FORMAT FOR CASE ANALYSIS (through concept

mapping
1. Introduction and Objectives
2. Pathophysiology and Management
A. Etiology
B. Symptomatology
C. Diagram/ Disease Process

D. Narrative Discussion
E. Diagnostics/ Laboratory/ Confirmatory Tests
F. Management
G. Prognosis
3. Discharge Planning
4. Related Nursing Theory
5. Review of Related Studies/ Literature
6. References
Sample NCP
AICU ORIENTATION (August 12, 2021)

➢ 23 cubicles (18 for admission (18 ICU beds); the rest are used as equipment room (where infusion
pumps, BP apparatuses, wheelchairs, etc. are stored), resident’s quarter.
➢ Inside the cubicle, there is 1 bed (standard hospital bed), wall-mounted suction, and oxygen outlet. 1
unit also has cardiac monitor and is connected to telemetry.

➢ Nurses’ Station, also called “charger’s area”

➢ Contains landlines
➢ Inside is a sink (pedal-controlled) for handwashing and adjacent to it is an area for preparing
medications (especially for those that need to be pulverized)
➢ The one circled in red is a whiteboard that contains the names of patients and on-board doctors; it is
updated every night shift (if the doctor is out of town, the present attending physicians), it is also
checked by the dietary unit, physicians, and nurses that do rounds.
➢ Bedside nurse to patient ratio is 1:2
➢ Telemetry= telemetry nurse prints 1 rhythm every shift and places it in the mounted file holder,
printouts are done when there are sudden changes in patients, for patients requiring cardiac
monitoring, and for cardiac arrest patients.
➢ Circled in red is a computer that contains information about supplies and laboratory tests that are
charged to the patient
➢ Circled in blue are supplies that are ready for the shift (e.g., ECG strips)
➢ Circled in orange is the procedure room, this is where procedures in the ICU are done because
commonly, they require machines, hence they’re not allowed in the cubicles. Another example is
hemodialysis (a maximum of 2 patients at a time can be catered in the procedure room)
➢ Beside the procedure room is the supervisor’s office and adjacent to the office is a hallway leading to
the CR (allowed to be used by student nurses)
➢ ABG machine= if patients need their ABG to be checked, don’t wait for the RTs, you may use the
machine.

➢ View from the entrance/ exit of medical staffs; this is where unused stretchers and O2 tanks are
usually parked.
➢ Doorbell= upon hearing, ask for assistance of telemetry or staff nurse to open the door.
➢ LEFT photo: Staff’s Dressing Room (the dressing room for student nurses is at the student’s
lounge; it is where student nurses change to their scrub suits, where the roll calling and checking for
the completeness of paraphernalia is done; it is also where their items can be left)
➢ RIGHT Photo: Resident’s quarter

➢ Closer view of telephones (when answering: Greet → Station → Name & Position → ‘How may I Help
you?’
➢ LEFT photo: view of cubicle 5 and 6
➢ Circled in red are emergency carts that contain defibrillators

➢ Procedure Room [storage for infusion pumps, dialysis machine (max. of 2 patients at a time), etc.]
➢ Dialysis= bed to bed transfer is done (the bed is wheeled to the unit including the suction and
attachments); The patient is endorsed by the bedside nurse to the dialysis nurse (the student nurse
assigned to the patient must go with him/her and continue bedside care and monitoring)
➢ Hallway to the right is the entrance and exit of staff nurses and patients
➢ As of the moment, cubicle 8 (left photo) is used for donning of PPE

➢ LEFT photo: This room is sometimes called ‘aquarium’, this is where supplies are stored
➢ RIGHT photo: patient’s gowns; IVF for emergency use only
➢ Mannitol= the icebox doesn’t have ice (its purpose is to keep mannitol at room temperature since ICU
is very cold)
➢ Linens= multi-purpose
➢ Refrigerator of ICU= contains insulins, medications with label, suppository Dulcolax (Bisacodyl;
stimulant laxative), etc.
➢ The Charge nurse is in charge of monitoring the temperature of the fridge
➢ Operating Sponges and Cotton Balls (circled in red) are charged to the patient.

