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!
Trust yourself. If in doubt get a more experienced nurse to co-check you. We once had a patient with good pedal pulses with 2 sec cap refill movement and sensation good...for36 hours......he was a para with bilateral AKA......Do your own assessment. Things CAN change with edema and wheezes.
Trust yourself. If in doubt get a more experienced nurse to co-check you. We once had a patient with good pedal pulses with 2 sec cap refill movement and sensation good...for36 hours......he was a para with bilateral AKA......Do your own assessment. Things CAN change with edema and wheezes.
When I was a new nurse I had a pt with zero breath sounds on the left. I thought I was crazy because all the other notes said clear bilat. I read the history and found out th pt had one lung....ha...ha.....ha
When I was a new nurse I had a pt with zero breath sounds on the left. I thought I was crazy because all the other notes said clear bilat. I read the history and found out th pt had one lung....ha...ha.....ha
Specializes in Trauma,ER,CCU/OHU/Nsg Ed/Nsg Research.
Stuff like this was cut down on our floor by having the charge nurse on days not taking a patient load, and doing all A.M. assessments. I've noticed much more accurate daytime assessments on my patients when I take them at night. Plus, it helps to not look at the flowsheet prior to doing your own assessment so as to not be influenced by what was previously documented.
Specializes in Trauma,ER,CCU/OHU/Nsg Ed/Nsg Research.
Stuff like this was cut down on our floor by having the charge nurse on days not taking a patient load, and doing all A.M. assessments. I've noticed much more accurate daytime assessments on my patients when I take them at night. Plus, it helps to not look at the flowsheet prior to doing your own assessment so as to not be influenced by what was previously documented.
I had a nurse chart previous to me on rounds pt comfortable and resting. I was very busy and had to put in a late entry. The client had passed away. So I guess comfy and resting was ok (HA HA)
I had a nurse chart previous to me on rounds pt comfortable and resting. I was very busy and had to put in a late entry. The client had passed away. So I guess comfy and resting was ok (HA HA)
P_RN, ADN, RN
6,011 Posts
Trust yourself. If in doubt get a more experienced nurse to co-check you. We once had a patient with good pedal pulses with 2 sec cap refill movement and sensation good...for36 hours......he was a para with bilateral AKA......Do your own assessment. Things CAN change with edema and wheezes.