VIEW COMPLETED NOTE

Patient identified by name, ID with picture and facial recognition. SN performed skilled observation and assessment of all body systems from head to toe. No signs or symptoms of acute distress noted. SN assessed home for safety & Risks for fall. Safety & preventative education. SN performed skilled observation and assessment, monitored vital sign and blood pressure and found them within normal limits. SN assessed mental and physical status, evaluated compliance, effectiveness and side effects of medication, diet and nutritional status, and patient’s and/or caregiver’s knowledge of signs and symptoms of complication. Cleaning performed using sterile technique per physician’s orders and according to policy and procedure. Cleaning performed using sterile technique, inner cannula unlocked and removed, soaked in NS, dry secretions removed with brush and rinsed with NS, dried with 4×4 gauze and pipe cleaner, cannula replaced and locked in place. Cleansed tracheostomy site using NS moistened in cotton tip applicators and 4×4 gauzes and dried with 4×4 gauze. Ostomy site tissue intact, nocomplications observed. Patient denies discomfort after procedure completed. Supplies used for suctioning discarded in biohazard bag., Suctioning performed per physician’s orders and according to policy and procedure using sterile technique and infection control. Patient placed in semi-Fowler’s position, suction control set at 100 mm Hg vacuum; suctioning performed using sterile technique, catheter inserted 1 to 2 cm beyond end of trachtube until resistance met and cough elicited, intermittent suctioning performed while rotating the catheter back and forth and withdrawing over a 5 to 10 second period resulting in moderate amounts of white, tenacious, yellow tinged secretions. Patient is incapable of perform tracheostomy care due: complexity of procedure, functional, physical, and mental limitations. There is no caregiver willing and able to perform this skilled care. Instructed patient/caregiver contact your healthcare provider or physician immediately: if you have an irregular heart rate, your fluids or using cool mist humidification. If you have any other problems or concerns. If you feel increased pain or discomfort. Patient/caregiver verbalized understanding teaching.