➢ Closer look of E-carts (each contain defibrillators, Telemetry nurse checks if it’s still functioning)
➢ RIGHT photo: monophasic defibrillator
➢ Turning schedule (circled in blue): patients are prone to decubitus ulcers, in order to prevent this,
bedside care is done → turning of patient at least every 2 hours if not contraindicated.
- if turning the patient to side every 2 hours will cause undue manifestations, then it is ok not to turn
the patient q2hours (it may be delayed or forewent)
- Always think 1,2,3 (Pwede ba ni? Safe ba ni? Ready na ko)
➢ Whiteboard (circled in red): pending and due labs, laboratory and diagnostics need to be updated
➢ Mounted file holder (circled in orange): Reports of Telemetry nurse to bedside nurse such as heart
tracing readings, ICU complex flow sheet (contains assessment), watcher’s gown (under the papers; to
be worn every time the watcher visits) are placed in here.
➢ ICU Complex Flow Sheet
➢ Divided into 3 columns (First division is for 7-3 shift, 2nd is for 3-11, and 3rd is for 11-7; must use color-
coded pen when filling out)

➢ Progress notes: where the nurse must write

➢ Closer look of the Patient Turning Schedule

➢ Emergency medicines
➢ Medications in the E-cart are monitored by the Telemetry nurse (student nurses are not allowed to get
meds from the e-cart)
➢ Common Emergency Cart Medications:
1. Epinephrine: vasopressor; used to increase cardiac output by increasing heart rate, heart muscle
contractility, and blood pressure. Epinephrine is used every 3 to 5 minutes during a code
2. Amiodarone: primarily indicated to treat ventricular fibrillation (VF) and ventricular tachycardia (VT)
that occurs during cardiac arrest.
3. Atropine: used to help keep heart rates stable after a heart attack.
4. Calcium Gluconate: strength of contraction of cardiac tissue. It is used to stabilize myocardium and
help get a patient out of a lethal rhythm.
5. Sodium Bicarbonate: used when the code response team believes that the patient may be acidotic
because the drug helps to increase serum PH, which in turn could prevent further coding
6. Dopamine: Treat insufficient cardiac output and for hypotension. During a code situation, it can act
as a vasodilator, which brings better circulation to the brain, myocardium, and kidneys.
7. Naloxone: antidotes in the event that patients are coding due to an overdose—either accidental or
stemming from drug abuse.
8. Others

➢ Lower drawer contains supplies

➢ Gray drawer contains electrodes
➢ Leucoplast
➢ ET Holder
➢ Guidewires
➢ Etc.

➢ LEFT photo: Lower layer of portable E-kit: contains bag valve mask, syringes, O2 Cannulas, suction
catheters
➢ RIGHT photo: intubation cart (shown in the photo are laryngoscopes (different sizes)
- Charge nurses check their functionality (contains mini bulbs that lights up (indicates that it works)
- After using, it must be in the wash room to be cleaned
➢ EQUIPMENT FOR SUCTIONING
➢ Single-use catheter (red arrow)
- single use per cycle (e.g., bedside= suctioning; if we need to repeat suctioning/ suction the patient
twice because at first attempt there are still remaining secretions, then you can use it again. After
the bedside care, that’s the time that it may be discarded.
- Dry set-up= the suction catheter is not submerged in the bottle if not used, the amount of water into
the 2 containers must be consumed. If there are still remaining, it must be removed (otherwise, will
serve as a medium for contamination of microorganisms)
- Use gloves and sterile forceps (tip) when attaching it to the tube and wall-mounted suction machine.
➢ Suction tubing (blue arrow)
➢ Specimen bottle (yellow arrow)
➢ Saliva Ejector (green arrow)
- You may use gloves to hold the ejector. Make sure that you won’t unsterilize the tube.
➢ Forceps= tip is sterile
➢ Sterile container= containes sterile water for rinsing
➢ Saliva ejector and forceps are changed every SHIFT

➢ Adjacent to Cubicle 1, before entering, is a cabinet that contains slippers to be used by watchers
when entering the unit.
➢ Washer room: contains disinfectant solutions for infectious and non-infectious items.

