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A nurse enters the patient's room to address a ventilator alarm. The alarm states "low-pressure" in the ventilator closed system, but after checking the ventilator and endotracheal (ET) tube, the nurse cannot determine the cause of the alarm. What action should the nurse perform next?

Explanation

• Ventilator alarms can indicate a variety of problems which may cause patient harm.

• A low-pressure alarm may indicate an air leak in the ET tube, a deflated cuff, or partial extubation. Air pressure is being lost somewhere.

• A high-pressure alarm often indicates a kink or obstruction in the tubing or the ET tube (such as the patient biting the ET tube), pooling secretions, bronchospasm, or pulmonary edema. Pressure is building up in the closed system somewhere, and this pressure can damage the delicate tissues of the lungs.

• If the ventilator alarm is sounding and the cause cannot be quickly determined and resolved, the possibility of causing harm to the patient by allowing the ventilator to remain connected to the patient is high.  The nurse should disconnect the ventilator and begin manual ventilation while calling for help to troubleshoot the ventilator.  This priority intervention confirms a patent airway and ensures adequate ventilation.

• Patients on ventilators should receive continuous monitoring of pulse oximetry, so this answer choice is incorrect.

• Administering oxygen is not a priority over protecting the patient from harm and ensuring adequate ventilations. Additionally, if there is low pressure, oxygen may simply leak out of the ventilator system.

• Ventilator settings are set according to provider orders, so it is not appropriate for the nurse to "reset" the ventilator without determining the cause and confirming new orders with the provider.

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