Assessment changes from person to person?!?

[mcknis]

I have realized as a new nurse during charting of my assessments that sometimes what I have seen is not what someone else has. For instance there have been times when I have heard clear lung sounds and others are documenting as diminished. I know that I feel competent in my skills, but have wondered if its my young ears vs old ears, new fancy stethoscope vs old "nurse" scope from WWI , etc? I thought it first was me so I would listen for much longer than usual. Then later I thought, maybe its the scope. So i went from my Littmann cardiology scope I used in school to a littmann select I used at work and all of a sudden i could tell the difference between clear and clear/diminished. it was odd. Everytime i used my CIII scope i could easy pick up on adventitious sounds but couldn't always pick up on diminished lung sounds because with this scope you hear everything clearly! Maybe its just me, but wanted to see if others have had differences in their assessments from other nurses...

[anonymurse]

Hey man it's always better to hear than not. I mean, RTs always have the crappiest scopes and they're always saying "What crackles?" Now let's say it's true, you can hear dim with one scope and fine crackles with another. Well choose to hear the crackles, 'cause no one's gonna come up and treat dim, right? I see dim charted where nurses can't be bothered to get the pt in position to adequately auscultate, that is, they won't listen to the lungs from the back. Absences are something else. One time I saw dim charted and heard absence, asked the pt and they said they'd had a lobectomy. With a better scope, you can confidently identify an absence.

About charting, chart what you hear. Trust your own eyes and ears. If you have time, you can ask another nurse to confirm, but one day when I didn't have time and I heard an absence of heart tones, I told the doc right away (the pt was on a stretcher about to go off the floor and the doctor was passing by). He told me to get a thoracentesis tray and he drew off a liter and a half.

When in doubt, don't rely on others' charting to guide you. Many times others will copy what was there before, and it can be wrong all the way back. Ask the patient. I saw PERRL and only PERRL charted for my pt. I was getting very little reactivity out of one eye and none out of the other and I began to doubt myself. I asked the pt and she laughed and said yes, no one had ever asked her before, but she had a glass eye on that side.

[mcknis]

I asked the pt and she laughed and said yes, no one had ever asked her before, but she had a glass eye on that side.

thats hilarious! I have been doing pupil assessment on all of my pts at admission, but seldom do it during their stay. I have yet to see a nurse assess pupil rxn on any pt. I asked the other day and several nurses told me,"we just do it when there is an abnormality we see, it just takes extra time we don't have."

[anonymurse]

thats hilarious! I have been doing pupil assessment on all of my pts at admission, but seldom do it during their stay. I have yet to see a nurse assess pupil rxn on any pt. I asked the other day and several nurses told me,"we just do it when there is an abnormality we see, it just takes extra time we don't have."

Well ya know, it just depends if they have some potential neuro issue. For instance, among lots of other indications, when I do my shift fall risk assessment and they've fallen in the past 3 months, I ask if they hit their head.

ER assessments are invaluable. I did an admission assessment on the floor last night and the guy said he'd never had his heart worked on, even when I asked specifically if he'd ever had a stent. The resident in the ER scribbled "stent" somewhere on her sheet, so when an intern later d/c'd his Plavix, I went back to the pt and described what a cath experience was like and then he said yeah, he remembered that, and after more talk finally he remembered getting a stent, so I called the intern back and he reinstated the Plavix.

Now sometimes no one really looks at a pt for decubiti. They don't want to get into that diaper 'cause they might have to clean something up. So I never trust others' skin assessments. I always ask the aides to come get me at bath time so I can see every square inch of a pt's skin, and last night sure enough this dude had necrosis so I got orders for Accuzyme etc. I have to see things for myself. It takes time, but I don't know how else to do it. And really it doesn't take that much time.

[TLCinCICU]

I have a cardiology stethoscope too. I love it. I have no doubts that I hear things peers don't. Bottom line, though, is that I'd rather be able to hear an ant fart than have doubts that I might have missed something. hehe

And similar to the glass eye story, I've found instances where someone would have charted 2+ for a DP pulse on a patient who has a BKA...

[anonymurse]

And similar to the glass eye story, I've found instances where someone would have charted 2+ for a DP pulse on a patient who has a BKA...

Yeah I've seen pulses charted for nonexistent limbs too! What a hoot!