I had the most exhilarating shift that I have ever experienced as if my mind thinking of another dimension.
Of course, everything should be noted in the chart. So here how it goes on my fdar charting. I was able to come up with 3 problems which made my shift extended.
F=Hemoptysis (4:30AM) (my shift would have been benign for all sake)
D= (+) hemoptysis, 300 cc blood
= c O2 via NC @ 6LPM
= c IVF patent and infusing well
A= ice cubes given orally (this is to stop bleeding orally)
= Tranexamic 2 grams given as ordered (this is an anti-fibrinolytic drug)
= referred to Dr. blabla; seen and examined
R= still c hemop
at the same time, patient experienced...
F= Difficulty of breathing
D= c O2 sat=81% BP=90/70 PR=120 RR=34 (this is already moderate hypoxemia i guess)
= gasping for breath
= use of accessory muscles
A= placed on high back rest
= seen and examined by Dr. blabla
Mr. X was still in distress...
F=Desaturation
D= O2 sat=41% BP= 90/60 PR=125 RR RR=28 (this is already severe hypoxemia, of course)
A= Code Blue activated (i believe it was a silent code, not like in USA its completely announced)
= Dr. blabla explained and consented for intubation
= Diazepam 5mg IV given as ordered prior intubation
= Intubation done by Dr. blabla
= ET inserted, size 8 @ level 22
= ambubagging and suctioning done while waiting for mech. vent. (this made me very exhausted, thanks God)
= foley cath (Fr. 16) inserted aseptically
= continuous monitoring of V/S done
R= responsive to calls (thanks God he can hear me singing, LOL)
= latest V/S: BP=140/70 O2 sat=96% PR=110 RR=28
= endorsed to 7-3 shift for continuity of care
that's how my charting ended in a concise and detailed manner.
will wait for another exciting shift to get my life miserable and exhausted...hehe lol