Published May 28, 2009
Just wondering how everyone else charts while a women is in early, active and transitional labor? Does anyone know what the correct guidelines are? At our hospital usually when a pt. is in early labor we (RN's) chart every 30-45 minutes. Active labor every 15-30 minutes (depending how many other pt.'s we are taking care of) and when in transition and during pushing every 10-15 minutes. The hospital I work at uses Centricity so the monitor strip is always stored if it's needed to look back on later. What does everyone else do? Thanks for the input.
45 min?! WOW! :omy: We chart Q 30 min on women in natural labor IE: no pitocin or other labor stimulating meds. Q15 in active labor or with pit and definately Q5 min while pushing. I've never used centricity. We use OB trace vue but are switching to centricity sometime in the near future. Review AWOHNN guidelines. Also the number of pt's being cared for make no difference in charting guidelines. Even if the strip is stored you still have to show you are monitoring it at the correct frequency. Even in early labor things don't always look good!
q5 minutes? You'd have missed my daughter coming out, haha. She was out in 6 pushes :x
babyktchr, BSN, RN
The published guidelines from AWHONN are very clear. Low risk labor, q30 mins then q15 in second stage. High risk q15 mins then q 5 in second stage. At anytime a low risk can go to high risk, so you adjust accordingly. Just because you store a strip, doesn't mean anyone looked at it the entire labor.
at my last job we a qs system for central monitoring but had all paper charting (pita!) so we had a labor flowsheet for q30" efm/toco for all laboring pts: pit, no pit, cervadil, cytotec, epidurals, whatever, and progress notes for q1' assessments (in longhand! kill me!). during "active" labor the flowsheet stayed the same but longhand notes were expected q30". pushing was q5" so the flowsheet would be abandoned in favor of one longhand progress note q15" with q5" updates in between whereyou hoped like hell nothing of particular interest happened because if all was well you could write "pt continues to push w/ctx. status unchanged." interventions (ise's, epis, cervical block) would have to be charted w/exact times.
now i work someplace with qs charting. annoyingly, we chart q15" on all "high risk" labor pts, which according to our policy manual includes anyone
-on pitocin or
-with an epidural
which is pretty much everyone.
oddly, when a cervadil is placed for a straightforward induction without an underlying issue we only monitor them for two hours then they are free to have intermittent monitoring q2' for 20".
i think it's totally nuts to chart q15 on a 2cm pit pt and barely at all on an unmonitored cervadil pt, but hey: i don't make the rules.
when it comes time for pushing we're supposed to "chart" q5" but of course this is not possible when you're holding a leg or trying to focus on your pt. i stick to my old q15" full assessment just like at my last job then hit the "mark" button q5" and chart "nurse & provider @bedside" on as many of those marks as i can in those moments. i avoid back-charting at all costs; not easy because so many of our bedside computers don't work.
when i'm pushing in a room where the computer doesn't work i write an initial "pt given pushing instructions, md so-and-so @perenium, pt pushing w/each ctx. nurse @bedside. qs system unavailable in room for charting. please see delivery note for details." poof. push the mark butten q5" to prove i'm in the room and that's it. if it seems like we're going to be pushing forever and a day (say, more than an hour) i excuse myself to a working computer to reiterate that the one in the room doesn't work.
We don't really have any policies at all where I work for charting on labor PTs. I just stick to AWOHNN guidelines.
I know the guidelines, now lets talk reality. Complete charting q 15 minutes on 2 patients being induced with pit is nearly impossible. God forbid one of them needs to get up to the BR and take a few extra minutes of your time. This 15 min. thing is killling us!!!
By using the site, you agree with our Policies. X