prototype of the system was built by the inventor in late 1980s. The inventor is Dr. Fleur T. Tehrani who is a professor of electrical engineering at California State University, Fullerton, in USA. Shortly after the Patent was issued in 1991, Hamilton Medical, a ventilator manufacturing company, contacted the inventor and discussed marketing the technology with her. Some years later, Hamilton Medical marketed this closed-loop technique under license of this Patent as ASV. Since the issuance of the Patent, a number of articles have been published by the inventor and her colleagues that are related to the invention, and some of them describe further advancements of the closed-loop techniques presented in the Patent.
Neutrally Adjusted Ventilatory Assist (NAVA).
It is a new positive pressure mode of mechanical ventilation, where the ventilator is controlled directly by the patient's own neural control of breathing. The neural control signals of respiration originate in the respiratory center, and are transmitted through the phrenic nerve to excite the diaphragm. These signals are monitored by means of electrodes mounted on a nasogastric feeding tube and positioned in the esophagus at the level of the diaphragm. As respiration increases and the respiratory center require the diaphragm for more effort, the degree of ventilatory support needed is immediately provided. This means that the patient's respiratory center is in direct control of the mechanical support required on a breath-by-breath basis, and any variation in the neural respiratory demand is responded to by the appropriate corresponding change in ventilatory assistance.
Choosing amongst ventilator modes
Assist-control mode minimizes patient effort by providing full mechanical support with every breath. This is often the initial mode chosen for adults because
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it provides the greatest degree of support. In patients with less severe respiratory failure, other modes such as SIMV may be appropriate. Assist-control mode should not be used in those patients with a potential for respiratory alkalosis, in which the patient has an increased respiratory drive. Such hyperventilation and hypomania (decreased systemic carbon dioxide due to hyperventilation) usually occurs in patients with end-stage liver disease, hyperventilate sepsis, and head trauma. Respiratory alkalosis will be evident from the initial arterial blood gas obtained, and the mode of ventilation can then be changed if so desired.
Positive End Expiratory Pressure may or may not be employed to prevent atelectasis in adult patients. It is almost always used for pediatric and neonatal patients due to their increased tendency for atelectasis. High frequency oscillation is used most frequently in neonates, but is also used as an always alternative mode in adults with severe ARDS.
Disinfection of Filters in Ventilation System
Filters in ventilation system should be cleaned at least once every week using disinfectants. Where hypochlorite solution is found not suitable for use with filters, tertiary ammonium compounds or other types of disinfectant should be used.
Procedures for Cleaning and Disinfection of Computer Stations
Keyboards and mouse of computer workstations, especially those intended for multiple users, should be cleaned and disinfected periodically.
Before cleaning, ensure that the computer and monitor are turned off. Direct the suction nozzle of the vacuum cleaner across rows of keys on
the keyboard to remove dirt/dust accumulated in between keys. Hand brush may be used to assist in removing settled dirt/dust between punches. Use cloth dampened with ethyl alcohol to wipe the keyboard and mouse. Wait till the alcohol has evaporated before returning the computer for
normal usage. Use 0.1% hypochlorite solution to wipe clean the surface of CPU and
monitor casings. Wait for 5 minutes and use another piece of cloth dampen
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with water to clean off residual hypochlorite. The glass surface of video display terminals with cathode ray tubes may be
cleaned and disinfected using diluted hypochlorite solution, and then with a cloth dampened with water.
The video display surface of LCD monitor should be wiped very gently using cloth dampened with water. No chemical disinfectant should be used to clean the delicate surfaces of LCD monitors.
The hazards of mechanical ventilation include infection, problems associated with positive pressure alternations related to endotracheal intubation, and loss of verbal communication.
Infection. Probably the complication of greatest concern in the incubated, mechanically ventilated patient is nosocomial pneumonia, which occurs 6 to 21 times more frequently in this population than in nonintubated patients. In the ventilated patient, nosocomial pneumonia doubles the overall mortality risk from 25% to 55% and greatly increases the cost of hospitalization. The introduction of an endotracheal tube (ETT) results in loss of the normal respiratory defense mechanisms. Several different mechanisms may be responsible for the development of pneumonia. The ETT bypasses the normal filtering mechanism of the upper airway, hampers the development of an effective cough, and impairs the Mucociliary transport system, which then results in retention of secretions and pneumonia. Mucosal injury cased by the ETT can provide binding sites for bacteria in the bronchial tree. In addition, the positive pressure on the pulmonary system, and they depend on the level of positive pressure delivered. Increased pressure levels can result in barotraumas, which may be manifested as Pneumothorax,
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Pneumomediastinum (air in the mediastinal space), or subcutaneous emphysema. During spontaneous respiration, venous return is enhanced by the negative thoracic pressure which occurs during inspiration; the positive pressure created during mechanical inspiration may hamper venous return and therefore reduce cardiac output. Patients may experience decreases in cardiac output and blood pressure with increases in positive pressure although the mechanism for this is not completely understood and may be affected by changes in ventricular filling pressure. As a result of decreased cardiac output, mechanically ventilated patients may experience decreased renal perfusion and decreased urinary output. This phenomenon is also thought to occur secondary to positive pressure effects on antiduuretic hormone (ADH) secretion. That is, the decreased venous return associated with positive pressure may stimulate osmoreceptors in the hypothalamus to increase ADH secretion, resulting in fluid retention.
