I. | Â | Initial laboratory assessment |
---|---|---|
 | a. | General screen: phosphate, albumin, calcium, LFTs |
 | b. | Prothrombin time/partial thromboplastin time |
 | c. | Magnesium |
 | d. | CXR |
 | e. | Electrocardiogram |
 | f. | If phosphate or magnesium ≤ 1.0 mg correct level within 24 h |
II. | Â | Subsequent laboratory assessment |
 | a. | Daily ABG's, CXR first seven days on ventilator |
 | b. | Repeat initial panel at ventilation day 5–7 |
 | c. | Repeat magnesium |
 | d. | If phosphate or magnesium ≤ 1.0 mg correct level within 24 h |
III. | Â | Nursing assessments and care |
 | a. | Daily weights |
 | b. | Intake and outputs every shift and 24 h |
 | c. | Communication with physicians regarding patient condition |
 | d. | Pulmonary care: every 2 h repositioning, semi-fowlers |
IV. | Â | Stress ulcer (initiate by day two in ICU) |
 | a. | Use of antacids, H2 blockers, sucralfate or enteral feeding |
 | b. | Monitor gastric pH if antacids of H2 blockers utilized |
V. | Â | Thrombus protection (initiate by day two in ICU) |
 | a. | Anticoagulation if no contraindication exists |
 | b. | Thigh-high Ted hose and compression stockings if |
 |  | anticoagulation contraindication exists |
VI. | Â | Dietary management |
 | a. | Document dietary assessment (protein/calorie requirements) |
 |  | within 72 h |
 | b. | Initiation of feeding with 72 h of ICU admission |
 | c. | Verify NG tube position by auscultation, aspiration or CXR |
 | d. | If enteral feedings held > 72 h was alternate supplement |
 |  | initiated |
VII. | Â | Ventilator management |
 | a. | Initial tidal volume 8–12 cm3/kg, rate 10–20, A/C mode, 100% |
 |  | FiO2 (unless prior PO2≥ 60) |
 | b. | ABG's 30 min after ventilator initiation |
 | c. | Prompt (within 60 min) changes for respiratory alkalosis |
 |  | (pH ≤ 7.52 with PCO2 ≤ 35) and/or respiratory acidosis |
 |  | (pH ≤ 7.30 with PCO2 ≥ 55) |
 | d. | PaO2 was maintained at ≥ 90% saturation during initial 30 min |
 |  | of treatment |
 | e. | Prompt (60 min) ventilator adjustments for sustained |
 |  | desaturations < 90% |
 | f. | ABG's 60 min after major ventilator changes; Mode, TV by 100, |
 |  | RR by 4 breaths per min unless set ≤ 10, then by 2 breaths per min |
 | g. | Documentation of ET tube size |
 | h. | Documentation ET tube cuff pressure at least daily, ideally every |
 |  | 8 h |
 | i. | Maintain ET tube cuff pressure < 30 mmhg |
VIII. | Â | Decision to wean |
 | a. | Medical stability (no fever, hypotension, arrhythmias) |
 | b. | Laboratory stability (Hgb ≥ 10, normal magnesium, phosphate |
 |  | > 1.0, normal calcium (expect decrease by 0.8 mg/dl for each |
 |  | 1g/dl decrease in albumin), sodium 130–150, potassium 3–5.5 |
 | c. | Optimal sedation (absence of neuromuscular blocking agents) |
 | d. | Weaning parameters |
 |  | 1. PaO2 > 55 mmHg on < 50% fio2 |
 |  | 2. VE < 12l/min |
 |  | 3. Two of the following four: MVV > 2 VE, TV > 5ml/kg, FVC |
 |  | > 10ml/kg, or NIF ≤ 20 cmH20 |
 | e. | Documentation of intervention of patient anxiety and/or fatigue |
 | f. | Documentation of attempts to manage patient pain |
 | g. | Successful planned extubation (patient did not require |
 |  | reintubation within 24 h) |