Question

the nurse is caring for a ventilator-dependent client assisted with positive expiratory end pressure (peep). the high-pressure alarm begins sounding. what actions should the nurse initiate?

Answer 1

When a high-pressure alarm sounds on a ventilator with PEEP, the nurse should promptly assess the patient and ventilator circuit for issues, such as obstructions or disconnections, and consult with the respiratory therapist or physician if needed.

Step-by-step explanation:

When a high-pressure alarm sounds on a ventilator for a client with positive expiratory end pressure (PEEP), the nurse should take immediate and specific actions to ensure patient safety and resolve the issue. The nurse should first check the patient for any signs of distress, dyspnea, or changes in oxygenation and ascertain if the alarm is due to a real change in the patient's condition such as a pneumothorax or bronchospasm. Simultaneously, the nurse should assess the ventilator circuit for any disconnections, kinks, or accumulation of secretions that could cause increased resistance and trigger the alarm.

Here is a list of steps that the nurse should initiate:

1. Check and ensure the patient's airway is patent.
2. Assess the patient's vital signs and oxygenation.
3. Inspect the ventilator settings and circuit.
4. Look for and alleviate any obvious obstructions or kinks in the ventilator tubing.
5. Listen to the patient's lung sounds to detect potential issues like pneumothorax or mucus plugging.
6. If an obstruction is not found, evaluate the need for suctioning.
7. Confer with the respiratory therapist and consider notifying the physician if the issue is not resolved quickly.

Immediate attention to these steps can help distinguish between a false alarm and a serious patient or equipment issue, ensuring both patient safety and equipment functionality.