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Discussion

Need some help with documenting

I am writing a care plan for a nonverbal patient and am drawing a few blanks.She is an 84 year old lady who slept my entire shift but would open her eyes for a few brief moments a couple of times, then she went right back to sleep. She would stir sightly to verbal and tactile stimuli, but for most part she was unresponsive. How do I document/word her response to verbal and tactile stimuli? How would I chart her LOC/ orientation? Should I just say pt not oriented to person/place/time and for LOC - stuporous? Also how would I document handgrips? When I grabbed her hands she would reflexively squeeze them before I asked her to but I'm not sure if I should document this as handgrips equal and strong since it seemed to be completely reflexive.

Any help is appreciated!

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    You describe what you see. Know your terms.....

    Stupor is the lack of critical cognitive function and level of consciousness wherein a sufferer is almost entirely unresponsive and only responds to base stimuli such as pain.

    Obtundation refers to less than full mental capacity in a medical patient, typically as a result of a medical condition or trauma.

    The root word, obtund, means "dulled or less sharp".

    An altered level of consciousness is any measure of arousal other than normal. Level of consciousness (LOC) is a measurement of a person's arousability and responsiveness to stimuli from the environment.[1] A mildly depressed level of consciousness may be classed as lethargy; someone in this state can be aroused with little difficulty.[1] People who are obtunded have a more depressed level of consciousness and cannot be fully aroused.[1][2] Those who are not able to be aroused from a sleep-like state are said to be stuporous.[1][2] Coma is the inability to make any purposeful response.[1][2] Scales such as the Glasgow coma scale have been designed to measure the level of consciousness.
    So what did you see.....
    he is an 84 year old lady who slept my entire shift but would open her eyes for a few brief moments a couple of times, then she went right back to sleep. She would stir sightly to verbal and tactile stimuli, but for most part she was unresponsive. How do I document/word her response to verbal and tactile stimuli? How would I chart her LOC/ orientation? Should I just say pt not oriented to person/place/time and for LOC - stuporous? Also how would I document handgrips? When I grabbed her hands she would reflexively squeeze them before I asked her to but I'm not sure if I should document this as handgrips equal and strong since it seemed to be completely reflexive.
    Pt in bed.....Pt appears to be obtund......pt opens her eyes for brief moments with light tactile and verbal stimuli.

    The question here is did she follow command? Did she grasp to command and then follow command when asked to let go? Would she track you in the room? lift one finger to command? You cannot document orientation for she didn't answer your questions....did she seem to know what is going on around her? You can't document either way on orientation.

    Pt lies with eyes closed when not stimulated appears to be unaware of her surroundings, does not track nurse in room. Hands grasps appear equal when fingers places in pt hands although patient does not release grasp on command.

    Is this normal for this patient? Is she being given sedation? How do you know she was "asleep?"

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    • Author

    No she did not follow to command, she would grip my hands reflexively but would not let go. I wasn't sure exactly how to word that, "pt does not move extremities to command?" we usually document handgrips and footpushes, whether they were equal and strong, and also if they overcome resistance. However, since she did not move to command, do I just leave that out? Or chart "unable to assess"?

    Thanks for your help!

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    • Experts

    patient extremities exhibit random movements. patient does not move extremities to command.

    Were her movements purposeful? Like crossing her legs and scratching her nose?

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    I am writing a care plan for a nonverbal patient and am drawing a few blanks.She is an 84 year old lady who slept my entire shift but would open her eyes for a few brief moments a couple of times, then she went right back to sleep. She would stir sightly to verbal and tactile stimuli, but for most part she was unresponsive. How do I document/word her response to verbal and tactile stimuli? How would I chart her LOC/ orientation? Should I just say pt not oriented to person/place/time and for LOC - stuporous? Also how would I document handgrips? When I grabbed her hands she would reflexively squeeze them before I asked her to but I'm not sure if I should document this as handgrips equal and strong since it seemed to be completely reflexive.

    Any help is appreciated!

    Just because she's non-verbal doesn't mean she's disoriented. She may very well be oriented x 3, you just don't know. You are unable to assess her orientation. Only when someone tells you that they are the President of the United States, that they are in a Chinese Food Restaurant (I actually got this answer once when I asked a teenager with a head injury where he was) and that it is 1974 can you documented that they are NOT oriented to person, place or time.

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    Just because she's non-verbal doesn't mean she's disoriented. She may very well be oriented x 3, you just don't know. You are unable to assess her orientation. Only when someone tells you that they are the President of the United States, that they are in a Chinese Food Restaurant (I actually got this answer once when I asked a teenager with a head injury where he was) and that it is 1974 can you documented that they are NOT oriented to person, place or time.

    If possible, it's perfectly acceptable to use the patient's own words (I know the OP's patient is nonverbal).

    I had a kid come into the ER one day after a car wreck, not a scratch on him, polite, calm, no reports of pain, and looked and sounded pretty good until I asked him if he knew where he was he said, "Sir, South Carolina, sir." (We were about a thousand miles from SC, and if you saw me you'd know that nobody would ever, ever mistake me for "Sir.") I wrote that right down. Stat head CT.

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    "Sir, South Carolina, sir." (We were about a thousand miles from SC, and if you saw me you'd know that nobody would ever, ever mistake me for "Sir.") I wrote that right down. Stat head CT.

    Bet he was Arm trained at Fort Jackson in Columbia, SC.

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    • Experts

    I remember one LOL (little old lady) we kept telling the MD she was confused...and documenting she was confused. He came in one morning and had a hissy fit about the stupid nurses and not correctly assessing his patients.....and documented how alert she was and oriented contrary to the foolish nurses notes.

    I suggested he go in and ask the patient where she was.....she knew who she was and knew the MD and I asked him to ask her WHERE she was.....when she proceeded to tell the MD how thoughtful it was that he came all the way up to Canada to see her and these lovely nurses had these newspaper shipped in from Indiana!!

    He came out of the room beat red....walked to the chart....crossed out his note and wrote...confused to place....:roflmao:

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    You don't know if she is unable to respond or just unwilling, or if her comprehension is good but she cannot verbally respond. In that case I would chart, "unable to assess orientation to place, time, or situation due to patient not verbally responding to questions regarding same." If they react to their name, they are oriented to person. If not you can chart that too.

    Chart what they are responsive to and whether they will follow commands. Do they make eye contact? Or just open their eyes to stimuli?

    Chart what you see, and those observations give a good picture of the patient's status.

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    Bet he was Arm trained at Fort Jackson in Columbia, SC.

    Sixteen, military brat, dad at the local base. :)

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