Vent settings

Dusting off the old ICU cobwebs here, but I remember documenting the vent settings every 8 hours and when there was a change. Charting was something like the type of ventilator, vent settings, and something about the mechanical inspiration correlated with visual chest inspirations.

When I do my vent documentation I always include:

what level the ET tube is taped at and that it is taped securely(or trach documentation)

cuff inflated

in-line suction in use

type of secretions being suctioned

vent settings(these go on our flowsheet)

type of sedation (if any)

bilateral soft wrist restraints(if in use)

vent model

Hope this helps:)

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.

Good luck :)

In our ICU alot of this information is documented by respiratory; it looks like most of the rest is in a checklist fashion on the nursing assessment form--I think a narrative note would be hard, too!

We also have to document as a part of our assessment in addition to respiratory's documentation. You are right some of this is in a checklist type form and the rest is written in the assessment. Fortunately we chart by exception with "FOCUS" notes so we don't have to include all this again in a note. (Thank goodness) Our nursing flowsheets are six pages...everything goes on these which is nice they fold out so it is always all together. Then we have Addendum sheets if VS or other things need to be documented more than q1h.