Questioning yourself...

[memphispanda, RN]

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 myself questioning my judgment and rechecking the patient...

It happened to me twice today. First patient I charted decreased breath sounds bilateral lower lobes, clear in the rest. The previous several shifts had charted expiratory wheeze. Now I listened to this patient multiple times and heard no wheeze at all. (Littman Classic II SE).

The second patient I charted as having 1+ pitting edema BLE. Previously he was charted with 4+. There is no way I would have called it 4+! But I checked several times throughout the day and while it did fluctuate a bit, it was never that severe.

I know part of my problem is that with my lack of experience I question my judgment. I do ask other people to come listen or look. I just feel like when there is such a big difference between what I see and what others have seen. I do realize it's entirely possible that these patients have changed also. I just hate feeling so unsure of myself!

[memphispanda, RN]

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 myself questioning my judgment and rechecking the patient...

It happened to me twice today. First patient I charted decreased breath sounds bilateral lower lobes, clear in the rest. The previous several shifts had charted expiratory wheeze. Now I listened to this patient multiple times and heard no wheeze at all. (Littman Classic II SE).

The second patient I charted as having 1+ pitting edema BLE. Previously he was charted with 4+. There is no way I would have called it 4+! But I checked several times throughout the day and while it did fluctuate a bit, it was never that severe.

I know part of my problem is that with my lack of experience I question my judgment. I do ask other people to come listen or look. I just feel like when there is such a big difference between what I see and what others have seen. I do realize it's entirely possible that these patients have changed also. I just hate feeling so unsure of myself!

[canoehead, BSN, RN]

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.

[canoehead, BSN, RN]

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.

[gwenith, BSN, RN]

Patients change and respiratory sounds are notoriously variable in interpretation. Just chart what you have found and move on.

As for the 4+ oedema - not to cite the obvious but was the patient sitting out of bed when you or the previous shift assessed them? Postion can change ankle the degree of ankle oedema in a relatively short time.

[gwenith, BSN, RN]

Patients change and respiratory sounds are notoriously variable in interpretation. Just chart what you have found and move on.

As for the 4+ oedema - not to cite the obvious but was the patient sitting out of bed when you or the previous shift assessed them? Postion can change ankle the degree of ankle oedema in a relatively short time.

[memphispanda, RN]

Originally posted by gwenith

As for the 4+ oedema - not to cite the obvious but was the patient sitting out of bed when you or the previous shift assessed them? Postion can change ankle the degree of ankle oedema in a relatively short time.

He was just in the bed...he has hx of right side CVA, his left side has atrophy and contractures so he is rarely out of bed. He did have scrotal edema that was pretty severe, but the ankles and feet were just a little puffy--certainly no worse than mine at the end of a 12 hour shift. :chuckle

[memphispanda, RN]

Originally posted by gwenith

As for the 4+ oedema - not to cite the obvious but was the patient sitting out of bed when you or the previous shift assessed them? Postion can change ankle the degree of ankle oedema in a relatively short time.

He was just in the bed...he has hx of right side CVA, his left side has atrophy and contractures so he is rarely out of bed. He did have scrotal edema that was pretty severe, but the ankles and feet were just a little puffy--certainly no worse than mine at the end of a 12 hour shift. :chuckle

[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

[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

[Agnus]

If you are TRULY unsure get someone to verify what you observe. Then document that two nurses checked this. Better yet get the other nurse to sign with you that your assessments were verified by her.

Breath sounds change quickly. If the patient had just had a breathing tx before your assessment and was due for one before the other nurse's assessment that can make a HUGE difference. Try to listen before and after tx. Aslo before and after activities that may get secretions moving or airways open.

Breath sounds are very changeable.

Edema is subjective. Had the pt, been sitting with limbs dependent when assessed by the other nurse? Since this is such a subjective call this is one where I would have an experience nurse who's judgement I trust check me. Over time you will get a better feel for this assessment.

Then, here is the clincher. Did the other nurse actually do a good assessment? Or did she just copy what the previous shift wrote. IT HAPPENS.

Trust what you see, hear, feel. Patient conditions change. That is WHY you are assessing them.

If an experienced and competent and concientions nurse verifies your findings several times (at the same time you do assessments) then you can feel confident that you are right and from then on do assessments without her.

My guess is that your assessments are right.

[Agnus]

If you are TRULY unsure get someone to verify what you observe. Then document that two nurses checked this. Better yet get the other nurse to sign with you that your assessments were verified by her.

Breath sounds change quickly. If the patient had just had a breathing tx before your assessment and was due for one before the other nurse's assessment that can make a HUGE difference. Try to listen before and after tx. Aslo before and after activities that may get secretions moving or airways open.

Breath sounds are very changeable.

Edema is subjective. Had the pt, been sitting with limbs dependent when assessed by the other nurse? Since this is such a subjective call this is one where I would have an experience nurse who's judgement I trust check me. Over time you will get a better feel for this assessment.

Then, here is the clincher. Did the other nurse actually do a good assessment? Or did she just copy what the previous shift wrote. IT HAPPENS.

Trust what you see, hear, feel. Patient conditions change. That is WHY you are assessing them.

If an experienced and competent and concientions nurse verifies your findings several times (at the same time you do assessments) then you can feel confident that you are right and from then on do assessments without her.

My guess is that your assessments are right.