Going to ER from ICU. Help! - page 2
I recently accepted an ER position, I did CVICU previously. I know that in the ED the assessements are more focused. However, during my share day the nurses would document a full-head to toe without... Read More
Jan 2, '13I never look at butts either on my assessment, lol. I figure the doc will, and they usually grab a witness which may or may not be me. But if they get a witness for a personal area, shouldn't I, and by that point do that many people really need to take a gander? I will peek at throats if the patient is cooperative. I looked in an ear ONCE because the patient had a TOOTH lodged in his ear and I wanted to see that (it was pretty awesome, huge molar, no clue how it fit in the first place).
Jan 2, '13The best antidote against that anxiety is to be honest. Chart what you see, don't make up anything that you did not see, and, if you have to answer for it under oath, hold your head up high and tell the truth. If your only plan is to tell the truth, you do not have to worry about developing strategies for handling any hypothetical future event. And yes, I have been deposed re: my notes on a patient. All of my answers were as follows: "yes," "no," "I do not remember," or "I do not understand the question." I was not afraid because I was not planning to do anything but tell the truth; including "I don't know," when that was the truth.
Jan 2, '13as a former ICU nurse I understand the need to do a head to toe assessment. I am now working for hospice and still do a head to toe assessment. Where my job now requires mostly documentation vs actually taking care of a pt I will never stop head to toe. You will adjust in the ER as it becomes more comfortable for you. Good luck.
Jan 2, '13To the OP congratulations on your new position. I always liked critical care, landing in the ICU would be awesome and though I would love the ER, I do not think a new graduate like myself is up to par on that.
You are getting sound advise from experienced nurses here, even I as a new graduate (not working yet), would know better than to chart something I did not do. It is true sometimes you can multitask and do several assessments at once.
To the other poster where student went to assess a patient with BKA, wow....that is doing the job half a#%, the fact that those students reported pedal pulses where there were none to take from . and BP when the patient was diseased, scares me...I cannot imagine if they would have made it through the program and to think of them as possible peers of mine.
Jan 2, '13Our charting has WDL and N/A buttons. It's nice because if someone comes in with say a broken/sprained extremity you can go through and chart on Resp, Cardio, Muscularskeletal, Skin, but then have the option for G/U N/A. In stead of just leaving it blank, you can hit that box acknowledging that you didn't ignore the system but that it didn't have any relevance to this visit.
Jan 2, '13Quote from VishwamitrWow. That is quite amazing!17 years ago, our nursing instructor sent nursing students into 2 separate patient's room; one student at a time, to "assess" pedal pulses of one and "measure the BP" of the other patient. We had a gag-order not to discuss our findings.
4 students were rusticated from the nursing program instantly because 2 students reported pedal pulses and 2 reported their blood-pressure "findings" with numerals.
Turned out, the former patient had bilateral BKA, and the latter had already died just a while ago.
I never document what I didn't assess or see for myself.
Jan 2, '13If I'm talking to a person who is young and healthy and has pink nail beds, I sometimes will put radial pulses present. Or I will touch their hand when checking vitals. All is warm, I document present pulses. I have never documented pedal pulses without assessing and on elderly or depending on history, I also check radial pulses (or in case of injury). I don't document breath sounds or heart sounds without listening. I come behind some people with crazy documentation.
Jan 4, '13You can also chart a quick assessment. For example, for SionainnRN’s hypothetical pt c a broken vs. strained ankle, you could note, "Well oriented and speaking clearly and appropriately. Respirations regular and unlabored. Skin warm and dry. Denies any complaint or medical problem other than the pain in his ankle."
O.K. O.K. I know that I am gonna get flamed because of the superficiality of my assessment, and I probably deserve it. (Exactly what does "speaking appropriately" really mean?). However, this note would record the fact that I was attentive to the possibility of additional problems in other organ systems, and honestly indicate what lead me to the conclusion that more detailed assessment could be safely deferred.
Just throwing this out there for discussion; not claiming to be right.
Jan 4, '13I think that is a fine thing to document. It indicates a basic assessment of neurological, respiratory, and circulatory status. Had your basic assessment revealed anything outside of normal limits, surely you would assess further.
Jan 5, '13Quote from CountyRatI usually word it a bit differently (for example, "answering questions appropriately), but I think this it a legitimate part of a neuro assessment.(Exactly what does "speaking appropriately" really mean?)
It is a bit of charting a normal, but, in cases of stroke w/u, this is a pertinent normal. You would certainly chart that they "inappropriately answer questions" if they said Teddy Roosevelt is the current President or if they answer the question "where are you know?" with "hamburger."