When weaning a client from the ventilator, what should the nurse document in addition to routine assessments performed for any client requiring mechanical ventilation with an artificial airway in place?
1. The details and length of the weaning trial
2. The client's oxygen saturation
3. The client's breath sounds
4. The client's respiratory rate
1
Rationale 1: When weaning the client from mechanical ventilation, it is important to document the length of time the client tolerated being off the ventilator, and how the client tolerated the process.
Rationale 2: Oxygen saturation would be documented for any client receiving mechanical ventilation.
Rationale 3: Breath sounds would be documented for any client receiving mechanical ventilation.
Rationale 4: Respiratory rate would be documented for any client receiving mechanical ventilation.
Global Rationale: When weaning the client from mechanical ventilation, it is important to document the length of time the client tolerated being off the ventilator, and how the client tolerated the process. Oxygen saturation, breath sounds, and respiratory rate would be documented on any client requiring mechanical ventilation.
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