➢ Watcher’s room= in front of the main entrance, located at the far end of San Lorenzoo, there is an
intercom used to contact the watchers in case doctors want to talk with them.
August 13, 2021

GRAND ROUNDS
➢ Not done in the nurses’ station but per cubicle
➢ The charge nurse will bring with him/her a 24-hour monitoring sheet
➢ Started with a prayer first
➢ 1 Receiving charge nurse, 1 Telemetry nurse, and bedside nurses (assigned per cubicle; bedside nurse
to patient ratio is 1:2)
➢ Content is usually composed of:
o Name/ Sex/ Age of patient
o Initial medical diagnosis
o Attending physicians, consultants, if rounds are done by attending physicians, and role of
physicians in the care of the patient
o Health History: narration of how the patient is admitted to the ICU; summary of what happened
to the patient prior to and on the day of admission
o Neuro Vital Signs, Vital Signs, unusualities and intervetions, evaluation, patient’s response, and
orders
➢ Grand rounds is followed by a detailed 1 on 1 endorsement (the outgoing nurse will endorse the
patient to the assigned ingoing nurse)
➢ Bedside endorsement is the perfect time to also do a quick observation on the patient
➢ Attending physicians usually approve the orders in the evaluation sheet
➢ Telemetry nurse must stay at his/her post to monitor the patient and inform the bedside nurses

1 ON 1 ENDORSEMENT
➢ The nurse will use a flow sheet (front part is for assessment, back is for monitoring)
➢ After the grand rounds, the nurses assigned to a particular patient must proceed to the cubicle for the
1 on 1 endorsement
➢ 1 on 1 endorsement is followed by bedside care

BEDSIDE CARE
➢ Part of the nurse’s responsibility is the checking of supplies (aside from assessment, monitoring, and
bedside care)
➢ Bedside table= where supplies of the patient are placed for use; in its drawer are the medications;
on top are usually prepared OF and suction set-up (if needed); and personal hygiene items such as
toothbrush, soap, and lotion.
➢ Bedside care may be done by 2 nurses epecially for patients with many attachments and decreased
level of consciousness. If the patient is conscious and able to move about, then you can do it alone
[just ask for the patient’s participation (only if the patient is very conscious)]
➢ Don working gloves prior to working, lower head part of the bed and the siderails, position the
mattress properly (move up to the head part of the bed), suction the patient
➢ Pillowcase is placed on the chest of the patient for secretions (prevent soilage)
➢ Bedside care and changing of linens are done every morning care or as needed (if the patient is
already soiled)
➢ Flip the patient’s pillow from time to time; otherwise, it will warm
➢ Position the Foley Catheter at the footpart of the patient at a lower gravity than the perineal area, and
anchored to the frame of the bed (not side rails)
➢ Look at the patient’s face always as bedside care is done, and address what needs to be addressed
➢ “UP and MINE” → communication between nurses; direction of the patient’s movement
➢ If restraints are present, loosen to avoid injury
 ➢ Check the diaper and change as needed

SUCTIONING
➢ When doing bedside care, suction the mouth first; place the saliva ejector in the mouth of the patient
and see to it that secretions are suctioned.
➢ After, rinse the ejector and place in the container with water.

➢ For the Endotracheal tube, use the suction catheter.

➢ Make sure to maintain the sterility of the suction catheter by using forceps, and only having one end of
the packaging opened.

➢ One nurse will hold the ET tube and opens it as the other nurse suctions. (the part connected to the
machine must face slightly downward.
➢ If there is a need to suction again; reattach the ET tube and rinse the suction catheter → suction again

BEDSIDE CARE (cont.)

