Documentation advice on Trach Sx PRN

Specialties Private Duty

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Specializes in Med/Surge, Private Duty Peds.

help with documentation for trach sx prn, i have done this in the hospital setting but not pdn.

in the hospital we had computer charting now i have to do hand written charting and want to be sure i cover myself, plus give a clear picture of why, when and how i suctioned my pt plus their response after sxing.

my pt is only 1 month old and i start this monday with this new case.

i was thinking along the lines of something like this;

pt noted to have raspy breathing, unable to cough up secretion, reps 30, facial grimacing noted. using sterile technigue suctioned thick clear white secretions from trach , no facial grimacing, resp 24 with no raspy breathing noted, pt tolerated suction well and was easliy calmed down when swaddled.

anyways thanks to all in advance for all comments, advice and help!

Specializes in Home Health/PD.

he will likely be on continuous spo2 monitoring, so i normaly include that. we have a few pediatric clients in our agency.

i normaly write:

spo2 decreased to 90% for aprox 2-3 min. tracheal sx x (however many times i did it) thin white secretions returned. sp02 increased to 96% within 5 min after sx.

i also posted a question similar to this one in the pediatric specialty fourm and got some good feedback

I agree with live, you need to note time differential between intervention and positive results. Sao2 would be nice and if the pt is on a ventilator, any information that would be pertinent. Also, I would note amount. ex. small amount, scant amount, moderate amount, copious amount. I know it is not concrete but would be helpful to next nurse. If the secretions are in any way colored - yellow, blood-tinged, green, I would add a temp too. Hope this helps. L

Specializes in Med/Surge, Private Duty Peds.

Thanks for helping with this! I seem to have gotten it .

Only thing is my little one is not on pulse ox, have no way to know what her sats are.

Went with mom for a check up and the doc said he didn't like pulse ox, cause they can be so mis-leading. One can look at the pt and see if she is in any distress. That when he does rounds in the newborn nursey if a neonate is on pulse ox and it read 70% and the kid is certainly pink then his o2 levels are not 70% just because a machine says it is.

She is only on apnea moniter due to trach. She can breath thru her nose some but has the trach due to choanal stenosis. You can definetly tell when she needs to be sx. Her resp increase and she gets that slight blue tinge around her lips and nose. After sxing, she turns pink again!

Thanks againfor the help!!

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