What To Chart After "pt. vomited"

Nurses General Nursing Nursing Q/A

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When a patient vomits theoretically there is always the risk of aspiration. I can never think of what to write after I write "patient vomited 30 ml's green tinged fluid." Do I write "lungs CTA." Do I write "no apparent distress." Do I write "VSS"? I get writers block on what to say???

BTW I know to chart anitemetic given, good effect, or whatever, about the medication.

BTW we don't have computer charting.

24 Answers

leslie :-D

11,191 Posts

elkpark said:
it would be more accurate and useful to ask the client how s/he is feeling and document the client's response ("client states, "I'm feeling better now'" (or whatever)).
brownbook said:
I like "patient resting comfortably" then I think of the lawyer in the courtroom. "Well, how do you know the patient was resting comfortably, maybe they were passed out." I know, it gets crazy and paranoia sets in!
canesdukegirl said:
Don't ever think that you are being paranoid when you are charting. I always chart as if I am testifying in court. My dad is an attorney and he DRILLED that into me when I first started nursing school. He told me to NEVER use the phrase "pt resting comfortably", citing that I am ASSUMING. He told me instead to chart exactly what I am seeing, factually. "Pt sleeping with HOB up 30 degrees, or pt lying supine in bed reading, or pt in recliner watching TV."

We never want to write notes that make the reader assume.

The only exception I would take is to NOT write pt sleeping.

Wouldn't that be an assumption as well?

Rather, "pt laying supine with eyes closed. resps even and non-labored."

elkpark, love your idea, about asking pt how s/he feels then writing response.

It's unfortunate we have to be so guarded and meticulous w/our nsg notes, but we really do need to write as if a lawyer may be reading it someday.

leslie :-D

11,191 Posts

What I wouldn't write (which I used to, btw) is "vss". Rather, I would write out ea vs.

"CTA" s/b written as clear to auscultation, just so there are no questions. And, while you want to address the risk of aspiration, you also want to address the possibility of sbo:

So, "abd soft, non-tender (or whatever your findings are), bowel sounds + x 4 quads, lg soft bm noted on this shift...

Anything that would either point to or r/o the aforementioned.

So yeah, you're on track.

After all interventions, you can then write 'pt appears to be resting comfortably' or however pt presents.

Flo., BSN, RN

571 Posts

Specializes in Developmental Disabilites,.

I just put it in the I+Os. Never even occured to me to do otherwise. But I am on a post op floor so people vomit all the time.

elkpark

14,633 Posts

leslie ? said:
elkpark, love your idea, about asking pt how s/he feels then writing response.

Welllllll, y'know, I'm a psych nurse, so my whole career has been asking people how they feel and documenting their response ... (I'm pretty good at it, too! :lol2: :lol2: :lol2:)

jkaee

423 Posts

Specializes in Gerontological Nursing, Acute Rehab.

Agree with what everyone has stated thus far, especially Leslie. Vomiting always warrants a complete abdominal/bowel assessment, as that's often the first sign of an obstruction, especially in your geriatric population. Another thing to keep in mind is that it may take a few shifts before lungs start sounding "junky" after an aspiration, so make sure to pass it on in report. The following shifts need to make sure to assess their lung/bowel status as well.

Specializes in Geriatrics.

Lungs clear to aus., will continue to monitor. I then will write a quick up-date at end of shift or if a problem occurres (Spelling right??).

Resting in bed with eyes closed, easily awakened, respirations even with no obvious destress noted at this time.

Both always work for me.

brownbook

3,413 Posts

Thanks, good ideas. I like "patient resting comfortably" then I think of the lawyer in the courtroom. "Well, how do you know the patient was resting comfortably, maybe they were passed out." I know, it gets crazy and paranoia sets in!

wezzie, RN

118 Posts

Specializes in Mental Health.

I'd write Lungs clear bilaterally all fields..

Specializes in Critical Care.

Everything Leslie said and remember..no matter what, when something happens the first thing a nurse does is ASSESS. Chart your assessment, lungs, bowels (ascultation and in bowel quadrants, I'd chart a palpation assessment as well->tender to palpation, bowel sound quality (are sounds present in all quads? typanic in nature?, etc.) Remember,as a nurse you can do assessments without an order. If this is a new situation, does it warrant a call to an MD and maybe labs ordered? (Labs: liver panel, amylase/lipase) any risk for pancreatitis/small bowel obstruction/ possible perforation? Also, is it important to make the pt NPO until this issues resolves? And then always chart a follow-up assessment as well as pt's statement regarding resoultion or possible worsening of symptoms.

Just some thoughts off the top of my head. A lot of what you need to chart is going to be based upon reason for pt's admission to hospital and how the emesis may relate to that symptom.

elkpark

14,633 Posts

brownbook said:
Thanks, good ideas. I like "patient resting comfortably" then I think of the lawyer in the courtroom. "Well, how do you know the patient was resting comfortably, maybe they were passed out." I know, it gets crazy and paranoia sets in!

You're right about that -- it would be more accurate and useful to ask the client how s/he is feeling and document the client's response ("client states, "I'm feeling better now'" (or whatever)).

brownbook

3,413 Posts

Thanks to you "all nurses," all good things to think about. No more writers block.

canesdukegirl, BSN, RN

1 Article; 2,543 Posts

Specializes in Trauma Surgery, Nursing Management.

Don't ever think that you are being paranoid when you are charting. I always chart as if I am testifying in court. My dad is an attorney and he DRILLED that into me when I first started nursing school. He told me to NEVER use the phrase "pt resting comfortably", citing that I am ASSUMING. He told me instead to chart exactly what I am seeing, factually. "Pt sleeping with HOB up 30 degrees, or pt lying supine in bed reading, or pt in recliner watching TV."

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