I just got my licence this year and I am starting a home health job. The person has a trach, g-tube, and is on a vent. at night. I will be watching this person through the night...
What exactly do I chart??? Unless there are complications or meds, what else should I be looking for and charting hourly if the person is just resting peacefully?
Apr 11, '11
Chart vitals. Chart that the patient is not in distress, safety precautions taken and needs anticipated and met.
Learning to chart well takes some time. Spend those night shifts looking through the old charts.
Do you have to chart q1 or q2hours?
Apr 19, '11
I didn't forget that I had this open. (Family issues
I was planning on looking at the old charting but there is only one problem: I will be the first nurse that they have so I have nothing to look over.
As far as charting q1 or q2, they really didn't give me an answer when I asked that question. The director just said to chart when I give meds or if anything happened, how they tolerated the meds and of course head-to-toe... that sort of thing. Lucky for me they gave me a sample charting sheet and gave me verbal instructions to use the sample as guide. The sample has charting q2 hours, when nothing else is going on.
Last edit by CalinurseDiana on Apr 19, '11
: Reason: added info
Apr 19, '11
At the beginning of your shift, chart your full assessment including vital signs. If your nurses note has a list of checkoff-type assessment questions, you can get by with a couple of sentences in your narrative about your assessment.Then chart, as you were instructed, every two hours and when you give meds. Of course, if there is a problem or change of condition, chart about that. At the end of your shift chart that the patient is ok, has no discomfort, etc., and the name of the family member or nurse that you reported off to and left the patient in the care of. When I was not required to chart every two hours on night shift, I charted my assessment when I took over care, once in the middle of the shift, and the end of shift turn over.
Apr 19, '11
When the patient is quietly sleeping, you cover that with stating their eyes are closed and describing the nature and quality of their respirations. If they are on continuous oxygen sat monitoring, you can include that reading.
Apr 20, '11
Thank you all for this information. It has really cleared up a lot of things for me. Tonight is my first night on. Wish me luck
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