Nursing care, nutrition and hydration for NIV adults

Nursing care

SectionRecommendationGrade of recommendation

25.

A clear plan for the nursing care to be provided while the patient is receiving NIV is to be documented within 24 hours of initiation of therapy. This plan is to include the psychosocial support including (but not limited to) cultural safety, spiritual needs, family needs and financial concerns.

Consensus

26.

Oral hygiene is to be attended every two hours as long as the patient’s tolerance to ceasation of NIV is longer than five minutes. Refer to the Oral Care Clinical Practice Guideline for further information.

Consensus

27.

Eye care is to be attended every two hours. Refer to the Eye Care Clinical Practice Guideline for further information.

Eye Care Clinical Practice Guideline

28.

A full body wash, including facial shave, is to be attended daily or more often as required in response to patient diaphoresis and the patient’s level of tolerance.

Consensus

29.

Patients are to receive pressure injury prevention management as per the Pressure Injury Prevention Guideline.

Pressure Injury Prevention Guideline

30.

Patients are to be encouraged to sit out of bed as tolerated. When in bed they are to be positioned in an upright position to facilitate chest wall expansion.

Pressure Injury Prevention Guideline

31.

The Physical Activity and Movement Guideline provides a graded mobility schedule. Patients are to be assessed and managed as per this guideline.

Physical Activity and Movement Guideline

32.

Pharmacotherapies (i.e. anti-anxiolytics) are to be documented by medical staff on clinical presentation or initiation of therapy and implemented by nursing staff as required in response to patient assessment (1).

Consensus

33.

Referrals to allied health professionals are to be implemented where services are available in the clinical setting to support the patient and his or her significant other/s psychosocial wellbeing.

Consensus

The evidence review for these recommendations was current to December 2012. Clinicians are advised to check the literature as research may have been published that change these recommendations .

There have been no definitive studies on what clinical nursing cares should be provided to a patient receiving NIV or the optimum frequency of these cares. A survey of clinical practice undertaken across the across 39 NSW ICUs simultaneously during the development of this CPG, informed the recommendation statements.

A number of clinical practice guidelines have been developed on oral care, eye care, pressure injury prevention and physical activity and movement. These guidelines should be referred to, to assist in the management of the patient requiring NIV.

Due to this patient group’s relative intolerance to disruption of therapy and limited activity tolerance, complications can be difficult to prevent. Patients may be at an increased risk of a number of complications including:

  • ocular complications due to the increased gas flows drying the cornea
  • poor oral hygiene due to the inability to tolerate removal of the BiPAP mask
  • pressure injury development on face due to mask interface and on dependant areas due to reluctance to move due to breathlessness
  • abdominal distension due to swallowing of air.

Nursing staff need to take proactive steps to limit complications.

Practice point 3 -  Oral care

Where the patient cannot tolerate mask removal for oral care use ice chips or artificial saliva solutions to hydrate the oral mucosa.

Psychosocial care

While there is evidence indicating that providing psychosocial support to intubated and ventilated patients including, but not limited to meeting cultural safety, spiritual and family needs and addressing financial concerns is helpful, no evidence was found for the impact of these interventions for patients receiving NIV.

The consensus of the development group for this CPG was to apply the evidence of best practice for the intubated/ventilated patient, to the patient receiving NIV (2). (3) (2010), suggests that significant improvements in patients’ outcomes including vital signs, sleep, satisfaction and decreases in pain and anxiety ratings are linked to psychosocial support for patients in the ICU. The same author found complication rates and length of stay are also reduced when psychosocial support is provided to ICU patients. Psychosocial support may include: religious, spiritual, sleep, familial, social, welfare (financial) and/or emotional support (2).

Nutrition and hydration

SectionRecommendationGrade of recommendation

34.

Oral feeding is to be initiated if the patient is able to tolerate small periods off NIV.

Consensus

35.

No oral intake is to be implemented if the patient has a decreased LOC or the patient is in respiratory distress with an increased work of breathing (i.e. R.R > 30/min). Intravenous fluids are to be commenced in these circumstances.

Consensus

36.

Patients receiving NIV are to have daily UECs and CMP blood samples taken for the duration of their NIV therapy to assess fluid and electrolyte status (6).

Consensus

37.

Patients receiving NIV are to have a strict fluid balance and stool chart implemented for the duration of their NIV therapy to assess elimination and fluid status.

Consensus

38.

Dietetics and nutritionist assessments are to be undertaken and documented for the patient receiving NIV 24 hours after initiation of therapy.

Consensus

The evidence review for these recommendations was current to December 2012. Clinicians are advised to check the literature as research may have been published that change these recommendations .

A number of authors have recommended that patients should be able to tolerate small periods off NIV for the purpose of maintaining nutritional intake to meet the increased physiological requirements associated with his or her increased respiratory effort. Patients unable to tolerate these periods of NIV should be considered for escalation of ventilator support.

Practice point 4 - Nutrition and hydration

  • Patients should have no oral intake if they:
    • have a reduced level of consciousness (consideration should be given to appropriateness of NIV for these patients)
    • are in respiratory distress (i.e. if respiratory rate is greater than 30 breaths per minute, continuous respiratory assessment is recommended).
  • To assist in evaluating fluid and electrolyte status patients should have regular (at least daily) EUC and CMP.
  • It is desirable to monitor and document elimination status daily (strict fluid balance chart and consider daily weigh).
  • If patients remain NIV dependent for > 24hrs consider dietician review where available.
  • Patients must have intravenous access so that fluids and other therapy may be administered.
  • Monitor for abdominal distension and consider using an NG tube where abdominal distension occurs.

Grading of recommendations

Grade of recommendation

Description

A

Body of evidence can be trusted to guide evidence

B

Body of evidence can be trusted to guide practice in most situations

C

Body of evidence provides some support for recommendation/s but care should be taken in its application

D

Body of evidence is weak and recommendation must be applied with caution

Consensus

Consensus was set as a median of ≥ 7

Grades A–D are based on NHMRC grades (4)

References

  1. Roberts CM, Brown JL, Reinhardt AK, Kaul S, Scales K, Mikelsons C, et al. Non-invasive ventilation in chronic obstructive pulmonary disease: management of acute type 2 respiratory failure. Clin Med. 2008;8(5):517-21.
  2. Papathanassoglou ED. Psychological support and outcomes for ICU patients. Nursing in critical care. 2010;15(3):118-28.
  3. Papathanassoglou EDE. Psychological support and outcomes for ICU patients. Nursing in Critical Care. 2010;15(3):118-28.
  4. NHMRC. Australian Guidelines for the Prevention and Control of Infection in Healthcare. Canberra: Commonwealth of Australia; 2010

Disclaimer

The information on this page is general in nature and cannot reflect individual patient variation. It reflects Australian intensive care practice, which may differ from that in other countries. It is intended as a supplement to the more specific information provided by the doctors and nurses caring for your loved one. ICNSW attests to the accuracy of the information contained here but takes no responsibility for how it may apply to an individual patient. Please refer to the full disclaimer.