➢ After suctioning, reposition the patient to face on one side (up and mine)
➢ Remove the top sheet, and do a quick inspection on the extremities of the patient.
➢ To reposition the patient to face on one side:
- Bend the knee and arm (place across the chest) on on side of the patient
- One nurse will hold onto the back and pelvis of the patient as the other nurse assists and makes
sure that the patient is secured not to fall.
- The nurse who moved the patient also inspect the patient’s back (noting for redness = sign of
pressure ulcers)
- Once done, change the drawsheet/ sheet under the patient

➢ Change the draw sheet and pull taut the bottom sheet

➢ Prepare the new drawsheet and place at the middle of the bed

➢ Put a diaper on the patient, place properly under the buttocks of the patient

➢ Do the same to the other side

➢ Once done, remove the old draw sheet (color blue)
➢ Pull taut the linens, making sure there are no creases.
➢ Fasten the diaper.

➢ Position the patient again to face on one side, and place a pillow at his back and in between the knees

➢ Flip the pillow where the patient’s head is resting.

➢ Place new pillow case on the chest area
➢ Get your new top sheet and drape the client
➢ Place the FC down, raise the siderails and head part of the patient.
ET Tube Preparation
Equipment:

• Guidewire
• Et tube
• KY Jelly
• 10 cc syringe

1. Get the 10 cc syringe.

2. Open the packaging of the ET tube.
3. Check the patency off the ET tube; if it won’t balloon= the cuff is busted; otherwise= patent
4. Withdraw 10 cc of air using the syringe → attach to the tip of the ET tube → administer air → cuff must
balloon (indicates that the tube is patent and can be used for intubation)
5. After confirming the patency, insert the guidewire through the tube.
6. Open the other end of the packaging and apply/drop KY Jelly inside (for lubrication and for patient’s
comfort upon insertion)
7. Ready the prepared ET tube near the doctor; when the doctor is ready for insertion, hold at the tip and
hand it to the docto or just leave it inside the pack (make sure that sterility inside is maintained)

SECURING ETT with Tape

1. There must be 2 nurses when securing ETT

2. Leukoplast is the type of tape that is used.
3. One nurse holds the ET Tube and make sure that the level of the ETT is at the level of the mouth while
the other nurse applies tape.
4. 2 plasters are used, for lower and upper .
Applying Mouth Guard

1. Allow the client to open mouth and carefully insert the mouth guard
2. Carefully twist until secured in the mouth
3. Suction may be inserted or placed at the sides.

WEANING
❑ When disconnecting a patient from the mech vent, do not detach the adapter from the ET
tube.

❑ Corrugated tubes in the mechanical ventilator (has inspiratory and expiratory port)

❑ How to distinguish inspiratory from expiratory port?

➔ The port attached to the humidifier is the inspiratory port
➔ In doing nebulization, the nebulizer set must always be
attached to the inspiratory port
❑ There are also tubes that are bi-valve (serves both inspiratory and expiratory functions)
❑ Moisture trap (due to the humidifier, there is sometimes a buildup of moisture in the tube and cause
aspiration when ingested by the patient)

❑ Port where medications may be instilled

❑ Nebulization Set
➔ There are mechanical ventilators wherein nebulization set can directly be inserted to.
➔ Usually, a mask or a mouthpiece is attached to the nebulization set.
➔ For intubated patients, obviously, it cannot be used in the mouth with a mask or mouthpiece.
➔ If the mechanical ventilator doesn’t have a nebulization set-up, attach to the and check for the mist
➔ Detach the inspiratory port and connect the adapter to the nebulization set and to the inspiratory
port again
➔ Once the medications are consumed, disconnect the nebulization set and reattach the inspiratory
port to the adaptor promptly. Expect for an alarm from the mechanical ventilator but reassure the
patient that this is normal.

