In today’s lecture, we will focus on a member’s question sent out through SimpleNursing’s Ustream with Mike Linares. For those who are interested, this Ustream session is a weekly live meet-up of SimpleNursing members with a fee of $39 a month. Here, you get to ask any nursing-related question that you want to be personally tackled by Mike Linares.
For this session, we’ll be helping out a member who is interested in physical assessment, particularly one who is experiencing chest pain. We will give you details on how to chart a nursing process in a simple, clutter-free, concise manner which your clinical instructor will greatly appreciate.
First, you have to make sure that you are following the strict guidelines when charting your nursing process; this guideline is known as D-A-R. DAR stands for data, action, and response.
When charting data, it is not necessary to give too much information when writing down positive findings. What we want to provide is the raw, ugly data. It is important to remember that when charting, you are not required to put everything down in a narrative form, starting from how the eyes looked, how the grip is better, and so on. What you should focus on are the negative occurrences that the client is physically manifesting and complaining about.
Charting in General
The guidelines for charting cover a huge scope; whether the issue is concerned with chest pain, diabetes ulcer, electrolyte imbalance (hypokalemia and hypernatremia), and so on. What you have to focus on is what the client is complaining about.
If the condition is hypokalemia, you can expect cramp complaint. If the condition is hypernatremia, you can expect fluid retention due to increased sodium; furthermore, there will be bounding pulses which is apparent with a jugular vein distention. The point is, whatever the client is experiencing, that would be your primary complaint which you need to chart, and it will be shown in physical signs and symptoms.
Chest Pain Charting
Back to the member’s question, “How do you chart a client with chest pain?” Here are the following things that you need to do:
Start off with the narrative.
When checking the client, start off with his or her level of consciousness (LOC) along with the vital signs. Taking note of your client’s LOC and vital signs will provide a snapshot of how your client is doing bot neurologically and physically.
The vital signs are essential because it will give you a glimpse of how the client’s cardiovascular system, oxygen exchange, temperature, and respiratory rate are doing altogether.
When charting LOC, you should indicate “Alert and oriented x 4” or AO x 4.
How would you know if the client is an AO x 4?
You have to ask four simple questions that can determine your client’s orientation. The four questions are:
- What is your name?
- What is your birthdate?
- What is today’s date?
- Who is the current president? (or anything relevant and is happening at present)
If the client manages to answer these questions, that’s the time you can chart an AO x 4; this means your client is responsive to the four questions provided.
But, what if you’re caring for a comatose client?
If the client is comatose, write “unresponsive.” However, if the client is responding to pain or to a sterile rub, you can write down “responsive to stimuli.”
Alert and Responsive is Zero
If a client who is alert and awake does not respond appropriately to the questions asked – doesn’t know his or her name, the time, date, location – indicate on your charting an AO x 0. This means that the client is alert but is not responsive.
Charting Focus Assessment
In nursing school, it’s quite difficult to anticipate what instructors want because they have repeatedly inculcated in you that you should do a head-to-toe assessment with every client you encounter. This situation can be confusing at first because you are aware that doing head-to-toe means you have to do an overall physical assessment. However, a head-to-toe does not literally mean that you have to start from the head all the way to the toes.
A head-to-toe assessment basically means that you need to do a full body assessment, to look at the client, and check if he or she has anomalies. You need not document everything you see, just the necessary ones, especially conditions that are related to your client’s condition.
Focus assessment, on the other hand, is an assessment that is primarily focused on the client’s chief complaint; which simply means prioritizing on why the client is inside the hospital in the first place.
So, for a client who has chest pain, after taking the vital signs, you should ask if he or she is currently experiencing any pain. If the client says, “No,” chart it down. This is how focus assessment is done – Client complaining 0/10 pain. There is no need to go through OPQRST.
Then cardiac assessment must follow. This is when you have to listen to the heart sounds of your client – atrial, pulmonic, and tricuspid (earth’s points). You also have to listen to the apex for what?
The answer for this will be discussed in our next lecture. See you there!