a question about documentation

[treeye]

on a night shift, a pt c/o nausea. I assessed pt and documented as following:

pt c/o nausea. No emesis, no palpitation or sweating. Bowel sound normal in all quads. Water offered. will continue to monitor.

is the above documentation sufficient?

From documentation point of view, if the pt suffered MI shortly after the night shift, is the documentation sufficient to prove standard nursing care? ( pt is ok, just trying to improve my documentation. thanks)

[Altra, BSN, RN]

Did you do anything to relieve the nausea, either by using a prn order or contacting the provider for one? And I'm not sure I would be offering anything p.o. to someone who is currently nauseated.

[Anna Flaxis, BSN, RN]

on a night shift, a pt c/o nausea. I assessed pt and documented as following:

pt c/o nausea. No emesis, no palpitation or sweating. Bowel sound normal in all quads. Water offered. will continue to monitor.

is the above documentation sufficient?

From documentation point of view, if the pt suffered MI shortly after the night shift, is the documentation sufficient to prove standard nursing care? ( pt is ok, just trying to improve my documentation. thanks)

I might also mention whether there is any complaint of pain (or denial of pain) associated with the nausea, and if so, note its location and character, using the patient's own words in quotes as much as possible.

Make sure to always chart your intervention and the results. It looks to me like the only intervention you offered was water. Did the patient not have any PRNs available for nausea? Also, I agree with Altra, I would be hesitant to give anything PO to someone complaining of nausea.

I might phrase things a little differently than you did. For instance, I might say the same thing only like this:

Pt. c/o nausea. No emesis observed, denies pain, palpitations, or SOB. Skin pink, warm, dry. Bowel tones active in all quadrants. Medicated per N/V protocol. Will continue to monitor.

I always make sure to make a follow up note 30-60 minutes later (or sooner if symptoms are more severe) and especially if I give a medication or state "will continue to monitor" (if you're going to chart "will continue to monitor", then you NEED to chart some further observations of what it is you monitored).

I might write something like "Pt. reports nausea resolved after medication received, left resting quietly in no acute distress".

Or "Pt. reports nausea continues, now a/w epigastric discomfort, describes as "like someone pressing on my stomach", non-radiating. Skin pale, diaphoretic. MD notified and orders received".

Also, be careful using the word "normal". What exactly is normal? I really like to stay away from that word, preferring to say "within normal limits", if I absolutely MUST say that something is normal.

[HouTx, BSN, MSN, EdD]

The patient's underlying diagnosis & problems would dictate the type of nursing interventions and degree of urgency. Nausea in a pt with cardiac hx would be treated entirely differently than nausea in a CRF or fresh post-op patient. Always make sure that your critical thinking is evident in your documentation. Assessment should include most likely underlying causes, in order of priority.... ex: for cardiac pt, you would do complete VS & probably get an EKG; for CRF, you may want to look at lytes, for post-op, make sure NGT is patent & working.... etc.