Patient Care Rounds Tracheostomy Care Results: Nancy Gilbert

Patient Care Rounds Tracheostomy Care Results: Nancy Gilbert

how are you today

Greet

Hello.

how do you feel

Question

I feel like I’m choking on my own snot, so . . . super. My trach needs suctioning.

sorry for that

Empathize

Thank you for saying that.

when did the symptoms start

Question

I’ve been sick a week. It started off just uncomfortable, but then it got harder to catch my breath. Also been coughing, and it hurts my lungs to breathe too deeply.

what makes the symptoms worse

Question

I feel worse laying down. And taking a deep breath is painful in my lungs.

can you describe the pain

Documentation / Electronic Health Record

Documentation

Flowsheets

Documentation

Student Documentation

Model Documentation

Subjective

feeling uncomfortable

Ms. Nancy Gilbert is a 65-year-old female with a permanent tracheostomy resulting from laryngeal cancer 5 years ago that was admitted for community-acquired methicillin-resistant Staphylococcus aureus (MRSA) pneumonia.

Upon initial assessment, she is alert and oriented to person, place, time, and situation. She states that she has had symptoms for the past week including a productive cough, fever, “aching” pain in her lungs, and throat pain related to clearing sputum. She rates her current pain level at 3 out of 10.

She states that she quit smoking when she was diagnosed

SBAR

Prompt	Learner Response	Model Response
Prompt: Hi. I’m ready to take over care of this patient. Could you tell me what the situation is?	User Response 65 year old femaalle with pneoomiaa after Ms. Nancy Gilbert is a 65 year old female traachestomy	Model Note with a permanent tracheostomy resulting from laryngeal cancer 5 years ago that is admitted for community-acquired methicillin-resistant Staphylococcus aureus (MRSA) pneumonia.
Prompt: What background information do I need to know?	User Response she has symptoms of productive cough and fever	Model Note She states that she has had symptoms for the past week including a productive

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