Questioning yourself...

  1. 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!
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  2. 22 Comments

  3. 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.
  4. by   gwenith
    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.
  5. by   memphispanda
    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
  6. 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
  7. by   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.
  8. by   P_RN
    Trust yourself. If in doubt get a more experienced nurse to co-check you. We once had a patient with good pedal pulses with 2 sec cap refill movement and sensation good...for36 hours......he was a para with bilateral AKA......Do your own assessment. Things CAN change with edema and wheezes.
  9. by   Furball
    When I was a new nurse I had a pt with zero breath sounds on the left. I thought I was crazy because all the other notes said clear bilat. I read the history and found out th pt had one lung....ha...ha.....ha
  10. by   nurse2002
    What do you say when the nurse before you charts that your patient's pedal pulses are palpatable (did I spell that right?)
    and they are a bi-lat below the knee amputee?

    Really, this has happened to me.
  11. by   Furball
    ...or "urine clear yellow, suff quants" on an anuric dialysis pt?
    Last edit by Furball on Apr 27, '03
  12. by   BBFRN
    Stuff like this was cut down on our floor by having the charge nurse on days not taking a patient load, and doing all A.M. assessments. I've noticed much more accurate daytime assessments on my patients when I take them at night. Plus, it helps to not look at the flowsheet prior to doing your own assessment so as to not be influenced by what was previously documented.
  13. by   sixes
    I had a nurse chart previous to me on rounds pt comfortable and resting. I was very busy and had to put in a late entry. The client had passed away. So I guess comfy and resting was ok (HA HA)
    did she have some explaining to do.
  14. by   karenG
    I love the way you spell- oedema over here!!!

    guess you have to chart what you find- dont forget negative recording can be important. sometimes what you dont find is worth recording!!!! I often record negative findings.......for example a child who is pyrexial and c/o headache- I will record no neck stiffness, no rash etc. means I can prove I thought about the differential diagnosis!

    Karen

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