Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Reason for NIV:
(Specify the primary reason for initiating NIV)
Respiratory failure (acute or chronic)
Hypercapnia (elevated carbon dioxide levels)
Hypoxemia (low blood oxygen levels)
Work of breathing (increased respiratory effort)
Postoperative respiratory support
Type of NIV:
(Specify the type of NIV being used)
Continuous positive airway pressure (CPAP)
Bi-level positive airway pressure (BiPAP)
NIV Settings:
(Document the specific settings of the NIV machine)
Interface (mask type – nasal, full face)
Pressure settings (inspiratory pressure (IPAP), expiratory pressure
(EPAP))
FiO2 (fraction of inspired oxygen)
Assessment:
Respiratory status:
Respiratory rate
Oxygen saturation (SpO2)
Arterial blood gas (ABG) results (if available)
Work of breathing (subjective and objective assessment)
Chest X-ray findings (if recent)
NIV tolerance:
Patient comfort and acceptance of the mask
Skin integrity at pressure points
Claustrophobia or anxiety related to NIV
Leak around the mask interface
Gastric distention (bloating)
Response to NIV:
Improvement in respiratory rate and effort
Improvement in oxygen saturation
Improvement in blood gas parameters (if on NIV for hypercapnia
or acidosis)
Ability to sleep comfortably with NIV
Plan:
(Outline the plan for ongoing NIV management)
Continue current settings and monitor response
Adjust NIV settings based on assessment findings
Weaning strategy from NIV (if appropriate)
Goals of NIV therapy (e.g., improve gas exchange, reduce work of
breathing, bridge to definitive treatment)
Need for additional respiratory monitoring (e.g., chest X-ray,
ABGs)
Patient education regarding NIV use and care
Nursing Considerations:
(Document any specific nursing interventions related to NIV)
Skin care at pressure points
Monitoring for signs of aspiration
Humidification settings
Monitoring for leaks and proper mask fit
Patient education and support
Follow-up:
(Indicate how often the patient will be reassessed and the plan for
discontinuation of NIV, if applicable)
Discontinuation of NIV:
(Document the criteria for stopping NIV therapy)
Sustained improvement in respiratory status
Ability to maintain adequate gas exchange without NIV
Resolution of underlying cause of respiratory failure