❑ Metered Dose Inhaler

➔ In administering to intubated clients, detach the canister from the plastic
holder
➔ Open the port → instill → push in synchrony with patients breathing, that
is upon inhalation (depending on how many puffs is required) → close
the port after
WEANING (cont.)
❑ There are two (2) ways to wean the patient:
1. Requires detaching the client from the mechanical ventilator (most common)
2. Does not require detachment from the mechanical ventilator
❑ The usual way of weaning detaching the client from the mechanical
ventilator and attaching him/her to an in-line nebulization set (also called
T-piece).
❑ Once attached to the client, a mist can be observed and will indicate that
it is working.
❑ When detaching the client from the mechanical ventilator, make
sure that the port is covered and not exposed to air, its sterility
must be maintained. If there is no cover, a clean gloves or plast
cover is used.
❑ Disconnect the humidifier from the wall-mounted oxygen source
and attach the humidifier with flow meter (it contains
measurement to know how many O2 lpm is administered and what
the FiO2 of the patient is.
❑ When the patient is being weaned, the
current FiO2 of the patient must be under
90%. Usually the patient is already at 60%
and below FiO2.
❑ If the O2 flow of the patient is high, the
valve is closed. If the FiO2 of the patients is
for example, at 30%, there will be an
opening. (Room air is already 28%)
❑ Turn on the source and disconnect the mech vent ports from
the ET tube, and attach the tube connected to the wall-
mounted source
❑ For example, if the order of the physician is “wean pt. 5 mins/
hour”, this means that the client is attached to the T-piece for
5 mins and for the remaining 55 minutes, the client is hooked
back to the mechanical ventilator (the T-piece is covered to maintain sterility).
WEANING
❑ The gradual lessening of ventilatory support to have mechanical ventilation successfully discontinued
❑ A process of reducing ventilator support and resuming spontaneous ventilation
- Mechanical ventilators have different setups (Assist controlled/ Controlled)
- Controlled= patient has no spontaneity of breathing; patient is dependent on MV (cannot be
weaned)
- Assist-controlled= has spontaneous breathing, but not enough to meet the metabolic demand
- Goal: to start weaning the patient as early as possible to also prevent complications related to
mechanical ventilators
❑ In most patients, successful weaning from mechanical ventilation occurs when the physical condition is
significantly improved.
- During weaning, the patient is doing cardio exercise
❑ Weaning is started when the patient is recovering from the acute stage of medical and surgical
problems and when the cause of respiratory failure is sufficiently reversed.
- Flow of airway management: if the patient will have respiratory arrest, distress, or a patient is
unconscious even when not respiratory distress but is not capable of maintaining an open airway →
requires intubation
- The common factors mentioned that requires intubation must be reversed for the patient to be
stable (physically, hemodynamically, and with his/her blood works) for him/her to be ready for
weaning.
- If the patient is still unstable for a week long, usually physicians will propose tracheostomy tube
insertion (one reason for patient’s inability to stabilize is the presence of secretions as this affects
the diffusion of CO2 and O2 gases; having a tracheostomy as compared to having an ETT,
secretions are more easily manageable. Tracheostomy is also more efficient in the airway
management, and pronged stay on ETT will have more complications that in tracheostomy)
❑ Successful weaning involves collaboration among physician, respiratory therapists, and the nurse.
❑ Weaning should be considered as early as possible.
- Not all patients require weaning process prior to extubation (delayed extubation: in patients
intubated for induction of anesthesia (nag unstable → sent to ICU → after 24 hours if mag-stable
→ extubate without weaning)
❑ A spontaneous breathing trial (SBT) is the major diagnostic test to determine whether patients can be
successfully extubated.
❑ The initial trial should last 30 minutes and consist of either T-tube breathing (continuous in-line
breathing) or low levels of pressure support (machine will wean the patient without detaching pt to
mech vent setup)
❑ Pressure support or assist-control ventilation modes should be favored in patients failing an initial
trail/trials.
❑ Adequate psychological preparation is necessary before and during the process.
❑ The nurse explains what will happen during weaning
- The doctor will have a conference with the family and the patient himself before weaning
❑ The nurse emphasized that someone will be with or near the patient at all times
- Remember! VISIBLE & CAPABLE
❑ Proper preparation can reduce weaning time
WEANING FAILURE

