If anyone has a few seconds could you please help me with this? I have to get tested out tomorrow on these skills, and part of the test is proper documentation...I won't be able to bring any notes in, but I want to have a good idea on how to document properly. That is something we never really went over and my skills book is pretty limited on what/how to chart.
Any help is greatly appreciated!
NG tube insertion/removal
Foley cath insertion/removal
Wet to damp dressing change
Thank you so so much, sorry for the short notice, ugh.
Dec 5, '05
Here are some examples from my skills book.
10/13/00 1400 16 Levin tube inserted in right nostril. 300cc of dark green fluid returned. Vomited 100 ml. of dark green fluid during tube insertion. Tube taped to right nare. Pt states nausea and abdominal pain relieved after tube insertion. Tube connected to low, intermittent suction.
10/13/00 0930 No. 16 Fr. Foley with 10ml water into balloon inserted with sterile technique. Closed drainage system attached. Pt expressing slight discomfort from ballon. Approximately 200 ml of dark yellow clear urine obtained into bag. Catheter taped to inner left thigh. Bed down, rails up, call light within reach.
10/13/00 0800 Wound packed with fluffed 4x4's moistened with normal saline. Abdominal dressing secured to wound with paper tape. Sterile technique maintained. Wound 20x30 cm area of black eschar. Wound yellow at base with pink tissue at the edges. Pt tolerated the procedure with no discomfort.
Source: Susan C. deWit, Fundamental Concepts and skills For Nursing
This is not word for word, but you get the idea. I find charting very challenging. Sometimes it takes me awhile to formulate in my brain what I want to say. Anyways hope this helps.
Dec 6, '05
Thank you so much! This is perfect...I really appreciate you answering this tonight. :typing My skills book doesn't have examples like these....I wish it did though.