CARE OF PATIENTS ON MECHANICAL VENTILATOR
As nurses care for patients requiring mechanical ventilator support, nurses must identify patient and family goals and expectations, attempt to move patients towards their maximum function and weaning potential, and maintain realistic goals for care. A vital capacity of at least 15mL/kg of body weight and a negative Inspiratory pressure of less than 30cm [H.sub.2.O] are the best predictors of successful weaning from short-term mechanical ventilation, defined as ventilation of less than 3 days duration. In clinical practice additional parameters such as minute volume, oxygenation, mean arterial pressure, arterial pH, and work of breathing may also used.
Nursing interventions to identify the adverse effects of positive pressure ventilation include monitoring of breath sounds, fluid balance, and cardiac output. Breath sounds which become distant, more diminished, or absent could indicate Pneumothorax. A drop in cardiac output, evidenced by decreased blood pressure, increased heart rate, decreased urine output, or change in level of consciousness, can indicate decreased venous return from positive pressure. Careful assessment of fluid balance and conservative fluid adjustments are warranted.
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INDICATIONS FOR MECHANICAL VENTILATION
Mechanical ventilation is indicated when the patient's spontaneous ventilation is inadequate to maintain life. It is also indicated as prophylaxis for imminent collapse of other physiologic functions, or ineffective gas exchange in the lungs. Because mechanical ventilation only serves to provide assistance for breathing and does not cure a disease, the patient's underlying condition should be correctable and should resolve over time. In addition, other factors must be taken into consideration because mechanical ventilation is not without its complications (see below). Common medical indications for use include
Acute lung injury (including ARDS, trauma) Apnea with respiratory arrest, including cases from intoxication Chronic obstructive pulmonary disease (COPD) Acute respiratory acidosis with partial pressure of carbon dioxide (pCO2) > 50
mmHg and pH < 7.25, which may be due to paralysis of the diaphragm due to Guillain-Barré syndrome, Myasthenia Gravis, spinal cord injury, or the effect of anesthetic and muscle relaxant drugs
Increased work of breathing as evidenced by significant tachypneic, retractions, and other physical signs of respiratory distress
Hypoxemia with arterial partial pressure of oxygen (PaO2) with supplemental fraction of inspired oxygen (FiO2) < 55 mm Hg
Hypotension including sepsis, shock, congestive heart failure Neurological diseases such as Muscular Dystrophy Amyotrophic Lateral
Sclerosis
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NURSING DIAGNOSIS;
Ineffective airway clearance related to increased mucus production associated
with continuous positive pressure mechanical ventilation.
INTERVENTIONS;
Continuous positive- pressure ventilation increases the production of
secretions regardless of the patient’s underlying condition
If excessive secretions are identified by inspection or auscultation suctioning
should be performed.
The nurse assess for the presence of secretions by lung auscultation at least
every 2 to 4 hours
Have patient cough and, if feasible, deep breathe every 2hrs to remove
secretions and to prevent hypoventilation.
Assess for adequate systemic hydration and provide supplemental
humidification of ventilator-delivered gases because these will assist with the
thinning of secretions.
Suction oropharynx as needed to remove pooled secretions.
Perform tracheobronchial suctioning to remove retained secretions
and improve oxygemtion
Perform postural drainage, vibration, and percussion maneuvers when
indicated to prevent pooling of secretions in the lungs.
Change the patient's position every 2hrs
Humidification of the airway via the ventilator is maintained to liquefy
secretions so they are more easily removed.
Sputum is not produced continuously or every 1 to 2 hours but as a
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response to pathologic condition.
Therefore, there should be rationale routine suctioning of all patients every 1
to 2 hours.
Although suctioning is used to aid in the clearance of secretions. It can
damage the airway mucosa and impair cilia action
Bronchodilators are administered to dilate the bronchioles and are
classified as adrenergic or anticholinergic..
Mucolytic agents such as acetylcysteine (Mucomyst) are administered as
prescribed to liquefy secretions so that they are more easily mobilized.
Nursing management of patients receiving mucolytic therapy includes
assessment for an adequate cough reflex, sputum characteristics, and
improvement in incentive spirometry
EXPECT OUTCOMES:
No evidence of infection.
Negative sputum culture.
NURSING DIAGNOSIS;
Impaired gas exchange related to underlying illness or ventilator setting.
INTERVENTIONS;
Humidification of inspired gas during mechanical ventilation is mandatory
when an endotracheal tube or tracheotomy tube is present
To maintain adequate humidification, the humidifier reservoir must be filled
with water to the level indicating “full,” and the water level should not be allowed to
descend below the “re fill” level.
The heating device should be adjusted so that inspired gas is kept between
34ºC and 37ºC. Higher airway temperatures (approximately 37ºC) usually facilitate
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the mobilization of tenacious secretions.
Expect outcomes:
The client will have adequate gas exchange as evidenced by maintaining
oxygen saturation.
NURSING DIAGNOSIS;
Imbalanced nutritional status less than body requirement related to intubation.
INTERVENTIONS;
Administer hyper alimentation or parenteral feedings as prescribed
Monitor intake and output chart.
Administer albumin or volume expanders as prescribed.
Monitor serum albumin level.
Although patients who are nasotracheally intubated may be allowed liquid and
semi liquid feedings orally, it is difficult to ingest sufficient calories, protein, and
fat.
When a tracheotomy tube is present, the patient should tilt the head slightly
forward to facilitate swallowing .Semisolid foods are easily swallowed than
liquids.
Enternal feeding via a small bore feeding tube is the preferred method to meet
caloric needs of ventilated patients
Metabolism of carbohydrates can contribute to an increase in serum CO2
levels.
