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Basic airway management is a concept and set of medical procedures performed to prevent and treat airway obstruction and allow for adequate ventilation to a patient's lungs. [1] This is accomplished by clearing or preventing obstructions of airways. Airway obstructions can occur in both conscious and unconscious individuals.
The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. [1] [2] [8] The length and focus of each component of a SOAP note vary depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status.
A progress note is the record of nursing actions and observations in the nursing care process. [13] It helps nurses to monitor and control the course of nursing care. Generally, nurses record information with a common format. Nurses are likely to record details about a client's clinical status or achievements during the course of the nursing care.
For example, digital intubation may be used by a paramedic if the patient is entrapped in an inverted position in a vehicle after a motor vehicle collision with a prolonged extrication time. The decision to use a straight or curved laryngoscope blade depends partly on the specific anatomical features of the airway, and partly on the personal ...
Progress Notes are the part of a medical record where healthcare professionals record details to document a patient's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. [1] Reassessment data may be recorded in the Progress Notes, Master Treatment Plan (MTP) and/or MTP review. Progress ...
Tracheal intubation is often used for short-term mechanical ventilation. It's when a tube is inserted through the nose (nasotracheal intubation) or mouth (orotracheal intubation) and advanced into the trachea. In most cases tubes with inflatable cuffs are used for protection against leakage and aspiration.
The pre-hospital setting provides unique challenges to management of the airway including tight spaces, neck immobilization, poor lighting, and often the added complexity of attempting procedures during transport. When possible, basic airway management should be prioritized including head-tilt-chin-lift maneuvers, and bag-valve masking.
An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care.