What are the key components of uneventful monitoring for intubated patients?

Ward Notes for Uneventful Monitoring of Intubated Patients

For intubated patients requiring routine monitoring, document continuous capnography, pulse oximetry, heart rate, blood pressure, and respiratory parameters at minimum every 10-15 minutes in a time-based record, with uninterrupted monitoring continuing until extubation or transfer. 1

Essential Monitoring Parameters

Respiratory Monitoring (Highest Priority)

Capnography is mandatory and must be continuous with waveform display for all intubated patients, as it is the gold standard for confirming correct tube position and detecting ventilation adequacy. 1 The exact end-tidal CO₂ value is less important than continuous assessment of respiratory gas exchange. 1

• Airway pressure monitoring including peak, plateau, mean, and end-expiratory pressures displayed as waveforms provides breath-by-breath information about chest-lung mechanics. 1
• Tidal volume, respiratory rate, and minute volume are key components that must be documented. 1
• Pulse oximetry must be continuous with oxygen saturation recorded at each interval. 1

Cardiovascular Monitoring

• Heart rate must be continuously monitored and recorded at minimum every 10-15 minutes. 1
• Blood pressure should be documented at the same intervals, though in stable patients this may be extended to 10-15 minutes if frequent cuff inflation causes agitation. 1
• ECG monitoring is recommended though not mandatory in patients without underlying cardiopulmonary disease. 1

Documentation Requirements

Time-Based Recording Format

Record all vital signs at minimum every 10-15 minutes in a structured, time-based format that includes: 1

• Date and time of each entry
• Oxygen saturation (SpO₂)
• Heart rate (HR)
• Blood pressure (BP)
• Respiratory rate (RR)
• End-tidal CO₂ (EtCO₂) value or waveform status
• Tidal volume and minute ventilation
• Level of consciousness/sedation depth
• Temperature (at appropriate intervals)

Ventilator Settings Documentation

For mechanically ventilated patients, document: 1

• Mode of ventilation
• Set respiratory rate
• Tidal volume or pressure support level
• FiO₂ (fraction of inspired oxygen)
• PEEP (positive end-expiratory pressure)
• Peak inspiratory pressure
• Plateau pressure (if applicable)

Sedation and Medication Documentation

Document the name, route, site, time of administration, and dosage of all drugs administered, including sedatives, analgesics, and paralytics. 1 For continuous infusions, record the rate in mcg/kg/min or mg/kg/h. 2

• Sedation level assessment should be documented using a standardized scale at each monitoring interval. 1
• Neuromuscular blockade monitoring with train-of-four ratio should be documented if paralytics are used, as residual blockade increases risk of complications. 1

Clinical Assessment Documentation

Airway Assessment

Visual inspection and auscultation findings should be documented, noting: 1

• Tube position at the teeth/lips (cm marking)
• Bilateral breath sounds present
• Absence of air leak around cuff
• Secretion character and quantity
• Any signs of airway obstruction or malposition

General Status

Document: 1

• Level of consciousness/response to stimuli
• Pupil size and reactivity (if not sedated)
• Skin color and perfusion
• Urine output (if catheterized)
• Any changes from baseline status

Sample Documentation Format

Example entry structure:

Time: 14:00

• SpO₂: 98% on FiO₂ 0.40
• HR: 78 bpm, regular rhythm
• BP: 128/76 mmHg
• RR: 14 breaths/min (ventilator set 12)
• EtCO₂: 38 mmHg, normal waveform
• Tidal volume: 480 mL, Minute ventilation: 6.7 L/min
• Peak pressure: 22 cmH₂O, Plateau pressure: 18 cmH₂O
• Sedation: RASS -2, propofol 30 mcg/kg/min
• ETT: 7.5mm at 22cm at lips, bilateral breath sounds clear
• Patient comfortable, no signs of distress

Critical Pitfalls to Avoid

Never rely on pulse oximetry alone as the primary indicator of ventilation adequacy, as there can be significant delay between inadequate ventilation and desaturation, especially with supplemental oxygen. 3 Capnography detects hypoventilation immediately. 1

Do not document vital signs less frequently than every 15 minutes during the intubation period, as studies show most serious adverse events occur within 25 minutes of medication administration, with median time of 2 minutes. 1 A 2.5-minute interval is recommended during periods of hemodynamic instability. 4

Monitoring must continue uninterrupted during any patient transfers including to radiology, between units, or to the ICU, maintaining the same level of monitoring throughout. 1

Abrupt discontinuation of sedation should be avoided without appropriate weaning, as this may result in rapid awakening with anxiety, agitation, and resistance to mechanical ventilation. 2