Although the oxygen saturation is above 92%, an orally intubated, mechanically ventilated patient is restless and very anxious. What intervention should be used first to decrease the risk of accidental extubation?

A mechanically ventilated, orally intubated patient who is restless and anxious is at risk for accidental extubation, even if oxygen saturation is adequate. The first priority is to reduce agitation safely through sedation and continuous presence of a caregiver or nurse, addressing both comfort and safety before considering restraints.

Rationale for Correct Answer

3. Administer sedatives and have a caregiver stay with the patient: Sedation decreases anxiety and restlessness, reducing the likelihood of self-extubation or tube displacement. A caregiver or nurse provides constant supervision, ensuring rapid intervention if the patient attempts to pull at the tube. This approach addresses the root cause of agitation while maintaining patient safety.

Rationale for Incorrect Answers

1. Obtain an order and apply soft wrist restraints: Restraints should be a last resort after sedation and close monitoring fail. Applying restraints first does not address anxiety, may increase agitation, and carries ethical considerations.

2. Remind the patient that he needs the tube inserted to breathe: Verbal reassurance alone is insufficient for a patient who is physiologically and psychologically distressed and may not fully comprehend due to sedation or confusion.

4. Move the patient to an area close to the nurses’ station for closer observation: While closer observation may help, it does not reduce agitation or prevent self-extubation by itself; sedation and continuous presence are more effective first-line interventions.

Take-Home Points

• Sedation and constant supervision are first-line measures to prevent accidental extubation in anxious, intubated patients.
• Restraints are a secondary measure and should be used only if sedation and monitoring are insufficient.
• Always assess agitation, pain, and discomfort in ventilated patients to guide safe interventions.
• Preventing self-extubation reduces risk of hypoxia, airway trauma, and ventilator complications.

Patients receiving positive pressure mechanical ventilation are at risk for cardiovascular compromise because increased intrathoracic pressure can impede venous return to the heart, reducing cardiac output. The nurse should monitor for hypotension, tachycardia, and signs of poor perfusion.

Rationale for Correct Answer

3. Signs of cardiovascular insufficiency because pressure in the chest impedes venous return: Positive pressure ventilation increases intrathoracic pressure, which decreases venous return to the right atrium, leading to reduced stroke volume and cardiac output. Monitoring blood pressure, heart rate, urine output, and perfusion is essential to detect cardiovascular compromise early.

Rationale for Incorrect Answers

1. Paralytic ileus because pressure on the abdominal contents affects bowel motility: While critically ill patients may develop ileus, it is not directly caused by positive pressure ventilation.

2. Diuresis and sodium depletion because of increased release of atrial natriuretic peptide: Positive pressure ventilation actually stimulates ADH release, leading to fluid retention, not sodium depletion.

4. Respiratory acidosis in a patient with COPD because of alveolar hyperventilation and increased PaO₂ levels: Respiratory acidosis occurs with hypoventilation, not hyperventilation. Alveolar hyperventilation lowers PaCO₂ and increases PaO₂, which does not cause acidosis.

Take-Home Points

• Positive pressure ventilation can compromise cardiovascular function due to decreased venous return.
• Monitor for hypotension, tachycardia, and low urine output as indicators of reduced cardiac output.
• Adjust ventilator settings carefully to optimize oxygenation without adversely affecting hemodynamics.