Sample Narrative Charting about Patients with CTT, ET and NGT

anurseuk · May 18, 2008

Can you go into more detail? Not quite sure what you mean:)

Penelope_Pitstop, BSN, RN · May 18, 2008

i don't have a sample for you, i'm sorry.

however, i will say that the best way to improve is practice! my favorite clinical instructor beat nursing notes into us and that's why i'm not bad at it.

you can always read through charts for other nurses' notes as an idea of what the norm is at your facility and department.

are you still on orientation? if so, your preceptor(s) should help you with this....even if you're not on orientation, you can always write the note as a "rough copy" and ask someone else if it sounds good.

and congrats on becoming a nurse!

jess

ERNurse03 · May 20, 2008

I'm not sure exactly what you are asking, but when charting such procedures you need to remember to include not only the details of the procedure but how the patient tolerated the procedure.

Example for NG insertion. 16 F NGT placed with ease through the right nares using clean technique after prep with cetacaine spray and xylocaine jelly for pt comfort. Placement checked per auscultation and return of gastric contents. 100 ml yellow liquid gastric contents returned immediately. NG connected to LIWS per order. Pt tolerated the procedure well and vital signs remain within normal limits.

The clean technique, cetacaine spray or xylocaine jelly may be PRN protocol, if so, you can just document "per protocol" instead of giving all those details.

For an ET I will usually chart this: 8.5 ET tube placed successfully after two attempts per respiratory or MD (whichever). Placement initially checked by positive breath sounds bi-lat and positive end tidal Co2. Stat x-ray ordered to confirm placement. Tube placed 22 at the lip and tube secured. Pt's SpO2 now 98% and pt's color is pink, patient is warm and dry.

Then you would chart either the patient is being bagged per RT or pt placed on a vent and be sure to document the vent settings. If there is anything suctioned from the lungs you would need to document the consistancy, the color and the amount.

Prior to documenting the placement procedure, of course you would also need to document what the patient looked like ie: why they needed intubated, then any medications that were given to relax or sedate the patient. Don't forget the soft restraint documentation if you are using those. Most places require separate papers for soft restraints or safety devices.

This probably isn't perfect, but it's worked for me for 11 yrs in the ER.