I am pretty confident in my head to toe assessments, however, when I find somthing is wrong, I am not sure how to document it in proper nursing terms.
Example: Head is symmetrical, but dandruff noted?
Eyes, scalera is white without pigmentation, pupils, equal and reactive to light?
M. M., dry and white? How do you write the problem in proper nursing terms?
Anyone please help with this. I am really confused and struggling. I want to be good and not miss anything that should be documented.
Jan 25, '07
I wouldn't say "dandruff." I'd probably say, "Pt noted to have flaking skin at scalp" or wherever.
You can write PERRLA for pupils equal, round, and reactive to light and accommodation. I wouldn't go into the sclera unless there was something different about them--as in "sclerae noted to have yellow tinge bilaterally."
MM?? Sorry, either I'm having a brain glitch or I'm not familiar with that abbreviation. What is MM??
Jan 25, '07
Mucous Membranes..... Do you say dry and white if some poor oral care or dehydration? You say moist and pink if they are ok. I am trying to tie this all together.
Jan 25, '07
We usually chart by exception, because if we charted everything that was OK, we'd never get anything done.
Usually if I have to chart on someone who's dehydrated, I'll chart something like, "Lips dry, cracked, so mouth care given. Skin turgor poor, eyes sunken. Pt was offered fluids, but refused. Low urine output, urine foul-smelling and dark yellow in color."
Mostly you just chart what you see. If you see something you shouldn't, you need to chart what you did to fix it.
In the case of my patient described, said Patient was a Hospice DNR and terminal cancer patient who had decided to stop eating and drinking, but occasionally would take a sip of water. She died about two weeks after her decision to refuse food.
My point is that normally, I'd call the doc and get IV fluids ordered or TPN or something to keep her going nutritionally.
You'll get the hang of it. I think it might help to get a book on the subject and also read the charts as much as possible to see how others describe the same observations. You'll develop a style after awhile.
Last edit by UM Review RN on Jan 25, '07
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