We are told to "chart what we observe (or auscultate, etc)". So that's what I do...
But what about those times when what I observe is vastly different from what the previous nurse charted? I find myself questioning my judgment and rechecking the patient...
It happened to me twice today. First patient I charted decreased breath sounds bilateral lower lobes, clear in the rest. The previous several shifts had charted expiratory wheeze. Now I listened to this patient multiple times and heard no wheeze at all. (Littman Classic II SE).
The second patient I charted as having 1+ pitting edema BLE. Previously he was charted with 4+. There is no way I would have called it 4+! But I checked several times throughout the day and while it did fluctuate a bit, it was never that severe.
I know part of my problem is that with my lack of experience I question my judgment. I do ask other people to come listen or look. I just feel like when there is such a big difference between what I see and what others have seen. I do realize it's entirely possible that these patients have changed also. I just hate feeling so unsure of myself!
