Ways to chart about mucus?

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Specializes in Cardio-Pulmonary; Med-Surg; Private Duty.

I figure that PDNs probably deal with more mucus than just about any other specialty of nursing, given that almost all of us deal with trachs on a regular basis, so might as well ask this question here.

So, what are some of the terms you use to talk about mucus in your charting?

Mucus and secretions, obviously, and thin/thick/frothy, color and opacity, etc. And scant/small/medium/large, and OMGXXXXL amounts. (Okay, maybe not the last one, but sometimes you WANT to use that in your charting! LOL)

I just feel like I'm using the same words over and over and over again.... anyone have any other ideas?

Also, what are you calling a "glob" of mucus? I know it's a valid word, but it seems like there should be a more professional/medical term to use!

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Specializes in Peds(PICU, NICU float), PDN, ICU.

I write the same thing for mine. "Suction x1 for x amt of thin/thick, white/off white/yellow/green secretions from trach." Its descriptive, describes intervention, and can be followed with an outcome such as "o2 Sat 100% on RA, lungs CTA bilat." If needed, prior to documenting suction I'll document why suction was needed...such as a desat.

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After "large", I use the term "copious". Other than that, I pretty much stick to the same terms as you posted, over and over. Have also used the term "sticky" on occasion. And then there is the presence of bloody color, "pink tinged", "reddish". I don't use the word blood or bloody, unless it is frank blood. I was taught not to use the word blood, but the color red, somewhere along the line because supposedly I don't know that it is blood, but I can describe the color.

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DO not forget to describe odor.

I also like to chart what i suctioned with and how deep.

I also add that i suctioned with a 8 fr suction catheter to a depth of 7 cm

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Specializes in Emergency room, Neurosurgery ICU.

for "sticky" I like to use tenacious, (I don't know why, but I just love that word!) I rarely have to use it with my patient. Other than the words you've posted, there really aren't many others to use, except maybe "copious" for those XXXXXL secretions.

I did a search for synonyms of "glob":

blob, chunk, clod, clot, clump, dollop, lump, gob, gobbet, hunk, knob, nub, nubble, nugget, wad

(I think nubble and gobbett are both great words, don't you? However, clump, glob, or lump are probably better for nursing purposes!)

Per medical dictionary, "clumping" or "clump"clump-ing (klubreve.gifmprime.gifpibreve.gifng)n. The massing together of bacteria or other cells suspended in a fluid.

so clump wins over glob, I guess as a more "nursey" term, eh?

:

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I also use tenacious, but when I don't remember that, I have used "sticky". It is so infrequent, I have to stop and think for a time. Also, with a long term client that is pretty consistent from shift to shift, I develop my mental visible 'amounts' and use "very large" before I go to the biggie of biggies, "copious"!

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Specializes in pediatric.

Same as everyone else: amount (scant, moderate, copious), color (clear, white, opaque, tinged with red, creamy, yellow, green), consistency (semi- thick, thick, thin, sticky) and like SDALPN, I typically chart size of catheter and depth of suction (nasopharyngeal suction with 8F to 12 cm, inline trach suction with 8F to 11.5 cm, oral suction with 10F to 6cm, etc.). I also state how the pt. tolerated it ("tolerated well with no desats" or "s/s of discomfort AEB eyes watering and facial grimacing.").

I like tenacious for sticky- will have to add that to the repertoire ;)

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After "large", I use the term "copious". Other than that, I pretty much stick to the same terms as you posted, over and over. Have also used the term "sticky" on occasion. And then there is the presence of bloody color, "pink tinged", "reddish". I don't use the word blood or bloody, unless it is frank blood. I was taught not to use the word blood, but the color red, somewhere along the line because supposedly I don't know that it is blood, but I can describe the color.

Thanks for that tip!

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Specializes in Pediatric Private Duty; Camp Nursing.

Good thing there are no points for creative expression in nurses' notes! Just the facts, ma'am!! Re: putting the info about size and depth, if I'm sick of repetitious writing (which I usually am if I write the same freakin' note every night) I'll put "as per MAR", because all that info is there too.

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Specializes in Peds(PICU, NICU float), PDN, ICU.

Wouldn't it be nice if we could just follow the care plan and just do charting by exception. Even just a daily signature to say that yes we followed the care plan, followed by charting by exception. More time for pt care, less time charting the same thing over and over.

I'll also add, that if I notice an increase in secretions that I'll note that in case its the start of a new pattern or infection.

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