How to document 'Foley Care Given'

[Sharwahi]

I am struggling with documentation. How would I document for the given scenario?

L.M ;56 year old female.

VS- 36.4; 80; 20; 120/85; Sa02 is 90% in RA

MD orders indicate that his Sa02 need to be over 95%.

1. Administer oxygen as ordered.

2. Insert Foley catheter

3. Document care given

Thanks

[Tiffanie7]

16Fr/10ml foley catheter inserted, x1 attempt, return of 200ml clear, yellow urine flowing, connected to foley bag, pt states discomfort with initial insertion, denies any pain/discomfort at this time.

Just an example of something I have written in the past.

Can add in the 02: 02 sats @ 90%, raised HOB, administered 02 @ 2L NC, sats now 95%. Would also put in how I observed the pt breathing-labored, shallow; breath sounds.

[cursedandblessed]

VS- 36.4; 80; 20; 120/85; Sa02 is 90% on RA, Pain X/10, O2 administered via nasal cannula 2 L/min per order for SaO2

[Daytonite, BSN, RN]

This is what I would often have charted. . .

(Date, time) B/P 120/85, T36.4 P-80, R-20 with Sa02 of 90% on RA. O2 started at __ L/minute via NC. After __ minutes Sa02 at __% on __ L of the supplemental oxygen. Respirations regular and unlabored. Per physician's order an indwelling # __French foley catheter inserted using sterile technique. Patient tolerated the procedure well. Bulb inflated with __cc's of sterile water. ___cc's of clear yellow urine returned upon insertion of catheter into bladder. No specimen ordered to be collected or sent to the lab for examination. Catheter connected to sterile tubing and collection bag and positioned to overside gravity drainage. Patient instructed to keep drainage tubing and collection bag below the level of her bladder at all times and to drink lots of fluids. Intake & output procedure explained to patient.

[Sharwahi]

Thanks a lot!

I am confused about how much information to include. Our Prof. don't want to write us stories but the I don't wanna miss on important information as well.

If someone can help me in drafting a template which can be used for at least the common skills such as CBI, NGT insertion, Wound dressings, pouchings etc.

Thanks again!

[Daytonite, BSN, RN]

I double checked my copy of Nurse's 5-Minute Clinical Consult: Procedure from Lippincott Williams & Wilkins under the documentation section to make sure I didn't forget anything. Try searching the internet for these nursing procedures and specifically the documentation of them. Nurse's 5-Minute Clinical Consult: Treatments also includes what to document.