Expect outcomes:
The client will exhibit adequate nutritional intake as evidenced by 1] stable
weight 2] intake of adequate calorie levels 3] no signs of catabolism 4] wound
healing 5]absence of infection.
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NURSING DIAGNOSIS;.
Sleeping pattern disturbance related to mechanical ventilation.
INTERVENTIONS;
Provide comfortable position.
Provide uninterrupted sleep time
Control environment to facilitate sleep
Administered sedatives.
Expect outcomes:
o The client will report feeling adequately rested.
NURSING DIAGNOSIS;
Impaired verbal communication related to endotracheal tube and attachment to
ventilator.
INTERVENTIONS;
The nurse assesses the patients communication abilities to evaluate for
limitations.
Questions to consider when assessing the ventilator- dependent patients ability
to communicate includes the following
Is the patient conscious and able to communicate
can the patient nod or shake the head
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Is the patients 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 (or) the patient centralize catheters.
Lip reading (use single key words), pad and pencil or Magic slate,
communication board, gesturing, or, use of a “talking” or fenestrated
tracheostomy tube may be suggested to the physician can the patient nod or
shake the head
The nurse should make sure that the patients eyeglasses and hearing aid and
a translator are available to enhance the patients ability to communicate
A speech therapist can assist in determining the most appropriate method
Expect outcomes:
The client develops adequate communication skills and thereby maintains
good interpersonal relationship with others.
NURSING DIAGNOSIS;
Impaired physical mobility related to ventilator dependency.
INTERVENTIONS;
Maintenance of muscle strength and prevention of the problems associated
with immobility are important.
Exercise tolerance is enhanced by adequate analgesia and adequate nutrition.
Perform active and passive range-of-motion exercises (e.g., leg lifts, knee
bends, quadriceps setting, arm circles) to maintain patient's joint and muscle
functioning and improve circulation.
If the patient can not perform these exercises, the nurse performs passive
range of motion exercises every 8 hours to prevent contractures and venous
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stasis.
Prevention of contractures, pressure ulcers, foot drop, and external rotation of
the hip and legs by proper positioning is important
Use footboard, and frequent foot flexion to prevent foot drop.
Change patient's position once in 2hrs and assess skin to maintain skin
integrity and prevent the development of pressure ulcers.
Get patient out of bed unless contraindicated to improve circulation and
oxygenation and facilitate exercises.
Provide progressive ambulation for patients receiving long-term ventilation to
prevent complications of immobility.
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.
Expect outcomes:
Normal range of motion of joints
Absence of contractures, foot drop, pressure ulcer
NURSING DIAGNOSIS;
Impaired Skin integrity related to mechanical ventilators
INTERVENTIONS;
Inspect and chart skin integrity 4 hrs.
Provide tracheotomy care frequently
Turn and reposition the patient 2 hrs.
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Maintain adequate nutrition and hydration
Expose skin to air if indicated
Expect outcomes:
The patient will maintain or develop clean and intact skin
NURSING DIGNOSIS;
Risk for trauma and infection related to endotracheal intubation.
INTERVENTION;
The patient is treated with antibiotics after appropriate cultures are taken by
tracheal suctioning or bronchoscopy (BAL)
Infection can be minimized by using strict aseptic technique while suctioning or
handling the artificial airway.
Frequent hand washing is imperative.
The nurse should wear latex gloves when in contact with the patient or
equipment and change gloves between activities (e.g., bathing the patient,
administering an intravenous drug).
Tracheotomy care is performed at least every 8 hours.
Expect outcomes:
The client will remain free of infection ,as evidence by clear sputum, no fever ,
clear lung sounds,
PSYCOLOGICAL NEEDS OF PATIENT;
Feelings of dependence
Concerns about technical problems
Pain/discomfort due to improper position
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Isolation from family
Economic concerns
Insomnia
PRINCIPLES OF PSYCOLOGICAL NURSING CARE;
Involvement of patient in “ patient rounds” rather than exclusion
Informing what procedure is about to occur or where the patient is
To help patient and family know what to expect while in the CCU,including
procedures, policies and prognosis
Use of touch to convey genuineness, caring, reassurance and acceptance.
Control of environmental stimuli such as noise, lights and decreased talk at
bedside to enhance uninterrupted sleep.
Increased explanations to reduce anxiety.
Continuous contact with family on regular open visiting hours and through
TV circuit.
Reassurance for feeling of uncertainty.
Accepting his fears as real to him.
Avoid using big sentences, professional terms while talking to him.
Do not show difference.
Do not show your own anxiety.
SOCIO-CULTURAL NEEDS;
The decision to use mechanical ventilation must be made carefully, respecting
the socio-cultural needs and wishes of the client and the family.
SOCIO- CULTURAL CARE
For a nurse involved in Tran cultural care, a variety of caring procedures and
approaches needs to be explored, depending on the characteristics of the client.
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ETHNOTHERAPY
Restoring of a greater sense of cultural identity. It helps in resolution of cultural
conflicts within the family, between the family and the outside community or in
the larger society in which the client exists.
TRANSITIONAL MAPPING
A comprehensive map is created that includes the position of each family
member, the entire family’s life cycle stages, cultural origin, family form and
current status with other family members and the community.
SAFETY;
The nurse should work to strength the various factors that affect the safety of
the client.
Communication must be creative in the case of the incubated patient and
information must be forthright
Patient should be involved in decision making as much as possible
The nurse must be encouraging hope an build trusting relationships with the
patient and family.
SOCIOL- ISOLATION;
Some clients with mechanical ventilator for a prolonged period of time express
the need to see their family members more often. Others feel too ill or fatigued
to have visitors.
