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.
yes...along those lines.what i wouldn't write (which i used to, btw) is "vss".rather, i would write out ea vs."cta" s/b written as clear to auscultation, just so there are no questions.and, while you want to address the risk of aspiration, you also want to address the possibility of sbo:so, "abd soft, non-tender (or whatever your findings are), bowel sounds + x 4 quads, lg soft bm noted on this shift...anything that would either point to or r/o the aforementioned.so yeah, you're on track.after all interventions, you can then write 'pt appears to be resting comfortably' or however pt presents.leslie

Thanks, good ideas. I like "patient resting comfortably" then I think of the lawyer in the courtroom. "Well, how do you know the patient was resting comfortably, maybe they were passed out." I know, it gets crazy and paranoia sets in!

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.

I'd write Lungs clear bilaterally all fields..

Everything Leslie said and remember..no matter what, when something happens the first thing a nurse does is ASSESS. Chart your assessment, lungs, bowels (ascultation and in bowel quadrants, I'd chart a palpation assessment as well->tender to palpation, bowel sound quality (are sounds present in all quads? typanic in nature?, etc.) Remember,as a nurse you can do assessments without an order. If this is a new situation, does it warrant a call to an MD and maybe labs ordered? (Labs: liver panel, amylase/lipase) any risk for pancreatitis/small bowel obstruction/ possible perforation? Also, is it important to make the pt NPO until this issues resolves? And then always chart a follow-up assessment as well as pt's statement regarding resoultion or possible worsening of symptoms. Just some thoughts off the top of my head. A lot of what you need to chart is going to be based upon reason for pt's admission to hospital and how the emesis may relate to that symptom.

Quote from brownbookThanks, good ideas. I like "patient resting comfortably" then I think of the lawyer in the courtroom. "Well, how do you know the patient was resting comfortably, maybe they were passed out." I know, it gets crazy and paranoia sets in!

Thanks to you "all nurses," all good things to think about. No more writers block.

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."

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

Quote from canesdukegirlDon'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."

Quote from elkpark it would be more accurate and useful to ask the client how s/he is feeling and document the client's response ("client states, "I'm feeling better now'" (or whatever)).

Quote from leslie :-Delkpark, love your idea, about asking pt how s/he feels then writing response.