I am in CCU this is how we document. I am shocked to hear that an ICU is that "careless" to not document all this. What is going on there to make this happen?
-Settings q2h .. type of ventilation (SIMV, etc) FIO2, PSV, Peep, set TV, actual TV, spontaneous TV, set respirations and spontaneous respirations. ABG at least BID. If there is any kind of change these must be documented and an ABG must be drawn within 15-45 minutes.
-ET size, what/where it is taped ie) 24 @ inner lip and cuff pressure
-How often suctioning required, sputum color, amount, consistency. Must do at least q2h.
-Vital signs q1h including temp we must put in a rectal probe if on a vent
-Sedation/paralytic use if indicated (generally at least a sedative unless trying to wean). Neuro assessment q2h if on sedative and TOF w/ paralytic q4 or if increase/decrease paralytic.
-Frequency of mouth care...must be at least q2h
-Wrist restaints ...must be documented q1h with circulation checks, releasing q2h, etc, etc, etc.
-Position changes must be documented q2h.
-And we must document a bedside check has been performed at least q8h including...Atropine/Lido at BS, suction works (must have at least two ready), ambu bag to 100% O2 at all times, with mask in room, syringe by vent, tubing with NS spiked and waiting, alarms on monitors checked for limits, and the alarms must be checked to make sure you recieve and give them off (this setting can get turned off)
-Then of course a full head to toe assessment q4h.