Provide patient with access to a television and radio
Consider extending visitors hours for long term ventilator patients who desire
more social interaction
Incorporate family into selected aspects of the physical care
Encourage patients in the home to make excursions outside the home,
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accompanied by willing family friends or members.
FEAR OF DYING;
The clients on a ventilator for a prolonged period of time develop a feeling of
doubtful recovery.
The nurse should provide support and information.
The nurse should keep the client informed about his or her progress.
The nurse should discuss the options of returning home on assisted ventilation
with a portable ventilator.
SOCIOCULTURAL FACTORS;
Sociocultural factors (delivery/user-system dynamics, social organization
and stratification, and systems of information and flows of influence) directly
affect the outcomes of the programs. 8 specific strategies for reaching the poor
include: 1) use of local social organizations of the poor at the community level,
2) use of self-help and other user-centered approaches, 3) use of indigenous
sociocultural forms, 4) recruitment/training of paraprofessional field workers for
the user system, 5) use of radio as a medium of mass communication to contact
and orchestrate involvement of local groups in development programs, 6) use of
additive rather than the substitution strategies which tend to be compatible with
the cultural/cognitive patterns of recipients, 7) adaptation of strategies to fit
recreational/work schedules and spatial/climatic and time/seasonal patterns of
the user, and 8) establishment of patterns of maintenance for continuation of an
adopted innovation.
Stress Management Techniques
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Body
Good nutrition (a well balanced diet) will improve your ability to appropriately
respond to stress.
Reduce the patient body pain.
Maintain passive exercise.
Get an adequate amount of rest each night.
Provide good sleep.
Reducing caffeine intake will help you manage your anxiety (2 ½ cups of
coffee doubles the epinephrine level).
Biofeedback techniques can help up to 80% of migraine sufferers.
Acupuncture has also shown promise.
Mind
Assess the patient conscious level.
Provide counseling to the patient.
Initiating a time management schedule remains a positive way to reduce
stress and anxiety.
Break large demands into small, manageable parts. Work through one
task at a time.
Do what needs to be done first, leaving other things for tomorrow.
Identify your goals and work toward them.
Take direct action when stress arises- identify your needs and articulate
them; be intentional about what you can do.
Acknowledge your thoughts and feelings concerning the stressors in your
life.
Remember to be kind to yourself and not dwell on the "should".
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SUCTIONING;
MEANING;
Suctioning is aspirating secretions through a catheter connected to a suction
machine or wall suction outlet.
DEFINITION;
Suctioning is the process of sucking. The removal of gas or fluid from a cavity
or rather container by means of reduced pressure.
PURPOSE;
To clear secretions from the artificial airway or tracheobronchial tree
To maintain the patency of the tracheotomy tube
To ensure maximum ventilation of the patient
To reduce the risk of respiratory infection
PROCEDURES;
using the ungloved hand disconnect the patient from the ventilator CPAP
device or other oxygen source
ventilate and oxygenate the patient with the resuscitator bag 5 to 6 times
Slide the cover of the catheter and rinse it through with sterile water/saline to
lubricate it.
Insert the catheter into tracheotomy as for as possible without applying
suction
Apply the suction and quickly rotate the catheter while it is being withdrawn
Limit suction time 10-15 seconds, discontinue if heart rate decreases by 20
beats per minute.
ventilate the patient between suction with 4-5 manual ventilation
Sterile normal saline 2-3 ml may be instilled into the airway following by
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manual ventilation then suction.
Rinse catheter with water between the suctioning
continue procedure as necessary to a maximum of 4 suction passes
Return the patient to the ventilator
Deliver tracheotomy care as required
WEANING;
Weaning can be defined as the process of assisting patients to breathe
spontaneously without mechanical ventilatory support.
WEANING PROTOCOL;
Weaning protocol and clinical practice guideline for weaning are
primarily used to outline the slandered of care for the purpose of weaning from
mechanical ventilation. In generally they often include three elements the patient
condition in which weaning may be attempted the detailed process of weaning
and the evaluation of weaning out comes.
There are many weaning protocols published in the literatures or
developed by individual hospitals or departments. Each of them can be useful
when the elements of weaning are incorporated with sound clinical judgment
and implementation. The criteria in the protocol should be used as guidelines
only and must not be carried out using a cookbook approach. Individual patient
differences must also be considered since disease processes and patient
characteristics are just two of many variables that may affect the outcomes of a
weaning protocol .weaning protocols range from simple to complex and provides
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a simple weaning protocol for mechanical ventilation.
METHODS OF WEANING;
• Synchronized Intermittent Mandatory Ventilation (SIMV)
• Pressure Support Ventilation (PSV)
• SBT
• No Support
• CPAP
• PS
DEPENDENCE/FAILURE TO WEANING;
Additional Features
Cardiovascular Function
Ischemia
Heart Failure
Metabolic Derangements
Hypophosphatemia
Hypocalcaemia
Hypomagnesaemia
Hypothyroidism (severe)
Nutrition
Poor—protein catabolism
Overfeeding—excess CO2
Deconditioning
TRIAL;
30-90 minutes
Once daily
A number of studies have demonstrated equivalent results
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between multiple daily tests and once daily tests
Following each SBT evaluate for possible extubation
BP, RR, HR, ABG should all be considered
Level of sedation
SBTs are superior to both IMV and PS in duration of weaning and likelihood
of success after weaning
In patients on PMV, daily trials may be required for a longer period of time.
