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Discussion

Speaking of vomit

When one of my patients' vomit I usually give zofran and try other measures to help ease their nausea. Since vomiting is frequent with our post op patients I usually do not write a note in the chart. However I'm now wondering if I should chart something. Should I also get a set a vital Signs?

I feel like such a bad nurse for not doing either of these things....

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    I write a note for every patient, every shift, even if just to say that their vitals were stable throughout the shift. Our EMR has a field under intake/output to chart episodes of emesis and, if applicable, the volume and appearance of it. Unless it was something pathologic like projectile vomiting I probably wouldn't write a note about it if you could chart it within your EMR.

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    You need to document it somehow. Did they c/o nausea first? Did they actually vomit? What it just once or multiple times? What were your interventions? Did this relieve pt's vomiting? Was nausea still present?

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    I took this as a joke.. No?

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    If you document the emesis in the I&O section and your MAR records that zofran was given, no I don't think you need to write a note. Now if the nausea is unrelieved or there is no order for an antiemetic and you've called the doctor multiple times with no response, I would write a note. I also took this as a joke post initially.

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    I document everything. I would write a little note stating the amount of emesis or how many times the patient threw up. I would then state my interventions. I usually don't get a set of vitals for vomiting...

    maybe if they were vomiting excessively I might take a set of vitals before notifying the doctor.

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    • Experts

    In case you aren't being silly and being funny.;) Yes you should document it...it is output after all

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    • Author

    I'm so sorry if my post came off as silly. I was dead serious. I will never ask a 'dumb' or silly question like this again on AN. I should have known better as I have been a member for eight years (under different account).

    I do appreciate your input regarding my question.

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    I'm so sorry if my post came off as silly. I was dead serious. I will never ask a 'dumb' or silly question like this again on AN. I should have known better as I have been a member for eight years (under different account).

    I do appreciate your input regarding my question.

    I'm really sorry. I had the stethoscope thread in mind and I thought you were playing off that. It was completely misread and bad on my part.

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    I'm really sorry. I had the stethoscope thread in mind and I thought you were playing off that. It was completely misread and bad on my part.

    Funny, I did too :)

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    • Experts

    I've taken care of postop patients for 13 years. I wouldn't necessarily narrative-chart every single episode of postop n/v unless there were something unusual about it - frank blood, projectile, intractable, etc. Charting it under I/O and charting your anti-emetics given in your MAR should be evidence enough to anyone reviewing the chart that you were aware of it and addressed it. If there is nowhere else for you to chart nonpharm measures, you may want to make a narrative of that just to CYA (but you will hopefully have a place to chart that in I/O). Double-charting is one of my pet peeves.

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    • Author

    All forgiven. I'm on maternity leave and in such fog. I want to make sure I'm doing the right things when I return to work next month.

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