DAR Help

[abak2kab]

Hi Everyone,

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!

-A.

[opensesame]

This actually looks pretty good, I take it your assignment is to write a DAR note?

Just a few suggestions:

in D: Need to note RR along with labored breathing and O2 sats. Need to note WHAT specific adventitious LS you heard (crackles, wheezes, etc). For the secretions, I would chart "bilious appearing" as sometimes infected lung secretions (as with pneumonia) can have a green tinge. This is distinctly different in appearance than bile even though they are both green.

in A: I think you are right to note that RR team was called, sometimes in my note I will refer to what other members of the team did by just saying "refer to XYZ's note". (I am sure the RR is required to write a note.) If you knew what the HR rhythm was on the monitor when they put it on, I would put that in the note.

in R: I would take the part out about being monitored by the RR team as they are not going to be responsible for the patient for the rest of the shift (I assume.) Since you noted difficult to arouse in your "D" section, you must address that here (is that improved/changed?)

[abak2kab]

Thank you so much! I had a friend help me since I was trying to finish this before the weekend ended but you put everything into perspective for me. My assignment was actually a case study but for some reason we had to turn in our revised dar and I forgot to ask my instructor specifically how I could do better on it. And thanks for the tip on the secretions..I had no idea!