Ventilated Patients

Absolutely. A patient can breathe over the vent.

Also some patients may not have a rate set...

So.. yes document the patient's rate and if the vent has a respiratory rate docuement that as well

Yes. Take the number from the vent or the end-tidal CO2 (per your hospital policy & the gear you have available), not the bedside monitor that relies on chest-wall motion.

Yes, imagine a pt with VS HR 90, BP 150/90, O2 sat 96. BUT.... they are breathing 45 times a minute over the set rate of 20. It's important information, as is knowing if the patient is never breathing over the vent at all.

We record both the set rate on the ventilator, if there is one, and the actual respiratory rate.

That’s what I thought. I don’t have experience with ventilated patients, but I have noticed in documentation that many nurses in the ICU settings are not documenting this rate, so I wanted to make sure I wasn’t missing something.

48 minutes ago, rn39648 said:

That’s what I thought. I don’t have experience with ventilated patients, but I have noticed in documentation that many nurses in the ICU settings are not documenting this rate, so I wanted to make sure I wasn’t missing something.

Just make sure that they are not charting in a different section. ICU charting is often different than an Acute Care or med/Surg area as well as ER, and out patient areas

They tend to write “HFOV” in the respiratory rate section. Is this appropriate enough though?

Yes. The HFOV is an oscillator, the rate for that is about 300 + breaths a minute. A patient should not be breathing with this type of ventilation. Many times in pediatric patients these patients are sedated and paralyzed.

What other types of ventilation situations would indicate that a patient is paralyzed and sedated (not breathing on their own and would not have their own spontaneous respiratory rate)?

In answer to your second question...some patients are over-sedated and don't breathe on their own. Some are neurologically incapable. So, not every patient who isn't breathing on their own has been chemically paralyzed. How can you tell if they have spontaneous breaths? Ask the RT to show you, since it depends on the mode. *Induced* paralysis with medication like Nimbex is used to *prevent* them from breathing on their own because they are fighting against the ventilator and doing themselves more harm than good (maybe too much pressure, maybe they don't have the metabolic reserve and are just exhausting themselves, etc...)

Paralytics are often used for ARDS patients. Even if I knew my patient was on a paralytic drip (which would indicate they should also be on a sedative, with appropriate monitoring of sedation and level of paralysis), I would still record their respiratory rate as measured by the vent/ end-tidal. As others have mentioned, I also record the vent settings. Depending on the mode, this will include a set respiratory rate.

My hospital doesn't use an oscillator for adults, but if you have questions specifically about it, the respiratory therapist might be a good resource. If you have a clinical trainer, I'd think it was very reasonable to ask them for a brush-up on the oscillator, which (as I understand) is a high-level intervention for a very sick patient...can't hurt to ask for some more info!

A patient can be sedated and paralyzed on any mode, or be in such a poor state that they are neither adding rate nor triggering a breath. On a conventional vent, if you are using APRV/Bi-Level, you DO want them to breathe over the vent.

On the oscillator, you never want them to breathe over the vent. Same for VDR and I think the Bronchotron.

For babies on jets, the rate is usually 360 or 420, and they can also have conventional breaths (sometimes called sigh breaths), as well as breathe over the vent but they shouldn't be fighting it. If they are asynchronous, that is my cue to speak to my RN and MD.

On a conventional ventilator in AC/PC, AC/VC, PRVC, SIMV, and any other mode except for PSV/Spont/PS/CPAP (which don't have rates, only apnea settings), the patient can trigger or not and add rate or not. If the rate is set on 12 and they are breathing 12, they aren't adding rate but they could be triggering.

Every ventilator uses different names for modes of ventilation. If you tell me the vent that you have and any specific questions, I'd be happy to help.

At my hospitals, if the patient is on the jet, oscillator, or VDR, the respiratory rate is left blank on vital signs and under oxygen device, you would select the appropriate piece of equipment. Only the RTs, under vent assessment would put the Hz and in the case of the jet, if any sigh breaths are added.

Any high frequency (jet, oscillator) would not have a rate documented. Everything else should.