Change in condition documentation

Long Term Care Columnist / Guide · Apr 9, 2017

Chart what you observed (R. seated on toilet, slow to respond to voice/touch, remains lethargic, VS WNL etc.) and what you did about it (did you call her family and doctor? Send her to the ER? Put her on alert charting and so on).

Cruella de ville · Apr 9, 2017

What was her BG?

Any s/s stroke?

Neuros?

Vasovagal?

How much sleep did she get the night before?

Any chance of overdose?

To answer your question, just chart your observations and what your interventions were.

After your assessment did you send to ER? Assist her to bed?

Did you update family and we're they on board with your actions?

NutmeggeRN, BSN · Apr 10, 2017

Homework?

CoffeeRTC, BSN, RN · Apr 12, 2017

I really hope this is homework.

Chart what you saw and what you did. I hope the MD was notified for some type of orders. Something is going on. You didn't mention what the resident did on the toilet. Was it a vagal response? Do they have s/ s of a uti? Diabetic? Low 02 sats?

As a nurse, I hope you know how to chart. We get a few new grads in my SNF and when asked, I will always help with charting etc, but allnurses shouldn't be your first resource.

quiltynurse56, LPN, LVN · Apr 30, 2017

Chart what you saw just like you did here. Also, chart anything you did to assess the resident. Call the doctor to let them know, they might want to see them at the hospital.

Natasha A., CNA, LVN · May 1, 2017

I really hope this is homework.
Chart what you saw and what you did. I hope the MD was notified for some type of orders. Something is going on. You didn't mention what the resident did on the toilet. Was it a vagal response? Do they have s/ s of a uti? Diabetic? Low 02 sats?
As a nurse, I hope you know how to chart. We get a few new grads in my SNF and when asked, I will always help with charting etc, but allnurses shouldn't be your first resource.

Charting is not really a skill that is taught in most nursing schools. As I do agree that nursing students should be well-prepared, most NG learn charting on the job training. I was one of them :)

Neats, BSN · May 3, 2017

I learned to chart while I was in the military we used what is called SBAR stands for

Situation

Background

Assessment

Response

As a manager I use this today and as a mother when my kids were teenagers I used this method of communication.

Based on what you have provider (very limited)

This resident is usually alert but confused. I found her on the toilet with her eyes closed and very slow to respond. She continues to be lethargic et is unable to stay awake to communicate with me. I need help with a progress note please. Vital signs are all WNL

I would write something akin to this

Situation:

This RN is contacting the residents oncall provider because of concerns over the observation of our patient sitting on the commode, eyes closed and very slow to respond to communication.

Background:

Are you aware this resident has a diagnosis of XXX and history of XXX and on 7 different medication for these diagnosis. There are no recent labs for this patient and he has many family/friend support, likes participating in activities such as BINGO and outings in the facility van. Has recently gone bowling and uses a walker to ambulate.

Assessment:

Currently resident vital signs are BP (manually), Pulse is XX and feels thready, strong, steady...I would not report WNL (I dislike this term), facial symmetry is XX, again very slow to respond to questions although knows his name and what month it is when asked. Is unable to transfer away from the commode on his own-this is new. It took 3 assistance to move this resident to his bed and staff is at bedside now taking another set of vitals. There are no signs of bruising, bumps, bleeding or scratches to indicate falling. AAO X 2 (is not really alert).

Recommend:

We transfer out to emergency room for continued evaluation as this is a significant change in his cognitive and ADL functioning. I will inform the family where he will be sent once we get orders from you to transfer to emergency room so they may be at their family bedside.

Again this is just an example of how I would chart in todays environment when there is no electronic charting or when I have to contact the provider for significant changes for my patient. If this is school work then you best bet is to use the student nurse thread, if you are a new nurse I strongly encourage you to hone your assessment skills and practice charting- practice on yourself, your children, family and friends.