I need help with my DAR. Since Rapid Response did most of the work, I did not know how to word it.
Anyways, here goes:
Focus: Pulse Ox, Respirations?
D: VS: T: 99.1, P: 104, R: 58, O2Sat: 84% on 40% humidified O2, BP: 98/66. Difficult to arouse, no cyanosis noted. Slightly labored breathing (his respirations had been high all week so it was sort of his baseline), productive cough with copious amounts of thin and green secretions (this was actually bile leaking out of his trach and G-tube which had been suctioned earlier in the morning), adventitious lungs sounds heard on auscultation.
A: Reported to RN. Rapid Reponse Team called. (Do I put this here or do I sort of do a DARAR?) Placed in flat position. (Ok this is where I get confused because I don't remember everything since it happened so fast..) Given 15L O2, EKG leads attached, IV fluids and antibiotics given, placed in Trendelenburg position. Suctioning and ABG taken from RT.
R: T:____(I didn't get the temp), P: 97, R: 24, O2 Sat: 100% on 15L O2 trach, BP: 94/62. Resting and breathing regularly. Lungs clear bilat. Being closely monitored by rapid response team (Can I put this here or should I take it out?)
I appreciate all your help and thank you for any responses!