Question if Respiratory failure appropriate
I am looking for feedback about whether or not this is a query opportunity.
The pt presented s/p exp lap and small bowel resection. She recieved an extra dose of dilaudid in PACU and shortly after on the unit a rapid response was called. This is what was documented:
".+Found unresponsive to pain and verbal stimuli,resp slow,agonal breathing.Sat 84 % 2L.ARapid response called and 100 % non rebreather applied.PCA Morphine stopped.IVF maint."
"RRT called unresponsiveness. O2 sat 57%"
The patient recieved narcan and was placed on 100% NRB.
The pt presented s/p exp lap and small bowel resection. She recieved an extra dose of dilaudid in PACU and shortly after on the unit a rapid response was called. This is what was documented:
".+Found unresponsive to pain and verbal stimuli,resp slow,agonal breathing.Sat 84 % 2L.ARapid response called and 100 % non rebreather applied.PCA Morphine stopped.IVF maint."
"RRT called unresponsiveness. O2 sat 57%"
The patient recieved narcan and was placed on 100% NRB.
Comments
Dawn M. Vitalone, RN
Clinical Documentation Improvement Specialist