Questioning yourself... - page 2

We are told to "chart what we observe (or auscultate, etc)". So that's what I do... But what about those times when what I observe is vastly different from what the previous nurse charted? I find... Read More

  1. by   hoolahan
    Love those classic examples of people not doing assessments. I was admitted s/p MVA w head injury 8 1/2 mo pregnant, and pupil checks were charted on me. I KNOW no one checked my eyes, and I did have a head injury! Also had complete I&O documented, yet no one ever gave me a hat to measure urine, or even asked me if I had voided!!!

    My favorite one is the pupils though. For heavens sake, if ya don't have a flashlight, just leave that assessment blank or put "not assessed" much better than having someone document the prosthetic eye behind you!

    I say, you call em as you see em, yes check w another nurse you trust for clarity if need be, but don't be afraid of "embarrassing" the prior shift, if they documented assessments w/o actually doing them, they SHOULD be embarrassed in my book!
  2. by   Disablednurse
    I agree with the above about getting someone else to check behind you if you are worried, But. Read the last several chart entries and see if they look about the same. Could be that the nurses before you were doing copy cat charting. Maybe they just took the word of an untrained nursing assistant (no, I am not bad mouthing the CNAs). I just always chart what I see and what I feel on the patient. A lot of people visualize things differently. For example, 4+ edema to me is when you press and lose your fingers in the edema, the spots do not return to normal for quite a while. Others might see 4+ differently. That is more or less a judgement call as long as you follow what you have learned, you are not in the wrong. It will get easier as time passes by.
  3. by   cokie
    it's YOUR assessment. that is the reason that we reassess the pt. every 8 at least. call the m.d. if the change is one that is problematic. i.e., crackles to the lungs previously unassessed. change in status, v.s......good luck. learn to trust yourself...if it helps, don't read what they wrote, nightshift doesn't.....
  4. by   ohbet
    Sometimes questioning your self is good,thats one of the reasons we confire with other collegues,which is good nursing. Sometimes questioning self,overquestioning self,can make you nuts.So its a matter of degree between being cocky nurse and a being paralyzed nurse,psychologically.
    As far as lung sounds,isnt it possible to hear wheezes on one shift and not the other? How do you know the previous shift didnt mis ascultate the lungs sounds? .
    About edema....measureing edema is a subjective judgment,what is 4 plus to nurse mary could be 1 plus to nurse joe.
    So take a risk and chart what you observe.
  5. by   srose
    Just want to say, that as a student nurse who just did her own charting for the very first time, I am SO HAPPY to read this post!

    I've only been on the hospital floor for a few weeks, and only charted a few times, but I've already caught myself questioning my assessment results when I read the previous shift's results in the chart.

    I'm so glad to hear that I'm not alone, and the importance of trusting myself and asking for validation from an experienced nurse when appropriate.

    Love this board!

    Rose
  6. by   nimbex
    Originally posted by canoehead
    You can have an experienced person double check your assessments, but in a very short time you will learn to trust your own eyes and ears. Unfortunately sometimes the previous shift sometimes charts what the shift before did...and the error compounds. I don't know if they just don't look, or if they don't trust THEIR assessment skills. Use the previous assessment as a guide for possible trouble spots, but know that patients can and do turn on a dime, and your job is to catch them at it.
    What is said up above, plus, who the heck can can say that a major change did not occur? I document what I assess period, regardless of what I was "told or charted", if I notice a change, I might say "here come look at or listen to this, what do ya think?"

    but bottom line, you assess it you chart it, once you're comfortable you won't question the prior documentation... but I have also used this as a usefull tool to go back and re assess, and see if I missed something. Nothing wrong with that.
  7. by   MandyInMS
    You'll gain confidence over time panda..until then trust your OWN eyes and ears..and as other posters have said: when in doubt you can always get another nurse to assess with you when unsure I've been nursing for 13 years and still doubt myself sometimes when it comes to breath sounds...esp.when prior shift has charted something wayyyy off from what I am hearing....2 heads...or ears in this case, are better than 1 ..lol
  8. by   altomga
    This happens to me on several occasions. The previous shift will chart pulses where the pt has no legs, sometimes even radial pulses on a pt that has no arms. And yes, clear urine on a pt that is anuric!! This are obvious incorrect charting "bloopers"....but the other things, lung sounds, edema, heart sounds, etc...Pt status changes...I note how the pt was earlier, but chart MY FINDINGS!! I will notify the MD of any differences that need to be reported. ie) clear lungs on days, but on my shift fine crackles are heard....

    It is not wrong to double check your assessment "just to be sure", but always chart your findings!! Doubt is natural, I will always double check just to be sure
  9. by   New CCU RN
    If the patient's assessment is going to be the same throughout their entire hospital stay, why bother assessing them?????

    They change.... if you assess something different, so be it. Don't doubt yourself. IF it something the doc needs to know, let them, and go on with it.
  10. by   jude11142
    Originally posted by jmtmom
    Hi!

    Follow your own judgment. I'm a new nurse myself (1 year). You would be surprised how many nurses simply chart what the previous nurse charted.

    For instance, I had a patient with bilateral draining leg ulcers with dressings. Three shifts for the previous THREE DAYS charted that skin was normal. By the way, the dressings were placed when the patient was on another floor days earlier. Three shifts of nurses for three days had not noticed his leg ulcers, leg ulcers were not charted, dressings were not changed.

    If you don't hear wheezes, don't say that you do. If lungs sounds are diminished in the bases when YOU listen, then that's what you chart. When we chart an assessment, we chart what WE see (or hear or smell or feel) at the time that we perform the assessment.

    Wheezes can come and go. It may have been there, but no longer present when you listened. Especially if wheezes were mild to begin with.

    I have another story: I was assessing a patient's pupils as they reacted to light. One pupil was non-reactive to me. Previous nurse charted 2+ pupils bilaterally. So I went back again. Still no reaction. I thought "I'm a new nurse, maybe I'm just not seeing the reaction to light". I look at the history in the chart. Guess what. The patient had a prosthetic eye!

    Don't ever feel as if your assessment must agree with previous assessments. Some people just chart and don't truly assess.

    Believe in yourself. I'm sure you're doing great!:kiss
    I have to agree, trust your assessments. Many times, I have also had assessed/ausculated/ etc.......something totally diff. from the previous nursing notes. When it came to lung sounds, I would go back and listen again..........chart on what you hear/see/ etc.........
    Unfortunately, some do look at previous entries and write the same............even had a nurse admit to doing so in order to save time??????????? Sure wouldn't want her for a nurse. Thankfully, she was fired soon after because she wasn't giving out all of her meds.........and she was signing for them. Everyone was wondering how she was getting done so quick with her med passes. The sad part, is that when she got caught, she told administration that when she oriented, 2 of the nurses told her that they sometimes skipped the colace/senokot/tylenol/vitamins etc......esp when they were having a "hard day"..........Scary huh?

    Anyways, always use your own assessments, only chart on what you see/hear.......if you have doubts, it's ok to ask a coworker or supervisor to take a look at the pt............never ever make up or go by previous entries in the chart.

    Never ceases to amaze me what people do.

    JUDE

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