in the wake of a rather silly lawsuit (patient claimed that three young, beautiful women and one fat old broad -- that would be me -- "strapped him down and fondled his privates" all night long and while he had rather enjoyed the experience, upon reflection he felt that "it just wasn't right, and other people wouldn't be as opened minded.") our manager called a staff meeting to ensure that such a thing would not happen again. (the lawsuit -- i'm sure she doesn't actually believe we sexually assaulted the patient). one thing that came out of the meeting was that there are patients who are as crazy as bedbugs but the charting doesn't reflect that. "let's make sure we document if the patient is confused, people."
that mandate has led to some rather interesting charting:
"patient grabbed my nuts and yelled "you won't get away from me this time." (nurse wasn't a native english speaker. cna pointed out that "nuts" isn't proper terminology. nurse revised the charting to read that the patient "grabbed my balls.")
"heard patient screaming and rushed to room to find foley catheter wrapped around his hand and stretched to near breaking. patient complains of penile pain. teaching done re: correlation between pulling on foley catheter and penile discomfort." later, the nurse charted that she "entered the room to find foley catheter lying on bed next to patient. patient states that "some dude came by and pulled it out. honest!""
"patient restless and agitated, asking for water despite npo status. claims that "that guy" (pointing to intubated, comatose patient in the next bed) gave him some earlier and he can't understand why he won't just go get him some more."
"patient concerned about hearing voices. intercom silenced." and later on that shift, "patient found with arterial line in teeth, bleeding from radial artery. pressure held. patient claims that the voices told him to take that thing out or he wouldn't get to go to his room."
"oriented to person, place and situation although he is inappropriate at times. attempting to converse with alaris pump." what didn't get charted was the part where he was furious that "that uppity bastard won't answer me."
"patient is confused no matter what the doctor says. the doctor wasn't in the room wrestling with him all damned night!"
"heart rate in the 120s, temperature is rising and patient is becoming increasingly agitated and demanding a margarita. patient was admitted to ccu approximately 72 hours ago. patient's wife states that patient never uses alcohol of any kind, although he does take little blue pills like candy. wife produced 5 quart bucket filled with valium tablets."
i guess we have a little more work to do on our charting!
lol, I'm definitely guilty of charting as above at some point. It's not easy trying to objectively describe some patient antics. Honestly, I think its better its write it (even if it sounds silly) than not if you can't think of a better way of describing something. Usually I try to stick with the generic "A+O" , "confused/agitated" etc--but really that doesn't tell you much. I feel less like an idiot writing it though. It's interesting when everyone starts documenting mental status though--I had a patient once who was documented to believe he was in a different, glorious place every day. The candy shop. Wall Street Journal headquarters. A trailer. The library. The circus. "pt believes it is 1988 and he is at Wall Street Journal headquarters" Thank you for telling us that, case management. "pt believes he is on the boarwalk headed to the cotton candy stand" Appreciate the info, chaplain.
It's funny--but it actually helped us establish a reasonable picture of exactly how confused the patient was during the week, and we even saw when he was kind of getting better. Near the end of his stay when he was kind of coming around, I asked him for for the millionth time "you know where you are?" he looked me dead in the eye "yeah, I don't f*&^ing know the answers to your questions". I moved on.
I'm with you, although one time I documented what happened when a patient assaulted me and the manager demanded that I change my charting so that it would not be apparent that I was hurt.
Specializes in med-surg, psych, ER, school nurse-CRNP.
I'm with you, although one time I documented what happened when a patient assaulted me and the manager demanded that I change my charting so that it would not be apparent that I was hurt.
And that's when I turned in my notice.
I'll second the "Jesus in a basket" comment. I'd have turned in my notice too. WHERE I would have turned it in is another matter entirely.
Specializes in med-surg, psych, ER, school nurse-CRNP.
And, Ruby, thank you. This should have come with a spew warning, but thank you. You know, once you clear the Mountain Dew out of your sinuses, the pain is actually almost bearable.
"oriented to person, place and situation although he is inappropriate at times. attempting to converse with alaris pump." what didn't get charted was the part where he was furious that "that uppity bastard won't answer me."
that's been me many times...just got in-serviced today on some new nifty alaris features we will be utilizing, should be a fun way to add more time to every task.
My favorite was the confused physical rehab pt that rang at 0300 c/o about the " man with a hard on" standing next to her bed.It was a transfer pole with a horizontal bar to grab onto.
Specializes in Onc/Med-Surg, ER, Nursing Supervisor.
"patient is confused no matter what the doctor says. the doctor wasn't in the room wrestling with him all damned night!"
lol. i'm still a sn, but one nurse i was working with had to chart why meds weren't given on time and they literally charted that the pharmacy people were morons. (despite several calls and trips to pharm, they just couldn't seem to get the meds right.)
Specializes in oncology,med-surg,orthopedics, tele.
Also important to emphasize in your charting when a person appears completely a+o, and ringing appropriately for assist. You never know when they'll do something off the wall later! I had a patient once who appeared completely a+o all night suddenly decide to get himself out of bed at 2am on his brand new hip, fall to the floor, and drag himself halfway to the bathroom. I didn't have his bed alarmed because he appeared to be totally with it & understanding of his situation. The patient weighed about 400lbs & fell in front of the door so we couldn't even get in at first! It took 6 people to get him back into bed. I felt completely at fault, even though I had no way of knowing he would do something like that. From now on I chart when my patients have been "ringing appropriately for assistance", in addition to the standard a+o. (and if there is an alarm built into the bed I slyly turn it on at bedtime for all new ortho patients!) PS-kanzimonkey, got your PM but I can't contact you back! email?
)
Moogie
1 Article; 1,796 Posts
I read that as "Viagra" at first, too.