ask the patient’s family whether they would like to see the chaplain and whether they would like to be with the patient before, during, and after life-support termination.
Document whether an advance directive is present and whether it matches the patient’s present situation and life-support wishes.
Note that the facility’s risk manager has reviewed the advance directive.
Document that a consent form has been signed to terminate life support, according to facility policy.
Document the names of persons who were notified of the decision to terminate life support and their responses.
Describe physical care for the patient before and after life-support termination.
Note whether the family was with the patient before, during, and after termination of life support.
Record whether a chaplain was present.
Document the time of termination, the name of the health care provider who turned off the equipment, and the names of people present.
Record vital signs after extubation as well as the time the patient stopped breathing, the time pronounced dead, and who made the pronouncement.
Document the family’s response, the nurse’s interventions for them, and postmortem care for the patient.
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Note that the procedure, its risks and advantages, alternative treatments, and the consequences of no treatment have been explained to the patient and that a consent form has been signed.
Record the date and time of the thoracentesis and the name of the health care provider performing the procedure.
Document the location of the puncture site, the volume and description (color, viscosity, and odor) of the fluid withdrawn, and specimens sent to the laboratory.
Chart the patient’s vital signs and respiratory assessment before, during, and after the procedure.
Record any postprocedural tests, such as a chest x-ray.
Note any complications (e.g., pneumothorax, hemothorax, or subcutaneous hematoma), the name of the health care provider notified and the time of notification, orders given, the nurse’s interventions, and the patient’s response.
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Record the date and time of the nursing note.
Chart the name, dosage, frequency, route, and intended purpose of the thrombolytic drug.
Note whether the desired response is observed, such as cessation of chest pain, return of electrocardiogram changes to baseline, clearing of a catheter, or improved blood flow to a limb.
Document the nurse’s cardiopulmonary, renal, and neurologic assessments.
Chart vital signs frequently, according to the facility’s policy.
Record partial thromboplastin time and other coagulation studies.
Frequently assess and document signs and symptoms of complications, such as bleeding, allergic reaction, or hypotension.
Note the time that the nurse notified the health care provider of complications and abnormal laboratory test values, the health care provider’s name, orders given, nurse’s interventions, and the patient’s response.
Document other nursing interventions related to thrombolytic therapy, such as measures to avoid trauma.
Use flow sheets to record the nurse’s frequent assessments, vital signs, hemodynamic measurements, intake and output, IV therapy, and laboratory test values.
Include any patient teaching and emotional support provided.
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speech through the upper airway when the external opening is capped and the cuff is deflated. It also allows easy removal of the inner cannula for cleaning. However, a fenestrated tracheostomy tube may become occluded. When using any of these tubes, the nurse needs to use aseptic technique to prevent infection until the stoma has healed. Caring for a recently performed tracheotomy requires using sterile gloves at all times. After the stoma has healed, clean gloves may be used.
Record the date and time of tracheostomy care.
Document the type of care performed.
Describe the amount, color, consistency, and odor of secretions.
Chart the condition of the stoma and the surrounding skin.
Note the patient’s respiratory status.
Record the duration of any cuff deflation, amount of any cuff inflation, and cuff pressure readings and specific body position.
Note any complications, the time that the nurse notified the health care provider, the health care provider’s name, and orders given.
Record nursing interventions and the patient’s response.
Document the patient’s tolerance of the procedure.
Be sure to report any patient or family teaching and their level of comprehension.
Depending on the facility’s policy, patient teaching may be recorded on a patient-teaching record.
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Record the date and time of the tracheostomy occlusion.
Describe nursing efforts to clear the tube and the results.
Note the time of notifying the health care provider (including name, interventions, and any orders given). If appropriate, record the time that a code was called.
Use a code sheet to document the events of the code. (See “The code record,” page 62.)
Record the patient’s respiratory status during the time of occlusion and after resolution of the occlusion.
Note the patient’s response to the event.
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Record the reason that the nurse performed tracheostomy suctioning as well as the date and time.
Document the amount, color, consistency, and odor of the secretions.
Note any complications as well as nursing actions taken and the patient’s response to them.
Record any pertinent data regarding the patient’s response to the procedure.
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stay with the patient and send a colleague to call the health care provider or a code, if necessary. Extreme caution needs to be exercised when attempting to reinsert an expelled tracheostomy tube because of the risk of tracheal trauma, perforation, compression, and asphyxiation. The institution usually has a procedure to follow because this is a medical emergency. It is imperative to follow the facility’s policy when a tracheostomy tube is expelled. The nurse should reassure the patient until the health care provider arrives.
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