“Technology Today”

The researcher has observed that approximately 70-80% of critically ill patients in the critical care units in the Nelson Mandela Metropolitan area are connected to mechanical ventilators. It is indisputable that in many circumstances mechanical ventilation is a life-saving therapy. However, the introduction of a machine to any clinical setting, which is a highly technical therapeutic intervention, is associated with many possible complications.

The nursing care of the mechanically ventilated patient is challenging on many levels: from the acquisition of highly technical skills, expert knowledge on invasive monitoring and the ventilator principles and the implementation of nursing interventions to care for the patient. It is thus imperative that the professional nurses rendering care to patients on mechanical ventilators are knowledgeable regarding the insertion, care and maintenance of the artificial airway, namely the endotracheal tube, the operational principles, settings and monitoring of the mechanical ventilator and the complications associated with the use of the mechanical ventilator. To improve the delivery of care to the critically ill patient, an understanding of the mechanical ventilator and the associated adverse effects and complications is

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essential. This understanding and knowledge acquisition will increase the critical care nurses‟ confidence and allow them to focus on the patients and associated problems while rendering safe and informed care. The professional nurses must also understand how to perform a physical assessment of the mechanically ventilated patients in order to prevent any complications related to the use of the mechanical ventilator. Patient comfort, communication with the patient and ensuring psychosocial well-being are other aspects that need to be incorporated into the nursing care of mechanically ventilated patients.

All mechanically ventilated patients have an artificial airway in situ to enable delivery of respiratory support and clearance of airway secretions. In order to ensure the safety of the mechanically ventilated patient, continuous assessment and monitoring of the artificial airway and the mechanical ventilator is required by the nurse practitioner caring for the patient. Assessment of the critically ill patients includes a vast amount of information and integration of patient data, obtained from taking the history of the patient, as well as performing a physical examination of all the systems in their bodies. Due to the range of activities related to the nursing care of a mechanically ventilated patient, this research study will only focus on patient safety in relation to the artificial airway, namely the endotracheal tube and the mechanical ventilator settings required to ensure prevention of ventilator complications and adverse effects in the critically ill patient. The rationale for the focus of the research study is imperative because if the artificial airway is not cared for and maintained once inserted and the mechanical ventilator settings are incorrect, it will impose on the well-being or safety of the patient as further described in this section.

Firstly, is important to know that once the artificial airway, namely the endotracheal tube, is inserted by the physician, anaesthetist or nurse practitioner, it must be verified that it is the correct position. Incorrect endotracheal tube placement places the mechanically ventilated patient at significant risk from various complications, e.g., absent or ineffective ventilation, aspiration and injury to the airway resulting from oesophageal intubation or from tube placement that is too high or too low in the trachea. Frequently used strategies to verify endotracheal tube placement include lung inspection and auscultation, end-tidal carbon dioxide monitoring and

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radiological examination (Pierce, 2007:71). The researcher has observed in clinical practice in the critical care units in the Nelson Mandela Metropolitan area that endotracheal tube placements in mechanically ventilated patients are often not correctly verified according to the methods stated above, or verification of the tube, if done, is not reflected in the records of the critically ill patient. An exploration and description on endotracheal tube verification as implemented by professional nurses to ensure correct placement of the endotracheal tube in the mechanically ventilated patient will thus be undertaken and compared with existing literature or recommendations.

Secondly, once the endotracheal tube has been correctly placed (as verified by the various techniques used) one needs to ensure that the endotracheal tube cuff

pressures are monitored to avoid the possible complications associated with the

tube itself that might impose on the patient‟s safety. Cuff pressures of the endotracheal tube must be maintained correctly in order to avoid complications, such as tracheal stenosis, tracheal, laryngeal or vocal cord mucosal injury from over- inflation, as well as complications linked to under-inflation of the cuff, such as unplanned extubations (Pierce, 2007:71). According to observations by the researcher and based on informal discussions with professional nurses within the critical care units, practice variances related to the monitoring of adequate cuff pressures appear to exist in the care of the mechanically ventilated patient. Failure to monitor endotracheal cuff pressures promptly and correctly might impose on the safety or well-being of a patient who is connected to a mechanical ventilator.

Thirdly, in ensuring the safety of a mechanically ventilated patient in a critical care unit, it is of crucial importance that the airway patency is maintained. Assessment of the airway patency encompasses the assessment of lung secretions and strategies to maintain it. Endotracheal tube suctioning allows the health care practitioner to assess the secretions but also support the patient by removing secretions. Endotracheal tube suctioning in itself, however, is potentially hazardous to the patient and should be performed with care and should be based on the most up-to- date evidence available (Morton and Fontaine, 2009:578).

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Finally, after it has been verified that the endotracheal tube is in the correct position and the nurse practitioner has ensured the patency of the artificial airway, it is essential to connect the patient safely and competently to the mechanical ventilator. Selecting and monitoring the appropriate ventilator settings can be seen as a balance between achieving the goals of sufficient oxygenation and carbon dioxide removal, whilst minimising the risk for ventilator-induced lung injury. Inappropriate mechanical ventilator settings have been shown to increase the risk of mortality in the critically ill patient (Allerod, Rees, Rasmussen, Karbing, Kjoergaard, Thorgaard and Andreassen, 2008:205).

The study will aim to explore and describe four nursing care practices as performed by professional nurses related to the safety of the mechanically ventilated patient. The nursing care practices identified are specifically related to the artificial airway and the mechanical ventilator settings as described and illustrated in Table1.1.

Table 1.1 Nursing care practices related to the safety of the mechanically ventilated patient

Assessment Nursing Care Practice

Artificial airway  Endotracheal tube placement verification  Endotracheal tube cuff pressure monitoring Airway patency  Endotracheal tube suctioning

Monitoring principles  Mechanical ventilator settings

The data obtained will assist in proposing clinical guidelines that is based on the best available evidence to address any identified knowledge deficits, if present. By developing evidence-informed clinical guidelines for two of the four identified nursing-care practices, it is envisaged that this research study will enhance the quality of patient care rendered and contribute to optimising the safety of the mechanically ventilated patient in a critical care unit.

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