WEANING FAILURE;
HR >140 bpm or a sustained increase of >20%
RR >35 breaths/min for >5 min
O2 Sats <90% for >30s
HR with a sustained decrease of >20%
SBP>180 for > 5 min
SBP<90 for > 5 min
Clinical features: Anxiety, agitation, diaphoresis
Staffs are not initiating weaning guidelines early this may be due to lack of
knowledge, lack of support or failure of the guidelines. Mechanisms are in place
to support nurses at the bedside.
Discharge Planning
• A process used to decide what a Client needs for a smooth move from one
level of care to another Medicare
• Only a doctor can authorize a patients release from the hospital, but the actual
process of discharge planning can be completed by a Nurse, social worker,
Case manager etc.
• For the complicated medical conditions discharge planning is done with a team
approach.
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BASIC’S OF A DISCHARGE PLAN;
• Evaluation of the patient by qualified personnel.
• Discussion with the patient or his representative
• Physical condition of your family member both before and after
hospitalization; Types of care needed, discharge will be a facility or home.
• Planning for home coming or transfer to another care facility.
• Determining if caregiver training or other support is needed.
• Referrals to home care agency and appropriate support organizations in the
community.
• Arranging for follow up appointments or tests
• Weather patients condition is likely to improve
DPRP 1.0 Procedure
Development and implementation of a comprehensive plan for the safe
discharge of the respiratory care patient from a health care facility and for
continuing safe and effective care at an alternate site.
DPRP 2.0 Description
The discharge plan is the mechanism that guides a multidisciplinary effort to
achieve the successful transfer of the respiratory care patient from the health care
facility to an alternate site of care. Implementation of the discharge plan is used to
assure the safety and efficacy of the continuing care of the respiratory care patient
(1-10). The discharge plan includes: 1) evaluation of the patient for the
appropriateness of the discharge; 2) determination of the optimal site of care and
of patient-care resources; and 3) determination that financial resources are
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adequate.
DPRP 3.0 Setting
The discharge plan can be developed at any site at which the respiratory
care patient resides.
DPRP 4.0 Indications
Discharge planning is indicated for all respiratory care patients who are
being considered for discharge or transfer to alternate sites including the home.
The alternate site may provide a higher or lesser level of care (depending on the
patient's condition). The discharge plan should always be developed and
implemented as early as possible prior to transfer.
DPRP 5.0 Contraindications
There are no contraindications to the development of a discharge plan
DPRP 6.0 Hazards / Complications
Undesirable and or unexpected outcomes may occur if the patient is
discharged prior to the full implementation of the discharge plan. An undesirable
and unexpected patient outcome may be a hazard or complication of the
discharge plan; however, not all undesirable outcomes can be attributed to the
discharge planning process but may be a result of the natural course of the
disease or other factors beyond the control of the discharge planning process.
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DPRP 7.0 Method
Discharge planning and implementation should begin as early as possible. The
complexity of the plan is determined by the patient's medical condition, needs, and
goals. Members of the discharge planning team and their responsibilities should
be identified and a coordinator specified.
NURSE’S RESPONSIBILITY;
The discharge planners should discuss with care giver willingness and ability
to provide care (physical, financial etc)
It is essential that you get any training you need in special care techniques
e.g. ventilator, wound care, suctioning, transfer someone from bed to chair.
Based on the language used by the family members an interpreter is needed
for the discussion on discharge.
Written materials must be provided in their own language.
Outcomes
Explain the procedure to the patient prior to procedure.
Aseptic preparation prior to commencing procedure.
Open sterile gloves and suction catheter packages.
Place clean Latex glove on non-dominate hand. Place on eye protection at
this time.
Clean end of blue bodied connector on trachea tube with alcohol swab.
Place patient on Oxygen monitor if available or patient in unstable respiratory
condition for monitoring of oxygen saturation's during procedure.
Pre-oxygenate patient with Lardel bag on a 100% O2 for 2 minutes prior to
suctioning.
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As patients requiring mechanical ventilation move beyond the acute unstable
phase of their illness, they no longer require intensive monitoring and
management. Specialty units or general medical-surgical floors are often able to
provide care to these stable patients who focus on rehabilitation and weaning from
the ventilator.
An understanding of the reasons for prolonged mechanical ventilation is
necessary for each patient and the type of ventilation used helps the nurse
establish realistic goals for the treatment and care of individual patients. Using
physical, nutritional, and ventilator assessment techniques help identify nursing
interventions and plan care to meet the goals identified.
As weaning and rehabilitation progress, avoiding complications or identifying
early sings and symptoms of complications will help prevent extended
hospitalization. Recovery of stable patients needing prolonged mechanical
ventilation may depend on their nurses’ knowledge, skill, and individualized
interventions to help them set and achieve goals. Positive pressure.
There are several effects of positive pressure on the pulmonary system, and
they depend on the level of positive pressure delivered. Increased pressure levels
can result in barotraumas, which may be manifested as Pneumothorax,
pneumomediastinum (air in the mediastinal space), or subcutaneous emphysema.
During spontaneous respiration, venous return is enhanced by the negative
thoracic pressure which occurs during inspiration; the positive pressure created
during mechanical inspiration may hamper venous return and therefore reduce
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SUMMARY
Mechanical ventilation is a form of artificial respiration that uses a breathing machine to assist patient with breathing it is used when the lungs are not functioning. First recorded in the bible old testament (1600BC) the creation of man god breathed into the nostrils the breath of life and man became a living soul. After Christian era 1876 Eugine Vailliz discovered the negative pressure device.1970 -1980 beginning of electronic ventilators. There are two types of ventilators. Negative pressure ventilators and positive pressure ventilators. Negative pressure three types time cycled, volume cycled, pressure cycled. How ever there may be clinical circumstances in
cardiac output. Patients may experience decrease in cardiac output and blood
pressure with increases in positive pressure although the mechanism for this is not
completely understood and may be affected by changes in ventricular filling
pressure.
