charting resting with eyes closed vs "asleep"

[smartnurse1982]

Anyone can give me the rationale for charting resting with eyes closed? In Ny where I went to school we just charted "Pt asleep." But in another part of the country they are saying its unprofessional. Which one is better to chart? Is there anything written evidence that supports one over the other?

[Otessa, BSN, RN]

I've written "appears to be sleeping" not the what the OP wrote as an option, hmmmm.

otessa

[nursel56]

Ha ha! And for most of my years as a nurse, "appears to be asleep" was supposed to save me from the dreaded "ass-u-me" thing. I suppose "resting with eyes closed" avoids any dangerous assumptions by nursing personnel, but if someone has their arm flung out sideways, mouth open and snoring to raise the roof, "resting with eyes closed" seems somehow. . . inadequate. Are we allowed to write down REM if we see it?

I now know why overcharting is a recipe for many types of tempests in teapots and the reason for the check-off boxes and small area for narrative in our Home Health charts. There are a lot of nurses who gauge their quality of nursing care by the length and amount of minute unnecessary details written down. If you checked the box "skin warm and dry" you don't need to write "skin warm and dry"!!Ironically, this makes their note less effective as people simply do not read a wall of itty-bitty printing. Sorry for the mini-vent. :)

I vow never to use the phrase "appears to be sleeping" again.

[smartnurse1982]

I had never heard of charting "resting with eyes closed" until today and I have been an RN for over 18 years.

Is this regional?

otessa

See, like u I 'm starting to think it is. But maybe not. Now I will tell u I have never heard of "appears to be sleep" untill today.as someone in an earlier post pointe out,what if someone slips into a coma and u chart asleep. Maybe resting with eyes closed would be more fitting,I guess. Oh well,wouldn't be nice if everyone was taught the same thing?

[smartnurse1982]

I work in AlF and all residents must have a weekly note whether they are baseline or not. Maybe I could be wrong but not charting on residents for up to 6 months doesnt seem right. (excuse my grammer/spelling Im typing on my phone)

It doesn't seem righ to me either. This chart I flipped through didn't even have a monthly summary.

[kimmie4476, ASN, RN]

I too use "resting with eyes closed, respirations even and unlabored" or "0 S/S of distress" instead of asleep, because, how do I know that they are asleep? Even snoring doesn not mean they are asleep

[morte, LPN, LVN]

I don't like writing that a person is "sleeping" or even "resting with eyes closed". Luckily, I work in the ED and most of my patients do not sleep. In the morning if I get endorsed patients I might wright "sleeping and arousable" or some other way to let someone know the patient is sleeping and not unresponsive. I have been endorsed "sleeping" and "drunk" patients before who decided not to wake up and then became ICU patients. How do we know that "sleeping" or "resting with eyes closed" is not really "bleeding in brain"?

Don't ya know! had that happen to me.....elderly "train wreck" recently out the ICU....Fowlers position VS gd....RR fine.....couldnt wake him in the AM.....not good.....

[anonymurse]

I chart "snoring" when I can.

[nursel56]

I see this "sleeping at long intervals" and "sleeping at short intervals" pretty often. That does tell me something about the patient. So I guess charting in the narrative every time they aren't resting with eyes closed and when they open them again is the most accurate way to do it? I'm probably overthinking this.