Realistic Patient Rounds Documentation
Patient 1: 57-year-old female – CVA, Type 2 Diabetes
RT: "This is a 57-year-old female, post-CVA with type 2 diabetes. She has a Shiley 8 trach on cool trach collar at 28% FiO2. Target SpO2 is 94-98% per BTS guidelines 1. She's stable, minimal secretions—thin and clear. She's learned to communicate when she needs suctioning, which is great for her autonomy. Completed full trach care: oral care with Yankauer, open suctioning, stoma care, fresh gauze, and changed the 8IC85 inner cannula. No respiratory distress, maintaining sats well."
Provider: "Any signs of aspiration or swallowing issues we should address with speech therapy?"
RT: "Not that I've observed. She's alert and cooperative. Might be worth a swallow eval if we're thinking about advancing diet or decannulation planning."
Provider: "Good. Keep monitoring. Let's get PT/OT involved for mobility assessment and speech for communication/swallow eval. Continue current respiratory support."
Disciplines involved: Respiratory therapy, nursing, physical therapy, occupational therapy, speech-language pathology, endocrinology (diabetes management), neurology (stroke follow-up).
Patient 2: 68-year-old female – COPD exacerbation
RT: "This is a 68-year-old female with COPD, Shiley 8 trach. She's on CMV 14/450/+5/40% overnight but we're weaning her to cool trach collar at 40% during the day per protocol. She gets DuoNeb q6h and budesonide BID 2. This morning she was diaphoretic with increased fremitus at upper chest midline and rhonchi at bilateral posterior bases. She complained of chest heaviness, worried about a collapsed lung. SpO2 was 92-94%, HR 71—not in acute distress but symptomatic. I gave her budesonide and DuoNeb immediately to optimize bronchodilation 2, 3."
Provider: "Did you get a chest X-ray?"
RT: "Not yet—wanted to run it by you first. After treatments, I did trach care and suctioned moderate thin white secretions. Placed her on CTC at 28%. She's been asking to go back on the vent multiple times, says she feels anxious. Her sats have been slowly trending down—started at 96%, now she's 85-89% on my last check. HR stable 64-71, but she's still diaphoretic with vasomotor flushing. No increased work of breathing or tachypnea, but she's clearly tiring out. I put her back on the vent at end of shift."
Provider: "Good call. The gradual desaturation with fatigue despite stable respiratory rate suggests ventilatory muscle fatigue—classic COPD exacerbation pattern. Her anxiety is likely hypoxia-driven 1. Let's get a portable chest X-ray to rule out pneumothorax or infiltrate, check an ABG to assess for CO2 retention and pH 2. If pH is dropping below 7.35 with rising CO2, she may need to stay on the vent longer or consider NIV settings adjustment 4. Continue DuoNeb q6h and budesonide BID 2. Add systemic corticosteroids—prednisone 30-40 mg daily for 10-14 days per ATS/ERS guidelines 2. Check if she needs antibiotics if sputum becomes purulent 2. Keep her on the vent tonight, reassess weaning readiness tomorrow based on ABG and clinical status. Target SpO2 88-92% for COPD patients at risk of hypercapnia 1."
RT: "Should I increase her PEEP or adjust pressures?"
Provider: "Hold on adjustments until we see the ABG and X-ray. If CO2 is climbing, we may need to adjust rate or tidal volume. Let's also make sure she's getting adequate diuresis if there's any fluid overload contributing."
Disciplines involved: Respiratory therapy, nursing, pulmonology, pharmacy (medication management), radiology, laboratory, physical therapy (when stable for mobilization).
Patient 3: 81-year-old female – Post-stroke, trach malposition
RT: "This is an 81-year-old female, post-stroke while visiting [RELATIVE]. She has a Shiley 6XLT with proximal cuff on SIMV 12/380/15/+5/40%. Orders are to wean to PS 15/5/40% when ready 5. Last week her trach dislodged during repositioning—X-ray confirmed malposition and [PROVIDER] repositioned it. I saw the X-ray; it was definitely not in good position. Today she's tachycardic, touching her trach, but not in acute distress. She also has atrial fibrillation, so baseline HR is irregular. I preoxygenated her and open suctioned—copious thick white secretions. Changed the inner cannula, reconnected to vent, completed trach care."
Provider: "What happened with the tachycardia?"