As a result of decreased cardiac output, mechanically ventilated patients may
experience decreased renal perfusion and decreased urinary output. This
phenomenon is also thought to occur secondary to positive pressure effects on
antidiuretic hormone (ADH) secretion. That is, the decreased venous return
associated with positive pressure may stimulate osmoreceptors in the
hypothalamus to increase ADH secretion, resulting in fluid retention.
226
which it is desirable to substitute helium for air. In this recent year there also has been increasing clinical interest in providing very low concentration of nitric oxide inspired gas of some patients. Trouble shooting is the finding the problems of patient with mechanical ventilator. Ventilator is having different modes these are IMV, SIMV, PSV, PEEP, and CPAP.
Filters in ventilation system should be cleaned at least once every week using disinfectants. Where hypochlorite solution is found not suitable for use with filters, tertiary ammonium compounds or other types of disinfectant should be used.. Complications of mechanical ventilator are baro trauma, pneumothorax and pneumomediastinum, volume pressure trauma, alveolar hypoventilation, alveolar hyperventilation, ventilator associated pneumonia. The nurse should provide cleared airway , maintain fluid volume, provide adequate protein and carbohydrate rich food through NG tube, provide comfort and calm environment to sleep, maintain a communication with patient ,mobilize the patient to prevent bed sore, provide protection and safe environment, provide psychological support, Weaning can be defined as the process of assisting patients to breathe spontaneously without mechanical ventilatory support. The discharge planners should discuss with care giver willingness and ability to provide care (physical, financial etc)
CONCLUSION
The physiological problems of clients with mechanical ventilation can be
minimize by the prompt practice of above mention nursing interventions.
Ventilation is only a part of the care. Comprehensive attention to all the other
issues of CARE is important if ventilatory support has to be successful.
Respiratory rehabilitation has become a grown-up and scientifically based
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discipline For respiratory insufficient patients, there and much to do beyond
the lungs!
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QUESTIONNAIRES
Anatomy & Physiology
1. What is the shape of lungs?
A] Cone shape
B] Oval shape
C] Round shape
2. The area between the lungs is called?
A] Heart
B] Mediastinam
C] Ribs
3. Exchange of gases between the blood with the lungs is called ?
A] External respiration
B] Internal respiration
C] Ventilation
4. The trachea is otherwise called?
A] Tracheal tube
B] Wind pipe
C] Larynx
5. Normal range of tidal volume?
A] 4 – 12ml/kg/body weight
B] 10 – 15ml/kg/body weight
C] 6 – 8ml/kg/body weight
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6. How much amount of air will passes into and out of the lungs during each
cycle ?
A] 700ml
B] 600ml
C] 500ml
7. Vital capacity (VL) =?
A] IRV + ERV + Tidal volume
B] Tidal volume + IRV + ERV
C] IRV+ERV
8. Alveolar volume is the difference between
A] Tidal volume & dead space volume
B] Minute volume & dead space volume
C] Minute volume & tidal volume
Psychology & Sociology
9. Crisis intervention means……?
A] It is a perception of an event or situation as an intolerable
difficulties.
B] It is a exploring the feeling and emotions.
C] Maintaining the good relationship
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10. What are the three basic components of attitudes?
A] Thinking, feeling & acting
B] Interest, emotions& Thinking
C] Thinking, acting & Interest
11. What is the basis for Family structure?
A] Pattern of the relationship
B] The membership of the family & pattern of the relationships
C] Number of the family members.
12. What are the factors affecting the social – cultural values?
A] Interpersonal relationship, religion, social system
B] Education, vocation, income
C] Diet, supportive system & family
Bio Medical Waste Management
13. What is mean by bio medical waste?
A] Animal waste
B] Human waste
C] Hospital waste
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14. What is disposed in Yellow pin?
A] Placing the expired drugs
B] Placing the sharp items
C] Placing the placental tissues, body tissues
Pharmacology
15. What is the complication of unpleasant drug?
A] Diarrhea
B] Nausea & vomiting
C] Headache
Mechanism of Mechanical Ventilators
16. What gas is used in mechanical ventilator?
A] Heliox
B] O2
C] Nitric Oxide
17. Which of the following is not an indication for mechanical ventilation?
A] Acute ventilatory failure
B] Sever hypoxemia
C] Airway obstruction
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18. What is to delivered in appropriate concentration through mechanical
ventilation?
A] O2
B] CO2
C] CO
19. What is the main indication for mechanical ventilator?
A] Vital capacity <3 times tidal volume
B] Respiratory force <35/min
C] PaO2<50mm Hg with PH<7.25
20. What is Mechanical ventilation?
A] Suction device
B] Positive or negative pressure breathing device
C] Device which is used to determine pulse rate
21. What is the main purpose of mechanical ventilation during surgery?
A] To oxygenate the blood
B] To enhance normal breathing pattern
C] To control patient’s respiration
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Complication of Mechanical Ventilator
22. What is the potential complication that may occur during mechanical ventilation?
A] Alteration in cardiac function, Barotrauma, Pulmonary infection,
Sepsis
B] Renal failure, Myocardial infarction
C] Respiratory arrest
23. What is the complication of positive pressure ventilation in pulmonary system?
A] Barotrauma
B] Hypotension
C] Hemorrhage
24. Which of the following is not a common potential complication of positive pressure ventilation?
A] Decreased in cardiac output
B] Accidental patient disconnection
C] Barotrauma
25. Who was first discover History of Mechanical ventilator the negative pressure ventilator?
A] Eugine vailliz
B] Jean L D Etailles
C] Marc Bartholomy
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Types of Mechanical Ventilator
26. What is the other name for a negative pressure?
A] Positive pressure ventilation
B] Pressure supportive ventilation
C] Spirophore (Non invasive)
27. What is the commonly used ventilator for infant and children ?
A] Volume cycle
B] Pressure cycle
C] Time cycle
28. Which of the following Pressure cycle ventilator mode condition is needs to
use ?
