Patient Name : FJ Age: 53years Code Status: Full Code

Patient Name : FJ Age: 53years Code Status: Full Code Allergies: No known allergies Last Bowel Movement : Sept 17 Chief complaint: Trach Dislodge Admit reason : Tracheostomy Dislodgement My Weekly Goal : I will focus on improving my competency in patient-centered care and documentation with minimal assistance Patient Details: The patient is a 53-year-old female with PMHX of HFpEF, aflutter, T2DM, chronic hypoxemic hypercapnic respiratory failure, super morbid obesity, anemia, and depression. Trach placement was placed 3 weeks ago due to prolonged intubation 2/2 pneumonia. The patient was brought in by EMS from her ECF after the trach was dislodged. Per the patient, the EMS reported staff at ECF was cleaning the trach and was unable to reinsert it due to the trach site closing up. They proceeded to call 911, and the patient was brought into the ED. On arrival to ED, ENT was able to dilate with ET balloon and 6 shiley was placed. She was put on Airvo 15L 32 FiO2 and has been in the 90-95s. On assessment, the patient is resting on the bed and oriented x4, with no apparent distress. She denied current chest pain, palpitations, shortness of breath, headache, nausea, vomiting or any other symptoms. No recent health concerns. Past Medical History HFpEF, Aflutter, T2DM, chronic hypoxemic hypercapnic respiratory failure, super morbid obesity, anemia, and depression Past Surgical History Bronchoscopy, Cardiac Surgery as a child(hole in her heart), Dilation/Curettage x4 miscarriages, Tracheostomy. Vital Vitals Morning Afternoon HR 86 93 RR 16 16 Sat O2 91 94 BP 101/60 137/63 Temp 97.4 98 Pain 0 0 Medication Ammonium lactate Top 1 application topical BID daily Cetirizine tab 10mg PO daily Ferrous sulfate EC tab 325mg PO daily3 Furosemide 40mg PO daily Humalog insulin correction scale Lantus insulin injection 25unit sq at bedtime Magnesium oxide 0.4Gm Gastric BID daily Venlafaxine immediate release 75mg PO BID daily Vitamin B12 PO 1000mcg PO daily Labs CBC CMP WBC – 8.9 Sodium 133 RBC – 4.75 Potasium 3.6 PLT – 40.9 Chloride 101 HGB 12.7 CO229 MCV 86.1 BUN 9 MCHC 31.1 Creatinine Serum 0.61 MCH 26.7 Glucose 119 RDW 19.4 Calcium 8.7 MPV 10.0 Phosphorus 3.7 Magnessium 1.6 Anion Gap 3 eGFR 107 Physical Exam General Appearance: Well developed, No Acute Distress Skin: warm and dry with no rash Head/Scalp: Normocephalic. No evidence of trauma Eyes/Nose/Ears/Mouth/Throat: Pupils are symmetry and reactive to light. Conjunctiva and eyelids are normal Neck/Thyroid: No JVD, 6 Shirley cuffless secured with trach ties Chest/Respiratory: Clear to auscultation bilaterally. Not labored, room air, No stridor or wheezing. On Airvo Cardiovascular: Regular sinus rhythm, no murmurs, rub or gallop. S1 and S2 normal Abdomen/ GI: soft, non distended Musculoskeletal: Joints and limbs are grossly normal. Motor strength is grossly normal Neurological: Oriented x4 Psychiatric: cooperative and pleasant Pulses/Edema: 2+ radial and pedal pulses, marked BLE edema/Lymphedema, trace BUE edema Problem List Dislodged Trach Chronic Hypoxemia Hypercapnic Respiratory failure Plan Airvo PRN albuterol nebs Monitor on continuous pulse ox T2DM HFpEF Afflutter Super morbid Obesity Task: Thoroughly discuss the assigned Weekly QSEN competency : “Quality Improvement” and how you integrated it into the care of your patient(s). Using the assigned QSEN competency of the week : “Quality Improvement” Provide three (3) specific and separate examples of how either you can use the QSEN competency, or your observation of someone’s else’s use of the QSEN competency, or failure to do so. Thoroughly discuss how you incorporated the Franciscan Values: “reconciliation” into the care of your patients or families. These values are grounded in prayer: Provide at least 3 examples in each journal entry of your use of the Franciscan Value “reconciliation” chosen for the week, or how you saw another person portray of that Value. Thoroughly discuss at least one of the following nursing concepts each week and how you integrated it into the care of your patient: Cultural Competence Provide three (3) examples in each journal entry of the chosen concept for the week. You may discuss your use of the concept or your observation of others’ use of the concept. All applicable reference should be cited

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