The nurse is caring for the intensive care unit patient who is mechanically ventilated and receiving a neuromuscular junction (NMJ) blocker, a sedative, and an analgesic
What are priorities of nursing care for this patient? (Select all that apply.)
A) Reposition patient frequently.
B) Ensure care of the patient's eyes.
C) Monitor temperature.
D) Provide a means for patient communication.
E) Increase ventilator breaths per minute as needed.
A, B, C
Feedback:
Frequent repositioning is important because the patient is unable to move and protect skin integrity independently. The loss of blink reflex due to muscle paralysis from NMJ blockers can result in conjunctival damage so eye care is very important. Monitor patient temperature for prompt detection and treatment of malignant hyperthermia. The patient cannot communicate while receiving NMJ blocker. Ventilator changes are made by physician order in most facilities and are usually based on arterial blood gas results.
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