A] Post-operative anaesthesia
B] Trauma patient
C] Infant
Mechanical Ventilator problems
29. Which one of the following should be carried out if the a nurse unable to troubleshoot alarms quickly?
A] Administration of oxygen
B] Manually ventilate the patient with a bag valve device
C] Suctioning the air way
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Modes of mechanical ventilator
30. What complication is corrected by Positive end respiratory pressure?
A] Hypoxemia
B] Hypercapnia
C] Respiratory acidosis Dis infection of Mechanical Ventilator
31. When PEEP is applied to the airway of a patient who is breathing
spontaneously, it is called ?
A] PSV
B] Pressure control ventilation
C] CPAP
32. Which solution is used for cleaning the surface of CUP & monitor casing?
A] 0.1% hypochlorite solution
B] Savlon
C] Sterile water
33. What solution is used the disinfect the LCD monitor of Ventilator?
A] Hypochloride
B] Water
C] Antiseptic solution
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34. Which one of the following group of drug should be administered to clear the
air way?
A] Bronchodilators
B] Anti inflammatory drugs
C] Anticonvulsive drugs
Care of patient on Mechanical Ventilator
35. What procedure is used to mobilize the secretion?
A] Postural drainage
B] Vibration
C] Chest physiotherapy
Nutrition
36. What is the complication of under nutrition?
A] Increased surfactant production
B] Increased metabolic rate
C] Fatigue of respiratory muscles
Acid base Management
37. What is the main purpose of humidifier in ventilator?
A] To humidify the temperature
B] To humidify the air inside the lungs
C] To warmth the inspired gas to prevent thickening of secretions
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Communication
38. Which one of the following communication approach will be used by the nurse to promote
optimal communication?
A] Lip reading
B] Non verbal communication
C] Verbal communication
39. Which type of communication approach can be used if a patient can write?
A] Lip reacting
B] Pad and pencil or magic state
C] Gesturing
Mobilization
40. What is the purpose of Active and passive leg exercise?
A] Increase venous flow
B] Decreased artery flow
C] Increased artery flow
41. What are the signs and symptoms of infection?
A] Monitoring change in color, quantity, odour and increased
viscosity of blood
B] Monitoring fever and chills elevated WBC, ESR level
C] Dyspnea, tachycardia
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42. Which one of the following will alert the nurse to the potentially dangerous situation?
A] Apnea alarms
B] Volume alarms
C] Pressure alarms
43. What care should be concentrated by the nurse to prevent lung infection in intubated patient with ventilator?
A] Mouth care
B] Tracheostomy care
C] Ventilator care
Stress Management
44. How do we reduce the patient stress?
A] Proper counseling
B] Sedatives
C] Maintaining good interpersonal relationship
Suctioning
45. How many minutes the suction should be done?
A] 10-15 sec
B] 5mts
C] 5sec 46. What are the complication of frequent suctioning?
A] Mechanical trauma to the mucosa
B] Chest trauma
C] Respiratory distress
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Weaning
47. Which of the following patient conditions is the least important consideration prior to weaning
a patient off mechanical ventilation?
A] Frequent arrhythmias
B] Ventilatory failure
C] Use of PEEP
48. What is the first step to Wean from ventilator?
A] T tube
B] SIMV
C]Spontaneous breathing trial
Nurses Responsibilities
49. What are the nurses’ responsibility before connecting the patient to ventilator?
A] Check water, disconnection, kinking of the tubing, check alarm functioning
B] Check the vital signs
C] Administrator antibiotics
50. What are the nurses’ responsibility to treat the hypokalemia?
A] Monitor serum electrolyte, bun, creatinine, digoxin level, continue ECG monitoring
B] Monitor calcium, HB, WBC level
C] Monitor PT level, continue ECG monitoring
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MAPPING OF QUESTIONNAORE.
