Documentation Tracheostomy Care
ADNG 1050 Foundations of Nursing Skills
Scenario:
· James Porter is a 68-year-old male with Chronic Obstructive Pulmonary Illness (COPD) exacerbation; respiratory failure requiring mechanical air trudge by map of tracheostomy. He is post-op day 3 following tracheostomy placement.
· Mr. Porter has been progressively weaning from the ventilator and is currently on a trach collar with humidified oxygen at 35% FiO₂. He is wide awake, oriented, but anxious when he feels increased secretions or whisper respiration.
· Whenever you enter the room to your scheduled tracheostomy care, Mr. Porter is sitting ethical in mattress. He gestures in direction of his trach and mouths the notice “clogged.” You behold practical white secretions seen across the interior cannula and hear low gurgling breath sounds. SpO₂ is 90%, respiratory rate 26/min, pulse 102 bpm.
🗂️ Documentation
📍 To full: Upload this document to your pc & occupy it out electronically (presently into the project)
📍 To present it in: Re-upload it to the supreme file/tumble box in D2L.
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✍️ 1. Write a DARP display alongside with:
D: Recordsdata
A: Motion
R: Response/Results
P: Belief
🧑🏫 2. Patient Education (Write as a Script) Benefit brief and to the level.
🔐 3. Nationwide Patient Safety Aim (NPSG) Decide 1 priority NPSG that’s relevant to this whisper and whisper us why in 1 paragraph.
NPSG Chosen: Why It Issues:
📝 4. Nursing Prognosis & Care Belief
✅ 3-Section Nursing Prognosis:
🎯 5. SMART Aim:
Student SMART intention:
🩹 List:
· 2 Interventions to provide this intention
· Rationale for every intervention
· Assessment for every intervention
1. Intervention:
· Rationale:
· Assessment:
2. Intervention:
· Rationale:
· Assessment:
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