ASSESSMENT / REPORT SHEET

NAME: ___________________________________________D.O.B._________________________CODE STATUS:______________AGE:_________________

DIAGNOSIS: _______________________________________

PAST MEDICAL HX.

LAB REVIEW:

COURSE IN HOSPITAL:

PRESENT STATUS:

SYSTEM REVIEW

NEURO/CNS

PUPIL Size:__________Rx.___________MUS. STRENGTH:___________________________

Level of Awareness:___________________________PAIN______________________________

NEURO. MEDS./INTERVENTIONS

Sedations:

RESPIRATORY:

ASSESSMENT:

BLOOD GAS:

MEDS. / INTERVENTIONS

VENTILATION SETTINGS: MODE PEEP FiO2_______HOB:_______

O2Sat.________RESP.RATE:__________ TRACH./ETT. Size: ETT. Location:

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CARDIOVASCULAR ECG RHYTHM INTERPRET. _________________

BP MAP HR CVP________________Temp._______

FLUID BALANCE:………………..

OTHER:___________________________________________________________________

LINES/LOCATION: PIV _____________________________________________________

CVP _______________ Arterial:_______________

Dialysis______________ OTHER:_____________________________

MEDS:/INTERVENTION:

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

GASTROINTESTINAL: ASSESS/BOWEL SOUND:__________FEED_________________

TUBES:/Drainage_________________________________________________________

Surgery/Dressing/Drainage__________________________________________________

OTHER:

GENITOURINARY: FOLEY:……………..OUTPUT………………….COLOUR……………

DIALYSIS:……………………….BOLUS………………FLUID BALANCE

PERIPHERAL: _____________________________________________________________________

SKIN:___________________________________________________________________________

ANTIBIOTICS/OTHER MEDS:_____________________________________________________

Priority/Plan:_______________________________________________________________________

OTHER:________________________________________________________________________________

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TYPES OF VENTILATION MODE

Mode or Breath Pattern: there are only a few different modes of ventilation:

CMV = Conventional controlled ventilation, without allowances for spontaneous breathing. Many anesthesia ventilators operate in this way.

Assist-Control = Where assisted breaths are facsimiles of controlled breaths.

Pressure set, Resp. rate set, but pt. can breath above set rate but not below set rate, PEEP set, FiO2

Intermittent Mandatory Ventilation = Which mixes controlled breaths and spontaneous breaths. Breaths may also be synchronized to prevent "stacking".

1) Control: How the ventilator knows how much flow to deliver

Either Volume Controlled (volume limited, volume targeted) and Pressure Variable

orPressure Controlled (pressure limited, pressure targeted) and Volume Variable

orDual Controlled (volume targeted (guaranteed) pressure limited)

SIMV – Control breaths and mandatory breaths – mandatory volume and extra breaths when pt. triggers ventilation.

AC-PC – Present rate and pressure, tidal volume fluctuates

AC-VC – The volume control mandatory mode, preset tidal volume and preset rate

CPAP/Pressure Support = Where the patient has control over all aspects of his/her breath except the pressure limit.

Spontaneous breathing, positive inspiratory airway pressure set to augments breathing, decrease work of breathing and muscle fatigue for pt., tidal volume pt.

receives varies from breath to breath

4) Breaths are either: what causes the ventilator to cycle from inspiration

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Mandatory (controlled) - which is determined by the respiratory rate.

Assisted (as in assist control, synchronized intermittent mandatory ventilation, pressure support)

Spontaneous (no additional assistance in inspiration, as in CPAP)

PEEP (Positive end expiratory pressure)

Opens collapsed alveoli increase air exchange and make it easier for patient to take breath, if too high cause overdistension of lungs, if too low can collapse alveoli during expiration.

WEANING

Patient must be hemodynamically stable, ensure good ventilation Vt – 5-8 ml/kg, RR <30,Sedative holiday, ensure airway patency, good cough, no edema in airway, ensure

adequate rest, build trust, ensure good nutrition, electrolyte balance, pt. motivation

VAP

Keep HOB elevated 30 degrees, DVT prophylaxis, antiseptic mouth care, nutrition, feeding tube oropharngeal not nasal, proper hand washing, spontaneous breathing trial, sedative

holiday.

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