Anatomy and physiology of respiratory system : [4] questions
Lung volumes & Capacities : [4] questions
Crisses intervention : [2] questions
Social –cultural influences : [2] questions
Biomédical waste management :[2]questions
Principles of drug administration : [2] questions
Mechanical ventilators : [5] question
Complications : [3] questions
Historical review of mechanical ventilators : [1] question
Types of mechanical ventilators : [1] question
Classification of mechanical ventilators : [2] questions
Ventilators problems : [1] question
Modes of mechanical ventilators : [2] questions
Disinfection of mechanical ventilation : [2] questions
Care of patient on mechanical ventilators
Airway managemant : [2] questions
Nutritional management : [1] question
Acid-base management : [1] question
Comfort & sleep : [1] question
Communication : [1] question
Moblization : [1] question
Skin integrity : [4] questions
Protection & Safty : [1] question
Stress management : [1] question
Suction management : [2] questions
Weaning : [2] questions
Nurses responsiblity :[2] questions
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ANSWER KEY :
Question No. 1 2 3 4 5
Answer A B A B B
Question No. 6 7 8 9 10
Answer C B A A A
Question No. 11 12 13 14 15
Answer B A C C B
Question No. 16 17 18 19 20
Answer A C A C B
Question No. 21 22 23 24 25
Answer B A A A A
Question No. 26 27 28 29 30
Answer C C A C A
Question No. 31 32 33 34 35
Answer C A B A C
Question No. 36 37 38 39 40
Answer C C A B C
Question No. 41 42 43 44 45
Answer B A B A A
Question No. 46 47 48 49 50
Answer A C B A A
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OUT COME OF EFFECTIVE NURSING
Hospital acquired infection pre test
Sl.No CRITERIA PRE TEST POST TEST
1. Infection Rate
2. Days of stay in hospital
3. Skin Integrating
4. Status of Respiration
5. VAP
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CHECK LIST FOR WEANING THE PATIENT FROM MECHANICAL VENTILATION
Hospital acquired infection pre test
Sl.No CRITERIA YES NO
1. GCS
2. Vital Signs
3. Vital Capacity and Respiratory Rate
4. Assessing the Psychological readiness and other factors
that many cause respiratory insufficiency
5. Setting the SIMV mode
6. Prepare appropriate equipment
7. Positioning the patient (Semi Fowler’s Position)
8. Perform bronchial hygiene
9. Connection the patient t‐piece
10. Assessing the patient condition after t‐piece application
by R.R, H.R, T.V PaCo2
11. Assessing the tolerance of the patient for next phase
12. Keeping the patient in spontaneous respiration
13. Recording at each weaning interval‐H.R, B.P, RR, FiO2,
ABG
14. Preparing the patient for intubation
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PLAGIARISM REPORT
Date : 11.07.2012
TO WHOMSOEVER IT MAY CONCERN
This is to certify that Ms.INDIRA.A, analysed the thesis “Effectiveness of
Structured Teaching Program for Nurses on Care of Patients with Ventilator and
the Outcome of Ventilator Care in the Selected Hospitals at Nellore, Andhra
Pradesh”, work Grammaly.com software system and the report generation on
10.07.2012 reveals that the percentage of unoriginal text is only 15%.
Place : Signature of the Guide
Date: Designation
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PART‐II(B)
CHECK LIST FOR ORAL HYGENE
Sl.No PROCEDURE YES NO
1. Check the condition of oral cavity
2. Determine frequency of mouth care needed
3. Take all the articles to the patients unit
4. Positioning the patient
5. Placing the mackintosh and face towel across the chest
and under the chin
6. Wash hands and providing privacy
7. Preparing mouth wash solution
8. Placing the kidney tray close to the check
9. Placing a gag in the mouth
10. Cleaning the mouth
11. Massaging the gums
12. Applying emollient on the lips and tongue
13. Replacing the articles
14. Recording the procedure
<7 ‐ Poor performance
7‐10 ‐ Average
>10 ‐ Good
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TRACHEOSTOMY CARE
Sl.No PROCEDURE YES NO
1. Assess the condition of the stoma before Tracheostomy care
2. Suction trachea and pharynx
3. Explaining the procedure to client or family members
4. Assemble all the equipment
5. Following universal aseptic precautions
6. Cleaning the external end of the tracheostomy tube with 2
gauze pads with hydrogen peroxide, discard pads
7. Cleaning the stoma area with 2 peroxide soakes gauze pads
8. Loosen and remove crust with sterile cotton swabs
9. Changing a disposable inner cannula, touching only the
external portion and lock it securely into place
10. Check the tracheostomy tube position and changing the
tracheostomy tie tapes
11. Placing a gauze pad between the stoma site
12. Documenting the procedure performance
13. Observation of the stoma
14. Reporting changes in stoma appearance or secretions
15. Ties should be changes every 24 hours, clean the fresh stoma
every 8 hourly
<7 ‐ Poor performance
7‐10 ‐ Average
>10 ‐ Good
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ENDOTRACHEAL / TRACHEAL SUCTION SKILLS CHECK LIST
Sl.No PROCEDURE YES NO
1. Washes hand. Identifies indications for suctioning
2. Explains procedure to patient
3. Assembles necessary equipment:
a) Prepares ambu bag and mask
b) Suction device with connecting tubing
c) Sterile suction catheter or in‐line suction catheter
d) Normal saline or water for clearing tubing
e) Following universal aseptic precautions
f) Yankuer suction‐tip catheter
4 Prepares for Suctioning
a) Dons personal protective equipment
b) Prepares catheter for suctioning (attaches to connecting
tubing; checks to make sure at 80‐120 mm Hg.). Checkes
function
c) Hyperoxygenates and hyperinflates before and after
suctioning (using ventilator 100% O2 setting and manual /
sigh breaths or ambu bag).
d) Stabilizes ET/Tracheal tube while inserting catheter into
trachea bronchial tree without application of suction during
inspiratory phase.
e) Applies intermittent suction while rotating catheter for
open suctioning; applies continuous suction and pulls
straight back for closed suction during expiratory phase.
Time not to exceed 10‐15 seconds
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5. Resume oxygen delivery system. Flushes catheter and suction
tubing until clear
6. Reassess patient’s respiratory status for expected and unexpected
outcomes
7. Discard used supplies per procedure
8. Dispose of suction catheter and connecting tubing as well as
solution 24 hours
9. Document need for suctioning and results in [progress not at least
once per shift and with any changes
10. Maintains sterile technique throughout procedure
<7 ‐ Poor performance
7‐10 ‐ Average
>10 ‐ Good
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