Patient-Ventilator Assessment Note

Patient-Ventilator Assessment Note

Date/Time: [Date and time of assessment] | Location: [ICU / ED / OR / PACU / Other] | Author/Role: [Name and professional role] | Encounter Type: [routine scheduled / post-intubation / post-transport / post-vent change / acute decompensation / SBT/SAT-related] | Airway Type: [ETT with size / Tracheostomy with type and size / NIV interface type] | Ventilator Model: [Model] (Only include if relevant to troubleshooting)

Clinical Context

[Primary respiratory problem, ventilator strategy, and any constraints such as permissive hypercapnia, ICP goals, or ECMO] (Limit to 1–3 sentences. If stable and unchanged, a single concise line is acceptable, e.g., "ARDS lung-protective strategy in use.")

Patient Status

• Vitals: SpO2 [value], HR [value], BP/MAP [value], Temp [value], FiO2 [value]
• Recent Blood Gas: [ABG/VBG] [date/time] — pH [value], PaCO2 [value], PaO2 [value], HCO3 [value] (If unavailable, state "ABG not available.")
• Work of Breathing: [calm and comfortable / tachypneic / increased effort with accessory muscle use / retractions]
• Ventilator Synchrony: [synchronous / asynchronous] (If asynchronous, note pattern: double-triggering, breath stacking, flow starvation, ineffective triggers.)
• Lung Exam: [Auscultation findings] (Only include if clinically relevant to decisions.)
• Secretions: [Character, amount, and impact on management] (Only include if they influence decisions.)

Ventilator Settings and Lung-Protective Metrics

[One-line vent summary] (Optional quick reference, e.g., "VC-AC RR 18, Vt 420 mL (6.0 mL/kg PBW), PEEP 8, FiO2 0.40; Pplat 26; ΔP 16; SpO2 93%")

• Mode and Set Parameters: [Mode], Set RR [value], Set Vt [value] or Set inspiratory pressure [value], PEEP [value], FiO2 [value], I-time [value] or I:E [ratio]
• Measured Values: Exhaled Vt [value], Total RR [value], MV [value], Ppeak [value]
• PBW and Vt/PBW: Height [value] ([measured / stated / unknown]), PBW [value] kg, Vt [value] mL ([value] mL/kg PBW) (If height missing: "Height needed to calculate PBW and verify lung-protective Vt.")
• Plateau Pressure: [Pplat value] cm H2O ([patient passive / actively breathing]; inspiratory hold performed) (If not obtainable: "Unable to obtain reliable Pplat due to [reason].")
• PEEP and Auto-PEEP: Set PEEP [value]; Total PEEP [value], Auto-PEEP [value] (via expiratory hold) (If not formally measured, note suggestive bedside indicators and label as "suggestive, not measured.")
• Driving Pressure: [ΔP value] cm H2O (Pplat minus total PEEP) (If not calculable, state limiting factor.)
• Oxygenation Adequacy: [Current SpO2 or PaO2 relative to target range; note if FiO2 adjustment being considered]

(Do not fabricate unmeasured values. If a parameter was not assessed, omit or state "not assessed" with reason.)

Airway Assessment

• ETT: [Size] mm ID, [depth] cm at [teeth / gums], [centered / deviated], bite block [present / absent] (Include only for ETT patients.)
• Tracheostomy: [Type and size], stoma [appearance] (Include only for tracheostomy patients.)
• NIV: [Interface type and size], fit [adequate / poor], leak [minimal / moderate / significant] (Include only for NIV patients.)
• Securement: [Method], [clean/dry/intact / soiled / loosened], migration risk [absent / present with details]
• Cuff Pressure: [Value] cm H2O (via manometer); [no intervention needed / air added / air removed] to target 20–30 cm H2O (If not checked, document reason and plan to recheck; do not omit.)

Skin Integrity

(Document findings at contact points relevant to current airway device.)

• ETT contact points: Lips, corners of mouth, cheeks — [intact / erythema / blanching / nonblanching / breakdown]
• NG/OG contact points: Nares, philtrum — [findings] (Include only if NG/OG present.)
• Tracheostomy contact points: Stoma margin, neck under ties/flange — [findings]
• NIV contact points: Nasal bridge, cheeks, forehead, ears under straps — [findings]
• If injury present: [Location, size, appearance]; Actions: [barrier dressing / offloading / repositioning]; [Notification status]
• If skin check deferred: [Reason]; reassessment planned [timeframe]

Assessment

• Lung-Protective Status: [Vt mL/kg PBW relative to target; Pplat relative to threshold; driving pressure relative to threshold; concerns for volutrauma, barotrauma, or dynamic hyperinflation]
• Oxygenation: [Within target / above target / below target] at current support; [trend and need for adjustment]
• Airway Safety: [Position and securement status]; cuff pressure [within target / adjusted / not measured]
• Skin/Device Risk: [No pressure injury signals / early warning signs present / active injury requiring mitigation]

Actions Taken

• [Time] — [Ventilator change]: [parameter] [before value] → [after value]; [rationale]
• [Time] — [Measurement performed]: [inspiratory hold / expiratory hold / cuff pressure check]; [result]
• [Time] — Suctioning: [indication], [tolerance], [secretion description]
• [Time] — [Airway repositioning or securement change]: [details]
• [Time] — [Skin intervention]: [barrier / offloading / repositioning]

(If no actions were taken: "No ventilator or airway changes made during this assessment.")

Recommendations

1. [Specific adjustment with target value and timeframe for recheck] (Distinguish protocol-driven adjustments within scope from those requiring provider order.)
2. [Recheck timing for Pplat, auto-PEEP, cuff pressure, or other parameters]
3. [Additional testing if indicated, e.g., ABG with rationale; weaning readiness screen result]

(Avoid vague language such as "optimize vent" or "continue to monitor.")

Notifications

(Include only when safety thresholds exceeded or escalation required.)

• [Time] — Notified [role/name] via [method] regarding [issue]; response: [orders received or plan confirmed]