RT: "After she napped, we repositioned her and alarms went off. SpO2 was 99%, but HR jumped to 140-155 and RR to 35-41. [PROVIDER] and I adjusted the trach—it wasn't sitting straight—and tightened the ties. She didn't like it initially but settled down. This happened several more times today. We put a sign above her bed: 'Call RT before moving patient to secure airway.' It seems like the 6XLT isn't fitting her stoma well. We didn't wean her today because her HR was more than 20 beats above her baseline of 77-85 6."
Provider: "Good thinking. The 6XLT is an extra-long tube—might be too long for her anatomy, causing irritation or malposition with movement. Let's consider switching to a standard-length Shiley 6 or even a 7 if the stoma can accommodate it. Get ENT or the trach team to reassess the fit. In the meantime, keep her on current vent settings, no weaning until we stabilize the airway and her HR normalizes. Make sure the ties are secure but not too tight—two-finger rule. Continue close monitoring, especially during repositioning. If she has another episode of acute distress with desaturation or bradycardia, be ready for emergent trach change or reintubation."
RT: "Should we get another X-ray to confirm position now?"
Provider: "Yes, get a portable chest X-ray to confirm trach position and rule out any pneumothorax or other complication from the repeated adjustments. Also check a 12-lead EKG to make sure the tachycardia is just her afib and not something new like RVR or ischemia."
Disciplines involved: Respiratory therapy, nursing, ENT/trach team, cardiology (atrial fibrillation management), radiology, neurology (stroke follow-up), physical therapy (safe mobilization techniques).
Patient 4: 59-year-old female – CVA, recently capped
RT: "This is a 59-year-old female, post-CVA, recently capped. She has NC at 2L ordered but she's not using it—maintaining room air sats fine. She's stable, no respiratory issues, didn't need our assistance today."
Provider: "Good. If she's tolerating capping well and maintaining sats on room air, she's a candidate for decannulation. Let's get speech therapy to do a swallow eval and assess for aspiration risk. If she passes, we can plan for decannulation in the next few days. Continue monitoring."
Disciplines involved: Respiratory therapy, nursing, speech-language pathology, neurology, physical therapy, occupational therapy.
Patient 5: 75-year-old male – Dysphagia, dialysis
RT: "This is a 75-year-old male with dysphagia, Shiley 8 trach on CMV 14/450/+5/30%. He gets DuoNeb q6h 2. He had dialysis this morning, so I prioritized his care—did trach care first, open suctioning, changed inner cannula and HME circuit. Gave DuoNeb before dialysis started. He has copious purulent yellow secretions—been suctioning him frequently throughout the day. He's stable on the vent, HR in the 80s, SpO2 99-100%. Since he's stable with low FiO2 and no contraindications, we started discussing a weaning trial."
Provider: "Purulent secretions—has he been started on antibiotics?"
RT: "I don't think so. Should we send a sputum culture?"
Provider: "Yes, send sputum for culture and sensitivity. Start empiric antibiotics based on local resistance patterns—likely amoxicillin-clavulanate or a respiratory fluoroquinolone per ATS/ERS guidelines 2. The purulent secretions suggest bacterial infection, which could complicate weaning. Hold off on aggressive weaning until the infection is treated and secretions improve. Continue DuoNeb q6h, optimize secretion clearance. Make sure he's getting adequate hydration post-dialysis—dehydration can thicken secretions. Also, get speech therapy involved for the dysphagia—he may need a modified diet or PEG if he's not swallowing safely."
Disciplines involved: Respiratory therapy, nursing, nephrology (dialysis), infectious disease, pharmacy, speech-language pathology, nutrition.
Patient 6: 57-year-old female – ICH, ESRD
RT: "This is a 57-year-old female with ICH and ESRD, Shiley 4 trach. She's on CPAP 12/+5/30% at night 5, 6 and cool trach collar at 28% during the day. She uses a speaking valve, so I always make sure her cuff is deflated for safety—same as checking vent alarms before leaving the room. She manages most of her own care: changes her gauze and inner cannula, lavages herself when I suction. She's been stable all day, very independent."
Provider: "Excellent. She's doing well. Continue current plan. Make sure nephrology is following her for dialysis schedule. If she's this independent, we should start thinking about discharge planning with home ventilation setup."
Disciplines involved: Respiratory therapy, nursing, nephrology, case management/social work (discharge planning), home health/DME company.
Patient 7: 58-year-old male – ICH, non-compliant
RT: "This is a 58-year-old male with ICH, Shiley 5 trach. He's awake but not alert or oriented. He keeps removing his trach collar—I've been putting it back on, but he takes it off again shortly after. His SpO2 drops significantly when it's off. At the start of my shift, his pulse ox wasn't working because it hadn't been changed—I replaced it and found he was desaturating badly without the collar. I had to lavage him to mobilize secretions because he was very dry from not wearing the collar. He needs a lot of one-on-one attention to keep it on, but most of the day it was off."
Provider: "This is a safety issue. He's at risk for hypoxic brain injury if he keeps desaturating. Let's try a few things: first, make sure the trach collar interface is comfortable—adjust the straps, use a softer collar if available. Second, consider a sitter or more frequent nursing checks to redirect him. Third, if he continues to be non-compliant and desaturating, we may need to consider restraints as a last resort, but only after exhausting other options and documenting medical necessity. Also, check if he has any underlying delirium or agitation that we can treat—review his medications, check for infection, electrolyte imbalances, or hypoxia itself causing confusion. If he's hypoxic, that's driving the agitation, so we need to keep him oxygenated. Consider a trial of low-dose sedation if safe, but be cautious with his ICH history. Get neurology involved to reassess his mental status."
RT: "Should I increase his FiO2 to give him more buffer when he takes it off?"
Provider: "Yes, increase to 35-40% to provide a safety margin, but the real issue is keeping the collar on. Work with nursing and the care team on a behavioral plan. Document every intervention and his response."
Disciplines involved: Respiratory therapy, nursing, neurology, psychiatry/behavioral health (if agitation persists), pharmacy (medication review), case management.
Patient 8: 31-year-old male – Cerebral palsy
RT: "This is a 31-year-old male with cerebral palsy, Shiley 7 trach on CMV 12/200/+5/30%. He gets albuterol q6h 2. [RELATIVE] stays with him and helps direct his care—tells us when to suction, when to try weaning. The staff follows her guidance. He's been tachycardic all day, HR 120-140, so he didn't meet criteria for weaning 6 and didn't get albuterol. I checked on him regularly, did trach care when [RELATIVE] requested, made sure he got familiar with me. [RELATIVE] said his respiratory rate calms down when I come in, which felt good."
Provider: "Tachycardia—what's his baseline? Any fever, signs of infection, pain, or anxiety?"
RT: "Baseline is usually lower, but I don't have exact numbers. No fever that I know of. He seems comfortable when I'm there."
Provider: "Let's investigate the tachycardia. Check a CBC to rule out infection, electrolytes to rule out imbalances, and make sure he's not in pain—consider a pain scale appropriate for his cognitive level. If he has a history of autonomic dysregulation with cerebral palsy, this could be baseline for him during stress or stimulation. However, persistent tachycardia can indicate inadequate ventilation, anxiety, or underlying illness. Review his vent settings—tidal volume of 200 mL seems low even for his size; calculate ideal body weight and ensure he's getting 6-8 mL/kg 5. If he's underventilated, increase tidal volume or rate. Also, involve his primary neurologist and consider palliative care or pain management if he has chronic discomfort. [RELATIVE] is a great resource—continue to involve her in care decisions. Hold weaning until HR normalizes and we identify the cause."
Disciplines involved: Respiratory therapy, nursing, neurology, palliative care/pain management, pharmacy, social work (family support).
Patient 9: 72-year-old male – COPD, non-compliant with HFNC/BiPAP
RT: "This is a 72-year-old male with COPD on HFNC 40L/80%—not very compliant with wearing it, also not compliant with BiPAP at night. This morning we found him with his NC off and his sats were in the 70s. We increased his flow from 40 to 45L and FiO2 from 80 to 100% to boost him 1, 7. I kept explaining he needs to wear it, but he was grumpy with me. I suspect some of his attitude is because he's hypoxic 1. I loosened the straps on the interface, which helped him keep it on throughout the day. He also gets DuoNeb q6h and budesonide BID 2. Towards the end of my shift, I asked him why he doesn't like wearing his BiPAP. He said he just doesn't like it. I told him we all don't like taking medications, but we have to or we get sick, and he agreed. I asked if he'd please consider wearing it tonight and working with the night RT, since morning report mentioned he didn't want to allow the RT to help him. He said he would."
Provider: "Good work building rapport. His hypoxia is definitely contributing to his confusion and irritability 1. The fact that he was in the 70s this morning is dangerous—he's at risk for end-organ damage, arrhythmias, and further decompensation. Let's address this aggressively: first, continue HFNC at 45L/100% for now, but our goal is to wean FiO2 once he's stable to avoid oxygen toxicity and CO2 retention 1, 2. Target SpO2 88-92% for COPD 1. Second, get an ABG to assess for hypercapnia and acidosis 2. If his pH is dropping or CO2 is rising, he needs BiPAP or NIV urgently 4, 6. Third, address the non-compliance: involve respiratory therapy, nursing, and social work to educate him on the consequences of not using BiPAP—explain that without it, he'll end up intubated or dead. Use motivational interviewing techniques. Consider a trial of different BiPAP masks to find one that's more comfortable. Fourth, optimize his COPD medications: continue DuoNeb q6h and budesonide BID, consider adding systemic corticosteroids if he's in an exacerbation 2. Fifth, check for underlying causes of non-compliance: depression, anxiety, cognitive impairment, or claustrophobia. If needed, involve psychiatry or palliative care for goals-of-care discussion if he continues to refuse life-sustaining therapy."
RT: "What if he refuses BiPAP again tonight?"
Provider: "Document his refusal, explain the risks clearly, and have him sign an AMA (against medical advice) form if he's competent to make that decision. If he's not competent due to hypoxia-induced confusion, we may need to escalate to ICU for closer monitoring or intubation if he deteriorates. Let's hope the rapport you built helps him comply tonight. Have the night RT check on him frequently and offer support."
Disciplines involved: Respiratory therapy, nursing, pulmonology, social work, psychiatry (if needed), palliative care (goals-of-care discussion), case management.
Patient 10: 57-year-old male – OSA, hypertension, stroke
RT: "This is a 57-year-old male with OSA, hypertension, and stroke history, Shiley 6 trach on CTC 28%. He has sensitive airways—I found out it's because he's on blood thinners and his platelet count is low. So I don't deep suction; I encourage him to cough to move up his secretions, which works well. [RELATIVE] visits every day and is very nice. He's been stable, just needs occasional suctioning."
Provider: "Good awareness of his bleeding risk. Continue shallow suctioning and cough encouragement. Make sure we're monitoring his platelet count and INR if he's on warfarin, or anti-Xa if he's on a DOAC. If his platelets drop further or he has any signs of bleeding (hemoptysis, blood in secretions), let me know immediately. Also, make sure he's on appropriate DVT prophylaxis given his stroke history, but balance that with his bleeding risk. Continue current respiratory support. If he's stable and tolerating the trach well, consider a capping trial to assess for decannulation readiness."
Disciplines involved: Respiratory therapy, nursing, hematology (anticoagulation management), neurology, cardiology, speech-language pathology (if considering decannulation).
Patient 11: 61-year-old female – Respiratory failure, stable
RT: "This is a 61-year-old female with respiratory failure, currently on room air. She gets budesonide BID 8, which I administered. She's stable, didn't require our assistance today."
Provider: "Great. If she's on room air and stable, she's likely recovering well. Continue budesonide BID to prevent exacerbation 8. Monitor for any changes. If she remains stable, we can start thinking about discharge planning."
Disciplines involved: Respiratory therapy, nursing, case management (discharge planning).
Common Pitfalls and Key Considerations Across All Patients:
- Oxygen titration in COPD patients: Always target SpO2 88-92% to avoid CO2 retention 1, 2. Avoid over-oxygenation.
- Weaning criteria: Do not attempt weaning if HR is >20 beats above baseline, patient is febrile, has active infection, or is in respiratory distress 6.
- Trach care and suctioning: Use open suctioning for stable patients on low FiO2; consider closed suctioning for high PEEP or FiO2 to avoid derecruitment. Always preoxygenate before suctioning 7.
- Medication timing: Administer bronchodilators and corticosteroids before procedures like dialysis or physical therapy to optimize respiratory function 2.
- Secretion management: Purulent secretions warrant sputum culture and empiric antibiotics 2. Thick secretions may require increased humidification, hydration, or mucolytics.
- Non-compliance: Address underlying causes (hypoxia, discomfort, cognitive impairment) and involve multidisciplinary team for education and support.
- Trach fit and positioning: Ensure proper trach size and length for patient anatomy. Malpositioned trachs can cause life-threatening complications—always verify with X-ray if concerned.
- Family involvement: Engage family members, especially in patients with complex needs (e.g., cerebral palsy, cognitive impairment), as they are valuable care partners.