The purpose of adding PEEP to positive pressure ventilation is to:

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.

When performing mouth care or repositioning an oral endotracheal (ET) tube, the nurse must take specific precautions to prevent accidental tube dislodgement and ensure airway security. Coordination between caregivers and continuous assessment of tube placement and breath sounds are essential to detect displacement early and maintain effective ventilation.

Rationale for Correct Answers

1. Confirm bilateral breath sounds after care: Checking for equal and bilateral breath sounds immediately after repositioning or oral care ensures that the ET tube has not shifted or migrated into one bronchus. Unequal or absent breath sounds can indicate tube displacement, requiring prompt repositioning.

5. One staff member holds the tube and one performs care: This is a critical safety measure. Having one nurse stabilize the ET tube while another provides oral care or repositioning prevents accidental extubation or tube movement. It maintains correct tube depth and placement throughout the procedure.

Rationale for Incorrect Answers

2. Use suction pressures less than 120 mm Hg: While this is an important airway suctioning precaution, it does not specifically prevent or detect tube dislodgement during oral care.
3. Use water swabs to prevent mucosal drying: This measure maintains oral hygiene, not ET tube placement stability.
4. Use humidified inspired gas to help thin secretions: Humidification prevents secretion thickening but does not protect against tube dislodgement.
6. Move secretions into larger airways with turning every 2 hours: Turning promotes lung expansion and secretion movement but is unrelated to detecting tube displacement during oral care.

Take-Home Points

• Always stabilize the ET tube during repositioning and oral care to prevent dislodgement.
• Two-person technique is the safest method for handling the tube during care.
• Reassess breath sounds and tube depth after any repositioning or manipulation.
• Early detection of tube migration or extubation prevents hypoxia and ensures patient safety.