UNIT FOUR
582
Clinical Skills and Care
Skill 28.5 (continued)
Sample of Electronic Documentation
Pt Sel
Log Off
Logged in: Hiam, Judith
Documenting in current time and date
Patient Charting Vital Signs Order Entry Order Review Patient Teaching Patient CARD Patient Data M.A.R Care Plans Reports
Page 1
To Begin: Double-Click the Report Admission History Care Plans Discharge Plan Discharge Summary/ Instructions MAR Nurse's Notes Patient Card Patient Teaching Vitals/I & O
Nurse’s Notes
Scenario #: None
Nurse: Judith Hiam Number: N2 Judith
Patient: ANDRE ANDERSON Number: 32
Printed: mm/dd/yyyy 15:09
Physical Assessment Phase: 0 Respiratory Treatments Respiratory Treatments and Care Notes mmddyyyy 21:40 Judith Hiam
SaO2 on room air was 90%. Breath sounds clear to auscultation, resp unlabored at 24/min. Notified Dr. Schiling. O2 applied at 2 L/min via nasal cannula. SaO2 after oxygen applied is 94%.
Respiratory Treatments and Care mmddyyyy 21:40 Judith Hiam
Patient Response mmddyyyy 21:40 Judith Hiam
Turn, cough, Deep Breathe per orders
Reports breathing easier
mmddyyyy 21:40 Judith Hiam O2 in use mmddyyyy 21:40 Judith Hiam
mmddyyyy 21:40 Judith Hiam
Compliant with treatment regimen
mmddyyyy 21:40 Judith Hiam
Continuous Pulse Oximeter in use
Voices understanding of teaching
Skill 28.6 Performing Nasopharyngeal and Oropharyngeal Suctioning
Assessment Steps 1. Verify the health-care provider’s order for nasopharyngeal or oropharyngeal suctioning. Note: In some hospital settings, a health-care provider’s order may not be required for suc- tioning. Follow your facility’s policy. 2. Assess the patient and the need for suctioning. Auscultate the lungs and listen for rattling or moist sounds in the airways as the patient breathes, in addition to oxygen saturation read- ings, color, and respiratory rate and rhythm. Planning Step 1. Gather needed equipment and supplies: sterile suction cath- eter and glove kit; saline; a sterile basin or cup to hold the saline; water-soluble lubricant; goggles and a mask; or a mask, face shield, and gown. For oropharyngeal suctioning, obtain a Yankauer or tonsil-tip suction device and clean gloves. Intervention Steps 1. Follow the Initial Implementation Steps located on the inside front cover and assist the patient to a semi- or high Fowler’s position. For Nasopharyngeal Suctioning 2. Ensure that the connection tubing is attached to the suction catheter on the wall and set the regulator at 80 to 120 mm Hg. Test the suction by placing your thumb over the tubing to determine that it is working correctly.
3. Open the sterile saline and mark it with the date and time if it is a multiuse container to ensure that it is not used beyond 24 hours or hospital policy. 4. Pour some saline into the sterile basin or cup. This will be used to moisten and rinse the suction catheter between suctioning. 5. Open the water-soluble lubricant. 6. Put a clean glove on your nondominant hand for controlling the suction. 7. Open the sterile catheter and glove kit. Put the sterile glove in the kit on your dominant hand because this is the hand that will hold and manipulate the suction catheter. If two gloves come in the kit, put them both on, but consider your nondominant hand as not sterile. 8. Hold the sterile suction catheter in your sterilely gloved dominant hand, being careful to keep the tip within your grasp to prevent it from becoming contaminated. 9. Hold the nonsterile connection tubing connected to the suc- tion canister in your nondominant hand. 10. Hold the proximal end of the sterile suction catheter in your dominant hand and connect it to the nonsterile connection tubing without contaminating your dominant hand. 11. Place the thumb-valve portion of the sterile suction catheter in your nondominant hand.
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