❑ Defined as either failure of Spontaneous Breathing Trial (SBT) or the need for reintubation within 48
hours following extubation.
❑ After the patient is extubated, protocol: DO NOT withdraw the ventilator from the patient’s bedside for
the reason that there may be a need to reintubate the patient.
- It is medically ordered by the doctor if it is already safe for the mechanical ventilator to be pulled
out from the unit (doctor will order “may pull out mechanical ventilator”)
- Always monitor even after extubation because early signs of weaning failure may prompt
reintubation.
- If the ventilator is unavailable, manual ambu-bagging is done

OBJECTIVE INDICES of WEANING FAILURE

➢ Tachypnea
➢ Tachycardia
➢ Hypertension
➢ Hypotension
➢ Hypoxemia (assessed through pulse oximetry and ABG= done before weaning)
➢ Acidosis (causes CNS depression; CNS is stimulated in alkalotic state= pt. is combative sometimes)
➢ Arrythmia

SUBJECTIVE INDICES of WEANING FAILURE

➢ Agitation or distress
➢ Depressed mental status
➢ Diaphoresis and evidence of anxiety
- Causes of anxiety: Dyspnea; inability to communicate and sleep disruption

CAUSES of SBT Failure

➢ Increasing effort is often related to cardiovascular dysfunction

➢ Inability of the respiratory pump to support the load of breathing
➢ Extubation failure may be related to the same causes in addition to upper airway obstruction or
excessive secretions

CRITERIA for VENTILATOR WEANING TRIAL

❑ Reversal of the underlying cause of respiratory failure

❑ Adequate oxygenation, indicated by the following
1. PaO2 ≥ 60 mmHg on FiO2 ≤ 40-50%
o FiO2 (mech vent can give 100% at most and 30% at least)
o In some weaning orders, FiO2 setup is also manipulated (e.g., reduce FiO2 by increments of
10 until 60% is achieved every hour)
2. Positive End Expiratory Pressure (PEEP) requirement ≤ 5-8 cmH2O
3. pH ≥ 7.25
❑ Heart rate is less than or equal to 140 bpm (inc. HR= inc. O2 demand and workload of the heart)
❑ Stable BP with no or minimal vasopressive medications such as dopamine or norepinephrine less than
or equal to 5 mcg/kg/min
❑ No myocardial ischemia
❑ Afebrile
❑ Hemoglobin is greater than 8-10 g/dL (Hgb=carrier of O2; anemic= weaning failure; Hgb must be Commented [CDC1]:
stabilized first either through blood transfusion or epoetin injection)
 ❑ Acceptable electrolyte values (electrolytes have something to do with cardiovascular and muscular
function)
❑ Adequate nutrition (if pt.is obese/ underweight, it has an impact on the breathing pattern; something
to do with muscle capacity if undernourished= ventilatory support is affected, etc.)
❑ Adequate cough (unconscious= no coughing reflex/ not able to expectorate secretions= not a
candidate for weaning trial because 1 culprit for intubation is presence of secretions)
o If the conscious patient is already extubated, with secretions at a level that he can
expectorate, or has a weak capacity to expectorate, with stable vitals and other criteria are
met= extubated, but mouth guard/bite block is retained and insertion of NGT tube for
access to evacuate secretions.
❑ Adequate mentation without IV sedation (a.m.a.p., patient must be awake because their breathing is
more effective than when unconscious)
❑ RR less than 35 (n: 16-20 but in weaning, even if it is more than that, as long as it isn’t associated with
bluish discoloration, diaphoresis, desaturation = it is FINE)

TECHNIQUES for Weaning

❑ Pressure Support Ventilation (PSV)
- Using this form of weaning, the ventilator delivers a set amount of positive pressure into the lungs
with each breath initiated by the client (the patient has spontaneous effort helped by the machine)
- The client controls both the depth and length of each breath
- This is used on clients who have been on mechanical ventilator for longer period of time.
❑ Synchronized Intermittent Mandatory Ventilation (SIMV)
- Does not disconnect the patient from the ventilator; most common
- The ventilator provides a set number of breaths and tidal volumes in coordination with the client’s
effort
- As the client breathes independently, the number of breaths by the ventilator decreases eventually
to zero
- Used when more time is needed for weaning
- The patient initiates breathing and the machine continues breathing for the patient
- In SIMV, to avoid stacking of breath, before the machine breathes for the patient, breathing is
initiated by the patient for synchronization. (Kung di muginhawa ang pasyente, di mubuga ang
ventilator)

