The patient is on mechanical ventilation. Which actions by the nurse are appropriate? (Select all that apply.)
a. Keep the patient in a supine position.
b. Note and mark the level of the endotracheal (ET) tube at the lips or nares.
c. Have suction equipment available for immediate use.
d. Perform mouth care at least twice daily.
B, C
The patient should be positioned with the head of bed elevated 30 to 45 degrees to reduce gastric reflux, thereby decreasing the risk for aspiration and ventilator-associated pneumonia. Note and mark the level of the ET tube at the lips or nares. This provides a baseline for depth of tube placement and ensures that the tube is not too close to the carina or in the right main stem bronchus. Set up suction equipment, including oral suctioning, to provide airway care and suctioning as needed of the ET or tracheostomy tube, to prevent plugging of the airway, and to reduce the risk for infection. Perform mouth care at least 4 times per 24 hours. Use a toothbrush and a solution such as chlorhexidine, which is effective in reducing oral bacteria and the risk for ventilator-associated pneumonia.
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