Documentation Tracheostomy Care
ADNG 1050 Foundations of Nursing Skills
Scenario:
· James Porter is a 68-year-old male with Chronic Obstructive Pulmonary Disease (COPD) exacerbation; respiratory failure requiring mechanical ventilation via tracheostomy. He is post-op day 3 following tracheostomy placement.
· Mr. Porter has been gradually weaning from the ventilator and is currently on a trach collar with humidified oxygen at 35% FiO₂. He is awake, oriented, but anxious when he feels increased secretions or difficulty breathing.
· When you enter the room for your scheduled tracheostomy care, Mr. Porter is sitting upright in bed. He gestures toward his trach and mouths the word “clogged.” You notice moderate white secretions visible around the inner cannula and hear coarse gurgling breath sounds. SpO₂ is 90%, respiratory rate 26/min, pulse 102 bpm.
🗂️ Documentation
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To complete: Upload this document to your computer & fill it out electronically (directly into the assignment)
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To turn it in: Re-upload it to the correct file/drop box in D2L.
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1. Write a
DARP note including:
D: Data
A: Action
R: Response/Results
P: Plan
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2. Patient Education (Write as a Script) Keep short and to the point.
🔐 3. National Patient Safety Goal (NPSG) Choose 1 priority NPSG that is relevant to this scenario and tell us why in 1 paragraph.
NPSG Chosen:
Why It Matters:
📝 4. Nursing Diagnosis & Care Plan
✅ 3-Part Nursing Diagnosis:
🎯 5. SMART Goal:
Student SMART goal:
🩹 List:
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2 Interventions to accomplish this goal
· Rationale for each intervention
· Evaluation for each intervention
1. Intervention:
· Rationale:
· Evaluation:
2. Intervention:
· Rationale:
· Evaluation:
🎥Video Review:
