3. Normal findings — documented with skill justification
Each normal line pairs the finding with the reason a licensed clinician was required and why today, and states values against the ordered parameter or the specific prior value — never bare “WNL” or “at baseline.”
Model normal 1
Nasal-cannula and nares care: the cannula delivering the ordered oxygen with the nares intact — no pressure breakdown at the septum or nares — padding and repositioning per plan, and the mucosa moist with humidification per order. Licensed nares assessment and device care required to prevent a device-related pressure injury and maintain oxygen delivery; a daily skilled need. Supports the Section O oxygen item and the care-plan goal. (Oxygen management routes to the Respiratory reference.)
Model normal 2
Post-sinus-surgery day 3: the nasal packing/splint in place per order without excessive saturation, mild expected oozing only, no fever, and the surgeon’s precautions (no nose-blowing, no straining) observed and reinforced. Skilled post-operative observation and precaution enforcement required; supports Section I and the goal.
