mod2 Discussion question 2.1

As stated on page 692 in the “Iggy” textbook, “The nurse plays a pivotal role in the coordination of care and the prevention of problems”. In a planned event, the nurse is responsible for ensuring all parties are present prior to the occurrence. This of course includes ensuring that the physician, anesthesiologist, nurse anesthetist, pulmonologist, paramedic, respiratory therapist - or WHOMEVER is going to do the intubating - is present. Even if the respiratory therapist does not perform the intubation, they are requested because they most likely will be responsible for making the connections to and adjusting the ventilator as well as performing an ABG afterwards. Radiology has a role as well, for after the patient is “tubed”, a portable x-ray film is needed for tertiary confirmation after primary and secondary actions are undertaken. If the worst-case scenario develops as an outcome of the intubation, a code team may have be paged or summoned by the nurse.

            Long before the actual intubation phase, nurses are usually the ones responsible for ensuring that the equipment is available, up to date, and functional. Documentation of daily inspections help to ensure this. Also prior to a planned event, nurses witness and sign consent forms and are responsible for alleviating some of the patient’s anxieties by further informing patients and answering some of their questions. Sometimes this “ounce of prevention” prevents problems from occurring. Simply forewarning patients about what changes they may expect after intubation may ward off complications arising from an inability to communicate or having to explain why the patient has a sore throat and is hoarse after extubation. The nurse should have already reviewed the patient’s medical record in an effort to become familiar with the patient’s allergies, medications, and any special anatomical considerations that may apply to the individual patient.

            In regards to the actual procedure itself, the role of the nurse will vary based

according to assignments and expectations of each individual facility and its protocols. In general, the nurse may expect to be responsible for “everything”. Duties MAY include, but are not limited to ensuring the patient has a functional IV and:

1. Gathering and checking the necessary equipment and supplies (may be done simply by getting the crash cart) and beginning to set-up and prepare the equipment.
• Laryngoscope handle, blades (and spare bulbs if not fiberoptic)
• Stylet (and lubricant to ease its removal)
• Stethoscope
• Syringe
• Suction device (on high setting initially, but decreased to ~120 mm/hg for use with a catheter) and set-up with tubing, yankeur and catheters
• Defibrillator/monitor with electrodes, defibrillation pads, razor and cables
• ETCO2 monitor and connectors for ET tube and for oral/nasal monitoring
• Pulse oximeter (if not part of cardiac monitor)
• Tracheal tubes, size expected and one larger and one smaller
• BVM with appropriate size mask
• Securing device for tube or tape
• Tincture of Benzoin and/or possibly a hydrocolloid dressing for the face
• Soft restraints
• Sedation and/or paralytics (and antidotes/reversals for each)
• Backboard in the event the patient arrests

2. Positioning the patient for the procedure may include raising the bed to a comfortable height (I’m tall), placing the patient supine with a slightly extended neck (or neutral/sniffing position for a child or infant and placing a roll under the shoulders), and may include moving the patient towards the head of the bed after lowering the head of the bed and removing the headboard.

3. If respiratory therapy is not attending to these duties, pre-oxygenating and/or hyperventilating also may within the duties of a diligent nurse.

4. As the procedure begins to unfold, the nurse is responsible for monitoring and ensuring several things:
• The nurse may be ordered to administer sedation and/or paralytics upon the initiation of the procedure, but be sure you do not administer paralytics unless authorized by you facility’s policy and your state’s nursing scope of practice.
• Initially, note the time; the amount of time expended attempting the procedure should be limited to 30 seconds MAXIMUM (ideally less than 15-20 seconds).
• Monitor the oxygenation status as noted through observation of SpO2 readings.
• Monitor the patient’s heart rate and rhythm. Intubation may cause a vagal effect. Stop the procedure if bradycardia or hypotension develops and pre-oxygenate with BVM ventilation until the rate returns to baseline prior to further attempts.
• ETCO2 status can be monitored through the use of nasal/oral cannula prior to intubation, and through a tracheal tube adaptor after intubation. After intubation, simply noting there is a waveform or a numerical reading is insufficient as a means of confirming correct tube placement. A right mainstem bronchial intubation could give THOSE results. ETCO2 is a primary form of correct tube placement, but IT ALONE IS INSUFFICIENT! Someone, likely the nurse, who is the catch-all blame for everything, must listen for bilateral breath sounds. Ideally, we like to think we are listening for “equal bilateral breath sounds”, but in some instances, this is not possible. Remember, if the patient has a pneumothorax, a pleural effusion, or anything else that impedes breath sounds on either side, equal breath sounds may be impossible to hear! Nevertheless, we are hoping to hear bilateral ventilatory sounds but we must remember what our pre-intubation exam revealed in regards to the symmetry of chest sounds and chest excursion (movement). The levels of the ETCO2 readings are beyond the intent of this discussion, but you do need to learn what numbers and trends to expect when the patient is SUCCESSFULLY  intubated. 
• As already mentioned, at some point in time, checking for symmetrical chest excursions and bilateral breath sounds is usually the responsibility of the nurse assuming care for a patient.
• The nurse should note air emerging from, and condensation in, the tracheal tube.
•  The nurse should observe (and record) the centimeter mark upon the level of the upper incisor teeth, and confirm that the tube is secured away from the corner of the patient’s mouth in an effort to avoid creating pressure sores. Also ensure the securing device is patent, but not so tight as to create a pressure sore.
• Assuming a cuffed tracheal tube was inserted, the pilot balloon should be palpated to confirm inflation, the pressure within it may have to be measured, and assurance of minimal to no air leak around it must also be ensured.
• The correct ventilatory rate must be initiated immediately after the patient is intubated and confirmation of placement by visual, tactile, auditory and ETCO2 measures are undertaken.
• The nurse may be ordered to administer certain medications such as (NAVEL) narcan, atropine, valium epinephrine or lidocaine endotracheally.
• Verification of placement by radiography must be undertaken soon after primary and secondary means are confirmed.

5. Upon the completion of the intubation, confirmation, and securing the tube, instilling medications, and assuring an appropriate ventilatory rate, it is almost time to consider the 6^th right – right documentation. Document everything, because “if it wasn’t documented, it wasn’t done”!

6. And as someone mentioned, let’s not forget to ensure that we attend to the patient’s nutritional and mouth care needs…to reevaluate “everything” about our patient frequently…to ensure that the ventilator is set according to orders…to assess for patient’s compliance with therapy…to suction ONLY as necessary…to communicate with and assess for our patient’s other needs…and to document, document, document!