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Discussion

charting in psych-important question

So I'm a newbie psych nurse, and I notice alot of othe other nurses don't chart alot of the "physical" issues in too much detail. I know in psych nursing, the focus is obviously on psych! BUT--(and maybe since this is because I work on an eating disorders unit and this particular psych d/o can have alot of phsyical s/s, although I'm sure there are comorbidities on every floor in a psych hospital)--I don't see them really charting on things like "edema 2+ pitting" AT ALL on the nursing progress note. Our PA does this when she rounds, but still, the nursing progres note does ask about "phsycial symptoms" so don't thinks like tachycardia, edema, etc need to be addressed in addition to common things like "nasal congestion"? We are still nurses after all, and there is still somewhat of a focus on overall wellness, am I right?

What do you guys think? How do you handle this?

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Heck, if any clients are having 2+ pitting edema, I sure hope the nurses are charting it! I've been a psych nurse for a long time, and, while I don't do a head-to-toe physical assessment on clients, I certainly monitor/assess and chart on any significant physical complaints or sxs, and make sure they are followed up on appropriately (by the doc/NP/PA). Often, the RNs are the only staff who notice physical problems in psych settings, and, if we aren't alert and assertive about getting them investigated, no one else notices.

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