help on charting and preventing pneumonia

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I have a patient with throat cancer and muscle weakness. Pt has heavy amounts of secretions with cough. He gets breathing treatment from me prn when sob. My job has inserviced us that pneumonia will be reportable soon and we must be prevent it or were at fault. Ive tried multiple times too suction the patient oral and nasal suction but fights! And good at pushing everything away. So how can i chart correctly on what ive been trying to do and what can i do to try prevent pneumonia??

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I have a patient with throat cancer and muscle weakness. Pt has heavy amounts of secretions with cough. He gets breathing treatment from me prn when sob. My job has inserviced us that pneumonia will be reportable soon and we must be prevent it or were at fault. Ive tried multiple times too suction the patient oral and nasal suction but fights! And good at pushing everything away. So how can i chart correctly on what ive been trying to do and what can i do to try prevent pneumonia??

I think its a bit hard to suction such a patient considering the site of the ca. and i think the best way now is to give cough expectorant,chest physio with incetive spirometry.May be try that

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What they are looking at is the idea that hospital-acquired pneumonia (HAP) is a bad thing and reimbursement for it will drop. Since a lot of HAP is related to poor respiratory and oral care, this is not unreasonable.

If your patient came in with huge respiratory secretions, he didn't get pneumonia while in your facility. If he refuses care, which is his right to do, you document, document, document what you observed, what you tried to teach him, what he said, and what you did or attempted to do and what the results were. If reimbursement is denied for him, your billing office has a nurse in there to read your documentation which will support the appeal.

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Chart that you got the pt out of bed, did the oral care, gave your antibioitcs, encouraged coughing and deep breathing. Chart refusals too.

Is this patient alert enough with a strong enough cough to be left with a yankeur suction with instructions to suction out his own mouth? Sometimes resistance can be overcome with a little sense of control.

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Specializes in Critical Care, Education.

Seems like the patient's physician should be involved in this effort. Have you discussed this with her/him about supplementing your efforts with antimicrobial mouth hygiene products or even escalating treatment to include a trach & mechanisms to occlude oropharangeal secretions to prevent pulmonary aspiration & bacterial colonization. You may also want to talk to your wound care nurse - they have all sorts of creative ideas for handling drainage that you may be able to adapt for use in this situation.

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Seems to cough alot and sounds like hes gurgling, almost drowning, his secretions then tries spitting them out but not alert enough.

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Chart that you got the pt out of bed, did the oral care, gave your antibioitcs, encouraged coughing and deep breathing. Chart refusals too.

Is this patient alert enough with a strong enough cough to be left with a yankeur suction with instructions to suction out his own mouth? Sometimes resistance can be overcome with a little sense of control.

Pt is alert but not oriented. Fluctuates when trying to make needs known. Doesnt get up. I try putting the yanker tube in pts mouth but closes it so hard and pushes my hand away. Tried nasal suction and same thing.

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In this case, I think it would be wise for the hospital to establish that the pt already had pneumonia when he was admitted. Obviously you can't chart such a statement, but your careful charting of his symptoms will back the hospital up.

When I was an aide on a post op oncology floor, preventing HAP was a big issue. Early and frequent ambulation, incentive spirometry, and keeping the HOB elevated. Make sure all these interventions are charted.

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I agree with the above posts. Most importantly chart refusal and your attempt at suctioning, and the difficulties that prevented you from doing so .

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