NURSING RESPONSIBILITIES

1. Assess patient for weaning criteria:

2. Monitor activity level, assess dietary intake, and monitor results of lab tests.
3. Assess patient’s and family’s understanding. Implement the weaning method prescribed
- REMEMBER! You may be the best nurse but you can never replace a family member (waw)
- Give leeway for visiting hours
4. Monitor VS, O2 saturation, ECG, and respiratory pattern constantly for 20-30 minutes and every 5
minutes. After until weaning is complete.
5. Maintain a patent airway; ABG. Suction airway as needed.
6. In collaboration with the physician, terminate the weaning process if adverse reactions occur.
- Adverse reactions: respiratory distress/tachypnea (RR of more than 35), tachycardia (HR of more
than 140 bpm), desaturation, arrythmias, hypotension, etc.
✓ Inc. HR of 20 bpm (20 bpm higher than the HR when you initiated weaning)
✓ Systolic BP increase of 20 mmHg (compared to start of weaning)
✓ Dec. O2 sat to less than 90%
✓ RR less than 8 or greater than 20
 ✓ Ventricular dysrhythmias, fatigue, cyanosis (late sign of poor oxygen supply; early sign=
restlessness), erratic labored breathing, paradoxical chest movement.
❑ In the ICU, the Weaning Monitoring Sheet is utilized. Indicated there are the medical order, the Vital
signs, O2 saturation, other notes/comments, and a column that has “referred to Dr.__”
❑ Assess for psychological dependence if the physiologic parameters indicate weaning is feasible and the
patient still resists.
❑ Successful weaning from the ventilator is supplemented by intensive pulmonary care.
The following are continued:
✓ Oxygen Therapy (through in line setup using a special humidifier with FiO2 setup; without
disconnection from machine= O2 support is still from machine but from PSV & SIMV)
✓ ABG Evaluation
✓ Pulse Oximetry
✓ Bronchodilator therapy (manage patients with airway constriction)
✓ Chest Physiotherapy (to evacuate secretions)
✓ Adequate nutrition, hydration, humidification
✓ Incentive spirometry (usually used as a post-op management, in lieu: coach and teach patient
to do deep breathing exercise like pursed lip breathing)
❑ These patients still have borderline pulmonary function and need vigorous supportive therapy before
their respiratory status returns to a level that supports ADL

WEANING ORDER & SCHEDULE

❑ “Start weaning patient at 10 am today @ 10 minutes hourly
❑ In-line is the T-piece
❑ During the time that the patient is connected to the In-line, VS is required. Included in the monitoring
is the Hemodynamic monitoring and O2 saturation (to assess if the patient can really tolerate the
weaning process)
In-line Mechanical ventilator
10:00- 10:10 10:10- 11:00
11:00- 11:10 11:10- 12:00
12:00- 12:10 12:10- 1:00
❑ “Wean patient every hour for 5 mins x 3 cycles; if tolerated, increase by increments of 5 every hour,
until 30 mins; if 30 mins is tolerated, do ABG.

In-line Mechanical Ventilator

8:00- 8:05 (1st Cycle) 8:05- 9:00
9:00- 9:05 (2nd Cycle) 9:05- 10:00
10:00- 10:05 (3rd Cycle) 10:05- 11:00
11:00- 11:10 11:10- 12:00
12:00- 12:15 12:15- 1:00
1:00- 1:20 1:20- 2:00
2:00- 2:25 2:25- 3:00
3:00- 3:30 (ABG before hooking back to MV) 3:30- 4:00

❑ “Wean patient up to waking hours 30 vs 30

❑ Waking hours= up to 9 pm, sometimes it’s just up to 8 or 8:30 pm

In Line Mechanical Ventilator

4:00- 4:30 4:30- 5:00
5:00- 5:30 5:30- 6:00
6:00- 6:30 6:30- 7:00