charting sleep question

oh, i thought this was going to be tips on how to chart while asleep..like at 3AM or so...lol....

Seriously though, how do you "know" they are asleep, what if they are just lying there with eyes closed....what about something more like patient resting comfortably....etc...

I always chart "pt sleeping easily arousable to ect ect resp equal and nonlabored . no c/o at this time..no distress at this time ect ect. That way they know you are assessing your pt. Also if there was a specific reason they came in for (this is ER mind you) ie SOB CP i will chart that and also pt denies such and such at this time.

Hope that helps !!

I know in nursing school we were always told not to chart that a patient was asleep. What if they were really dead?? I think they said to say "Patient resting in bed with eyes closed. Respirations even and unlabored" Just throw something in there to show that you actually did check. I'm a little paranoid so I always make sure the patient is breathing even if I'm pretty sure they're just asleep. My hospitals system for charting rounds doesn't have a "resting with eyes closed" option so I always just mark that they were asleep. Hopefully it won't come back to haunt me someday :uhoh21:

Yes you can only chart that they are resting with their eyes closed, because you don't know if they are sleeping.

We were also taught not to chart resting comfortably because some patients pain threshold may be lower or higher than anothers so we have to chart no c/o pain or discomfort. ie; resting with eyes closed, no c/o pain or discomfort.

I know in nursing school we were always told not to chart that a patient was asleep. What if they were really dead?? I think they said to say "Patient resting in bed with eyes closed. Respirations even and unlabored" Just throw something in there to show that you actually did check. I'm a little paranoid so I always make sure the patient is breathing even if I'm pretty sure they're just asleep. My hospitals system for charting rounds doesn't have a "resting with eyes closed" option so I always just mark that they were asleep. Hopefully it won't come back to haunt me someday :uhoh21:

Thats another thing they threw in too. Our nsg instructor would scream at us if we wrote respirations even and unlabored. We HAD to write regular and non labored. She would say "how can you tell if their respirations are even, are you counting in between intervals to see if there is the same amount of time between each respiration and does each breath last as long as the other. Boy oh Boy was she a stickler.

I was taught not to chart that a patient is sleeping. But if they are, I do. I always found it just a tad bit insulting the implication that nurses weren't considered intelligent enough to know the difference...

I was taught not to chart that a patient is sleeping. But if they are, I do. I always found it just a tad bit insulting the implication that nurses weren't considered intelligent enough to know the difference...

I agree- especially if they are snoring!

I agree- especially if they are snoring!

:rotfl:

Or if they are a baby or very little kid... it's not like they know how to fake sleeping!!

I chart pt appears to be sleeping comf when checked I've never been told this was unacceptable, even on the flowsheet, when reassessed after being medicated for pain,we write asleep, NM have never had a problem so far...

I always chart something like, "Patient resting quietly with eyes closed. Respers even et non-labored. No signs of distress noted."

Hope this helps some.

If we give the patient a PRN sleep med, how do we assess its efficacy unless we chart that the patient is sleeping? To say "appears" sleeping means that we cannot document that the med worked. But I wouldn't want to wake someone up to confirm that they were sleeping!

On the other hand, patients can fake sleep for various reasons.

Really, a very tricky question.