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Documenting findings, some assistance

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by wannabeny wannabeny (Member) Member

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I'm unsure if how I would go about documenting certain things. I have to do a narrative assessment note on one of my patients. This is my 1st clinical rotation assessing severely handicapped patients (most are vent dependent, neurologically devastated, wheelchair bound, etc).

Patient suffered near fatal drowning and is vent dependent. I noticed during my assessment, patient had pink gums, a very enlarged tongue, and could see some healthy teeth (no cavities, or broken teeth as far as I could see).

His tongue was so large, I couldn't see really inside of his mouth, beyond that.

Would I document just what I was able to see? Would I mention an enlarged tongue and it's characteristics?(pink, no lesions or cuts).

And with patients on vents, how do you document their lung and heart sounds? She suggested if I was able to hear heart sounds, document "heart sounds present", if you couldn't hear clear S1, S2 sounds.(so hard overthe vent!). Forgot to ask about the lung sounds though 😑

I am so used to documenting on patients that are quite stable and have normal assessment findings, this is a HUGE jump.

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It is very difficult to hear anything over the vent.  You just do the best you can.  Make sure the rest of the room is quiet (close door if you need to).  Close your eyes to really concentrate and listen.  Make sure the pt has been suctioned first.  Compare your findings with the nurses on the floor to make sure you are on the right track.

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