charting sleep question

[The Bell Jar]

So is it really unacceptable to chart that a patient is sleeping?Even if they are in bed with their eyes closed,you can only state that they are in bed with their eyes closed.Never 'Pt in bed asleep."??

[bookwormom]

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.

[fultzymom]

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.

If you chart that the patient is resting quietly with eyes closed, no distress noted, that pretty much covers everything, don't you think? To actually say someone is sleeping is kind of a judgement. If you have someone who is restless and you have the documentation, then you say, as stated above, that should work.

[Ivanna_Nurse, BSN, RN]

Wow. I always chart that they are asleep if I think that they are. On the other hand, I work in a small ICU where my eyes are peeled on them all the time. I usually chart something along the lines of..

Pt asleep but easily aroused when checked. Monitor remains attached and XXX noted. Respirations easy and regular. And then I throw in a blurb regarding what they were admitted for.

Cheers, ~Ivanna

[Lorie P.]

since i come on at 11pm and most of my pts have had sleeping or pain beds i will chart:

resting with eyes closed, easily aroused, denies any pain , discomort, resp even and non-labored with nad ( no active, acute or apparent distress) noted, cont to monitor.

now if a person is snoring i chart like this; pt snoring loudly, softy ( which ever it is) resp even and non-labored with nad noted, continue to monitor.

another way i chart after a pt has been given pain meds is like this : just an example,

pt c/o abd pain 6/10

lortab 5mg po

abd pain now 3/10 and continue to monitor.

so far have never had any problems and risk management has often told me, excellent charting when things have been sent to their office for what ever reason.

[morte, LPN, LVN]

yup, was taught it was the only time you could use the word "appears"...as in appears to be sleeping...with discription....now...grammarians, why non labored rather than unlabored?

[lil' girl, LPN]

:rotfl:

And then they say " I did't sleep at all last night". Go figure.

[lil' girl, LPN]

yup, was taught it was the only time you could use the word "appears"...as in appears to be sleeping...with discription....now...grammarians, why non labored rather than unlabored?

LOL I wish someone had had the nerve to ask our instructor that one!

[caliotter3]

I don't remember anyone saying anything about this in nursing school. I worked night shift while I went to nursing school, and was taught by my supervisors not to use the word "sleeping" because, like everyone has said, you don't know if they are sleeping unless you disturb them. This question is one of those mysteries of nursing life as far as I'm concerned. I love it when they snore, because then I get to write something about the sounds they are making while breathing!

[sharann, BSN, RN]

Maybe those instructors were taught that "sleeping patient" was a medical diagnosis? We wouldn't wan;t to be doing any of THAT would we. How about this. I was told to chart on a dressing, "dressing stained with bright red fluid". Don't call it blodd they said, that would be a diagnosis, and maybe it wasn't blood. Sure, maybe the patient was leaking strawberry jam out of their wound!

[caliotter3]

Just as long as it is not any of that brown or green stuff coming from the general area of the end of the gi tract! Now there's a potential diagnosis!

[EmmaG, RN]

Maybe those instructors were taught that "sleeping patient" was a medical diagnosis? We wouldn't wan;t to be doing any of THAT would we. How about this. I was told to chart on a dressing, "dressing stained with bright red fluid". Don't call it blood they said, that would be a diagnosis, and maybe it wasn't blood.

Arg. That is a pet peeve of mine. I'm not a complete idiot...

[S.T.A.C.E.Y, LPN]

"Pt resting in bed, eyes closed, breathing easily. No acute distress."