What To Chart After "pt. vomited"

When a patient vomits theoretically there is always the risk of aspiration. I can never think of what to write after I write "patient vomited 30 ml's green tinged fluid." Do I write "lungs CTA." Do I write "no apparent distress." Do I write "VSS"? I get writers block on what to say???

BTW I know to chart anitemetic given, good effect, or whatever, about the medication.

BTW we don't have computer charting.

canedukegirl...still a student, but that is great great advice..i will remember this!

canesdukegirl said:
Don't ever think that you are being paranoid when you are charting. I always chart as if I am testifying in court. My dad is an attorney and he DRILLED that into me when I first started nursing school. He told me to NEVER use the phrase "pt resting comfortably", citing that I am ASSUMING. He told me instead to chart exactly what I am seeing, factually. "Pt sleeping with HOB up 30 degrees, or pt lying supine in bed reading, or pt in recliner watching TV."

Actually, even charting "sleeping" is making an assumption -- you don't really know someone is sleeping (as opposed to lying there, awake, with her/his eyes closed and choosing not to acknowledge your presence) unless you wake them up and ask them! ? Again, more useful and accurate to chart something like "lying quietly in bed, eyes closed, resp. even and unlabored."

BTW, my father was a physician and gave me the same advice when I was in nursing school (long, long ago :)). The other charting advice he gave me, which I have kept close to my heart all these years, was "Never write anything in a chart that you wouldn't want to have to explain in a courtroom seven years later."

Specializes in Pediatric/Adolescent, Med-Surg.

Well, you don't know if they are aspirating because in theory they could be silently aspirating.

typically I will write "pt had a small/large emesis episode. Emsis was non bloody, Zofran/Phenergan given"

brownbook said:
When a patient vomits theoretically there is always the risk of aspiration.

The same can be said when a patient eats..or swallows their own saliva...most people have vomited enough times during their life that they have it pretty down pat. Is it really necessary to do a full systems check because your patient barfed? Would a simple "pt vomited 35mls green liquid. Denies further nausea" not suffice? Obviously if they are gasping for air or are otherwise struggling then further assessment may be necessary but just because my patient puked doesn't mean I'm going to run into their room with a stethoscope and listen for bowel sounds...or lung sounds for that matter.

Specializes in Psych/CD/Medical/Emp Hlth/Staff ED.

We use strict charting by exception which I thought was becoming fairly common these days, although it sounds like many nurses still chart lengthy descriptions of normal findings. Is this still that common or does it just seem like from this thread?

Specializes in Pediatric/Adolescent, Med-Surg.
HamsterRN said:
We use strict charting by exception which I thought was becoming fairly common these days, although it sounds like many nurses still chart lengthy descriptions of normal findings. Is this still that common or does it just seem like from this thread?

Even though I, and I'm sure most of us, were taught charting by exception, many places still have nurses write narritive notes of the day's account. I agree that it's not really charting by exception, but instead "covering your a.."

Flo. said:
I just put it in the I+Os. Never even occured to me to do otherwise. But I am on a post op floor so people vomit all the time.

Here too. I might chart "Pt with lg emesis, Zofran given", but that isn't a given.

Emily

HamsterRN said:
We use strict charting by exception which I thought was becoming fairly common these days, although it sounds like many nurses still chart lengthy descriptions of normal findings. Is this still that common or does it just seem like from this thread?

bolding, mine.

if vomiting is something we'd expect, then no, I cannot see doing a head/toe assessment.

depending on their hx, comorbids, etc, I will intervene accordingly.

I've stated before and will repeat, there is no rubberstamping any one intervention r/t x, y, or z.

our nsg must be based on the unique presentation of ea pt we care for.

but the bottom line is (for me), I'd opt to chart defensively versus charting the absolute minimum.

we really need to cover our butts at all times.

leslie

OK, maybe I make my OP to brief. I do work out patient surgery, so like one poster said, I expect PONV, the patients are in and out the same day, antiemetics are routinely ordered. I'm comfortable with charting "vomited 20 ml fluid, lungs clear to auscultation." Just to CYA.

Anyway I did appreciate all the ideas, I get complacent in out patient surgery, good for me to remember all the potentials that could go wrong. Once in a while a patient doesn't recover and respond as they should and do need to get admitted. I lose my acute care thinking and skills!!!!!

Is sleeping comfortably better to say because it means they are still breathing? I just am not sure how it is very different than saying the patient is resting comforably?

I just had a pt. yesterday who vomited a large amount after lunch. I as a new nurse wasn't exactly sure what to do right away but I did lsiten for bowel sounds, looked at abdomen, asked pt. if they feel any pain with palpation of abdomen. I administered pt's prn zofran for nausea and vomiting after helping nurse aide put pt. in bed with hob at 90 degrees. I asked a nurse who has been a nurse for years if I should report the vomiting to the CNP and she said well what do her lungs sound like? and how much has she vomited? Has it been going on all day? and when was her last bm?? I think she likes to kind of freak me out but it was helpful and reminded me of things to look at.

Thank you that is helpful! I like "resting in bed with eyes closed, easily arousable, resps even and no obvious distress noted at this time" I will use that for sure.

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