A & O while intubated

jemb · Oct 6, 2004

Seems like no one would have a good argument against it if you charted that you asked her "..insert specific question...", to which she nodded head in a yes (or no) response. I don't know why anyone would have a problem with your charting that you asked her to hold up the # of fingers to indicate her pain level, and that she held up 8 fingers.

If, however, the charting were ambiguous, such as the patient 'indicated that her pain level was 8/10', without charting how you were able to communicate clearly with her, I can see that there could be a problem.

Think maybe you just needed to change the wording?

CRNAsoon · Oct 6, 2004

Thanks for your input; however, I did chart extensively about my methods of data gathering, like you indicated in your reply.

The only thing I can think of is that maybe she didn't want me to indicate 8/10 on the flow sheet (we have a flow sheet that we leave out so the docs can walk by and quickly assess pt status). I indicated the pain level on the flow sheet and then turned it over to the narrative section and fully described the situation.

Tweety, BSN, RN · Oct 6, 2004

I don't know how you could chart in good conscious that the "patient might be in pain" when the patient clearly indicated that she was. Chart the truth, what you assessed and how you assessed it. Is there an educator that you can speak to about this?

Of course, there is no way to assess a vented or trached persons orientation. I was told this in an inservice by or educator the other. When doing a Glasgo coma scale on a trached patient, even if they are writing, she says we have to put nonverbal. To me that falsely lowers their scale. So maybe this is what your preceptor is saying.

Sounds like your conscientious. Good luck.

dazzle256 · Oct 6, 2004

I recently cared for a post-surgical patient that was intubated and c/o pain. Even though she was being ventilated, I was able to ask a series of questions in order to communicate with her and assess her cognitive status. She seemed very lucid and was able to nod appropriately, mouth words, and use hand gestures to indicate her responses. When communicating regarding her pain, I explained the 0/10 pain scale and asked her to show me the number of fingers that corresponded with her pain level. She raised eight fingers without hesitation. I went on to ask if this was a tolerable level for her and she nodded "no". I specifically asked if she would like medication for her pain and she nodded "yes".
When I charted my assessment and my intervention, my preceptor stated that an intubated pt could not have a pain number. Because of the nonverbal status there was not any way we could be certain of her responses so we should just chart that the patient was being ventilated and that she might be in pain. This frustrates me so b/c I was able to communicate very well with this patient and her pain was an 8. I was taught in school to chart objective things not guesses. If she says her pain was 8 then it was an 8 and I should be able to chart what I objectively observe.
I'm just curious if anyone else has run into issues like this. Do you chart your assessment as you objectively see it or just notate ambiguously b/c the pt has an ETT?

You were correct in your assessment and charting. You don't have to be verbal to be able to communicate.

pickledpepperRN · Oct 7, 2004

You are correct. I often care for patients in our ICU who are ventilated and alert. A clipboard, paper, and pencil are a BIG help. (Pens don't write upsidedown). Some patients cannot do this, some write each letter on top of the first so you can't show the writing to the MD but can tell what they mean if you see them write it.

The main thing is that it is a requirement to assess the patients pain level each time vital signs are taken and more often as needed.

This patient was clearly alert. As a patient advocate I would document exactly what I observed as suggested above. I would then go to the RN responsible for the patient, and up the chain of responsibility in writing. If a pain medication was ordered I would give it. Either way if the physicians progress notes don't indicate the orientation of the patient I would personally notify that doctor. If if were my night shift i would call early or leave a message with the service. At a teaching facility I would take an intern or resident in to talk with the patient.

The best interests of the patient include involving the patient in decisions regarding care. Pain relief is basic.