Patient Safety Assessment, by Kevin Bullock. Health care workers in all health care settings
should always adhere to the latest World Health Organization guidelines on hand hygiene and
barrier precautions before and after contact with a patient, bodily fluids, or patient
surroundings. For more information, please watch our video entitled "Hand Hygiene."
Hi, my name is Kevin Bullock. I'm a clinicial supervisor in the Department of Respiratory
Care at Boston Children's Hospital. And this will be a lecture on the comprehensive patient
ventilator safety assessment that will be broken up into two parts, the patient and
the ventilator.
The purpose of a patient safety assessment is to assess patient stability, ensure airway
stability, ensure optimal patient ventilator interaction, and also to ensure appropriate
emergency equipment is present at the bedside. We will begin by assessing the vital signs.
This is the first part of the patient safety assessment because patient stability is of
the utmost importance.
We take a look at the vital signs monitor to assess if our patient's vital signs are
within the target ranges for the patient's age, weight, and disease process. If the answer
is yes, we are stable, we can proceed with our patient safety assessment. If the answer
is no, our patient is unstable, we will still continue with the patient safety assessment,
noting that it may reveal the cause of the instability.
We will then move on to the patient's breath sounds to assess if there are any adventitious
breath sounds that may be contributing to instability. When assessing a patient's breath
sounds, we should auscultate similar regions on opposite sides for comparison.
While we have our stethoscope on, we should also auscultate the neck to listen for a leak
around our endotracheal tube cuff and assist us in our cuff management. We should also
assess the inflation of our pilot balloon. After we assess breath sounds, we will move
on to the patient's airway. We want to ensure that the airway is secure, either by tape
or a fixation device that is the appropriate size for the patient and that it is at the
correct insertion depth. Here's a chart of suggested size endotracheal tubes for the
newborn ranges.
Once we get to 6 months of age or greater, we use a formula to estimate the patient's
endotracheal tube size. Your age plus 16 divided by 4 will give you an approximate size. We
may then multiply that size times 3 to approximate the depth of insertion. All patients we would
add to 2-4 centimeters for a nasal intubation. Approximating the appropriate size endotracheal
tube is essential to determining the appropriate insertion depth.
When assessing our patient's airway stability, we want to note the size of the endotracheal
tube and its exit mark from the mouth. At Boston Children's Hospital, we use the lip
for our exit marking. Other institutions may use the teeth or gums.
Once we have assessed the appropriate size and depth of insertion of the endotracheal
tube, we'll move on to the endotracheal tube cuff, should one be present on the endotracheal
tube.
There are various methods of assessing the endotracheal tube cuff that should be determined
at the institution you are in. The goal of assessing cuff inflation is to prevent tracheal
damage from overinflation, placing undue stress on the walls of the trachea. It is also to
prevent microaspiration and therefore ventilator-associated events. Proper cuff management will also allow
effective ventilation and more accurate monitoring of tidal volumes and end-tidal carbon dioxide.
Minimal leak technique is a method that may be used to assess a slightly at the peak of
inspiration. Minimal occlusive volume will take your minimal leak technique and add just
a little more air to occlude that leak. The last measurement of cuff inflation would be
by an actual cuff pressure monitor. When we monitor cuff pressure, we want to maintain
a cuff pressure between 20 and 25 centimeters of water and not to exceed 30 centimeters
of water.
Next we will move on to the skin assessment. We want to assess the skin to prevent device-related
pressure ulcers. This is especially important in patients with low cardiac output states
or severe edema. Endotracheal tube placing pressure on the lips can cause mucosal damage,
erythema, breakdown, and in severe cases, necrosis.
This is especially true with nasal intubations. It is a highly vascular area and is prone
to being torqued and having many more pinch points, depending on how the tube is fixated
to the patient. When we assess the skin, it could be quite difficult to actually see the
skin underneath the tape or fixation device. So we must do our best job to try to visualize
the skin.
As we assess its exit marking, we should take this opportunity to assess the patient's skin
underneath the fixation device. Oftentimes, routine takedown of the tape is necessary
to get a full assessment of the skin. In cases where there may be damage occurring due to
the device placing pressure, we might want to move the endotracheal tube to a different
position, particularly when it is an oral intubation, just as simply as sliding it to
the middle of the mouth and re-securing it or to the opposite side of the mouth and re-securing
it.
Unfortunately, we do not have this option with a nasal endotracheal tube. It will take
reintubating the patient in the opposite nare to relieve the pressure on the nare. Sometimes,
though, we may alter our taping methods to relieve the pressure in the area of concern.
Once we have completed assessment of the vital signs, breath sounds, endotracheal tube security,
and skin integrity, we must look for any special considerations for our patient and their artificial
airway. Does the patient have a critical or difficult airway? Should there be signage
at the bedside indicating the grade of airway and who must be present should the endotracheal
tube come out and need to be placed back in?
Is there a laryngeal mask airway at the bedside? Or is it an infrequently used airway, such
as a double lumen endotracheal tube, a bronchial endotracheal tube, a special ray endotracheal
tube, or a wire reinforced endotracheal tube? Other special considerations might be if your
patient is awake and requires a bite block to keep them from occluding their airway.
All assessments should be the same for a patient with a tracheostomy tube. The only consideration
we should have there is whether there is a same size tracheostomy tube at the bedside
as well as a smaller size tracheostomy tube and if anything about that tracheostomy tube
is custom. We will want to make sure that we have that custom tube at the bedside or
a backup plan in case one is not commercially available.
With tracheostomy tubes, we also want to note whether there is air in the cuff, or sterile
water in the cuff, or if it has an inner cannula or not. Now we need to ensure that there's
appropriate emergency equipment at the bedside. We make sure we have an appropriate sized
manual ventilation device, an appropriate sized anesthesia mask, that both of them function
properly, and in some special considerations for premature infants or congenital heart
disease patients, do we require a blender at the bedside to adjust the FiO2?
Next, we will take a look at the patient-ventilator interaction. We want to make sure our patient
is comfortable. Are they triggering? When they ask for a breath, is the breath delivered
in a timely fashion? Are they synchronous with the ventilator? Do they inhale and exhale
without any interruption of the mechanical ventilation breaths? Are spontaneous breaths
supported? Does inspiration terminate appropriately as well as exhalation?
We'll note chest rise. Is it adequate? Is it symmetric?
In the last step, turning towards the ventilator, we will assess the graphics. I will point
you to Craig Smallwood's ventilator waveform interpretation OPENPediatrics lecture to get
a more in-depth glance at how to assess graphics. But we should look at the pressure, flow,
volume, and end-tidal waveforms.
Assessment of these waveforms will help us to optimize synchrony, triggering, and overall
ventilation for our patient. And this concludes our patient safety assessment.
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