L&D nurses a few questions please...

[anangelsmommy, ADN, BSN, RN]

I will be doing visits and I have some questions on how how people are noting these things. I am unable to find anywhere how these things are noted. I would LOVE if I could find a good book on how to write good notes! I have worked for a company for several years where most of my work was fill in your vitals and note by exception so now I am sort of paying for it....and now I need some advice please:

This is for well mom and baby visits-

how are you recording your fundal heights - i am looking for post partum - so are you doing -cm (down arrow) or are you doing #F and Firm? or another way? I had learned cm but supervisor is telling to just do fingers?

infant cord, what do you normally put for the infant cord? black, intact, WNL? I only have a tiny space.

Anyway, I think I can figure out everything else.

I appreciate your help, I love this site!!

an angels mommy

[klone, MSN, RN]

Fundal height - documented in cm above or below the U. If it's above the U, it's documented as x/U (x being number of cm). If it's below the U, it's documented as U/x. E.g. F @ U/1 (firm at 1 cm below the umbilicus). 1 finger is approximately = 1 cm, so I would still document it the same way.

For cord stump, we just document dry/drying and clamp on/off/removed. Then if there's anything that's not WNL, we would indicate that (such as if the area around the umbilicus is reddened, or if there's any discharge). Since I work in a hospital setting, we don't have to document if the stump is still on, because they always are.

[anangelsmommy, ADN, BSN, RN]

Thank you I am more comfortable with with cm, I know they are equal but it seems more accurate and professional. I appreciate the feedback, since most visits are to be done within 5 days unless there is a reason for f/u the cord should be on - unless it is a preemie- then there wont be one if they have done an artial line. so actuall there will be times note that on preemies. But then it will be pink and dry unless otherwise noted. but things to look for are weeping - in rare cases of patent urachus, infection, hernia etc. they give me a box about the size of my initials! but i have room at the bottom for notes. So anything out of the ordinary I can note there. I a self proclaimed perfectionist!

thanks for your input! I know that they also have me doing homans but the last I was told this was old school and we werent doing this at the hospital anymore? what is your thought on this?

[klone, MSN, RN]

There's a lot of mixed opinions on Homans. The facility I work at, which is a cutting edge university hospital, still wants to document Homans. I know a positive Homans is not very predictive of DVT, though (and a negative Homans certainly doesn't rule it out). The concern that doing Homans could dislodge a DVT is unfounded, I believe. WALKING could dislodge a DVT, and we don't tell them not to walk.

I do Homans as part of a series - I run my hands somewhat firmly down their legs and ask if there are any discrete areas of tenderness; I visually examine fronts and backs of the lower legs, looking for areas of swelling or redness, and I palpate pedal pulses to check for equal strength.