Questioning yourself...

[memphispanda]

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!

[karenG]

I love the way you spell- oedema over here!!!

guess you have to chart what you find- dont forget negative recording can be important. sometimes what you dont find is worth recording!!!! I often record negative findings.......for example a child who is pyrexial and c/o headache- I will record no neck stiffness, no rash etc. means I can prove I thought about the differential diagnosis!

Karen

[karenG]

I love the way you spell- oedema over here!!!

guess you have to chart what you find- dont forget negative recording can be important. sometimes what you dont find is worth recording!!!! I often record negative findings.......for example a child who is pyrexial and c/o headache- I will record no neck stiffness, no rash etc. means I can prove I thought about the differential diagnosis!

Karen

[hoolahan, ASN, RN]

Love those classic examples of people not doing assessments. I was admitted s/p MVA w head injury 8 1/2 mo pregnant, and pupil checks were charted on me. I KNOW no one checked my eyes, and I did have a head injury! Also had complete I&O documented, yet no one ever gave me a hat to measure urine, or even asked me if I had voided!!!

My favorite one is the pupils though. For heavens sake, if ya don't have a flashlight, just leave that assessment blank or put "not assessed" much better than having someone document the prosthetic eye behind you!

I say, you call em as you see em, yes check w another nurse you trust for clarity if need be, but don't be afraid of "embarrassing" the prior shift, if they documented assessments w/o actually doing them, they SHOULD be embarrassed in my book!

[hoolahan, ASN, RN]

Love those classic examples of people not doing assessments. I was admitted s/p MVA w head injury 8 1/2 mo pregnant, and pupil checks were charted on me. I KNOW no one checked my eyes, and I did have a head injury! Also had complete I&O documented, yet no one ever gave me a hat to measure urine, or even asked me if I had voided!!!

My favorite one is the pupils though. For heavens sake, if ya don't have a flashlight, just leave that assessment blank or put "not assessed" much better than having someone document the prosthetic eye behind you!

I say, you call em as you see em, yes check w another nurse you trust for clarity if need be, but don't be afraid of "embarrassing" the prior shift, if they documented assessments w/o actually doing them, they SHOULD be embarrassed in my book!

[Disablednurse]

I agree with the above about getting someone else to check behind you if you are worried, But. Read the last several chart entries and see if they look about the same. Could be that the nurses before you were doing copy cat charting. Maybe they just took the word of an untrained nursing assistant (no, I am not bad mouthing the CNAs). I just always chart what I see and what I feel on the patient. A lot of people visualize things differently. For example, 4+ edema to me is when you press and lose your fingers in the edema, the spots do not return to normal for quite a while. Others might see 4+ differently. That is more or less a judgement call as long as you follow what you have learned, you are not in the wrong. It will get easier as time passes by.

[Disablednurse]

I agree with the above about getting someone else to check behind you if you are worried, But. Read the last several chart entries and see if they look about the same. Could be that the nurses before you were doing copy cat charting. Maybe they just took the word of an untrained nursing assistant (no, I am not bad mouthing the CNAs). I just always chart what I see and what I feel on the patient. A lot of people visualize things differently. For example, 4+ edema to me is when you press and lose your fingers in the edema, the spots do not return to normal for quite a while. Others might see 4+ differently. That is more or less a judgement call as long as you follow what you have learned, you are not in the wrong. It will get easier as time passes by.

[cokie]

it's YOUR assessment. that is the reason that we reassess the pt. every 8 at least. call the m.d. if the change is one that is problematic. i.e., crackles to the lungs previously unassessed. change in status, v.s......good luck. learn to trust yourself...if it helps, don't read what they wrote, nightshift doesn't.....

[cokie]

it's YOUR assessment. that is the reason that we reassess the pt. every 8 at least. call the m.d. if the change is one that is problematic. i.e., crackles to the lungs previously unassessed. change in status, v.s......good luck. learn to trust yourself...if it helps, don't read what they wrote, nightshift doesn't.....

[ohbet]

Sometimes questioning your self is good,thats one of the reasons we confire with other collegues,which is good nursing. Sometimes questioning self,overquestioning self,can make you nuts.So its a matter of degree between being cocky nurse and a being paralyzed nurse,psychologically.

As far as lung sounds,isnt it possible to hear wheezes on one shift and not the other? How do you know the previous shift didnt mis ascultate the lungs sounds? .

About edema....measureing edema is a subjective judgment,what is 4 plus to nurse mary could be 1 plus to nurse joe.

So take a risk and chart what you observe.

[ohbet]

Sometimes questioning your self is good,thats one of the reasons we confire with other collegues,which is good nursing. Sometimes questioning self,overquestioning self,can make you nuts.So its a matter of degree between being cocky nurse and a being paralyzed nurse,psychologically.

As far as lung sounds,isnt it possible to hear wheezes on one shift and not the other? How do you know the previous shift didnt mis ascultate the lungs sounds? .

About edema....measureing edema is a subjective judgment,what is 4 plus to nurse mary could be 1 plus to nurse joe.

So take a risk and chart what you observe.

[srose]

Just want to say, that as a student nurse who just did her own charting for the very first time, I am SO HAPPY to read this post!

I've only been on the hospital floor for a few weeks, and only charted a few times, but I've already caught myself questioning my assessment results when I read the previous shift's results in the chart.

I'm so glad to hear that I'm not alone, and the importance of trusting myself and asking for validation from an experienced nurse when appropriate.

Love this board!

Rose

[srose]

Just want to say, that as a student nurse who just did her own charting for the very first time, I am SO HAPPY to read this post!

I've only been on the hospital floor for a few weeks, and only charted a few times, but I've already caught myself questioning my assessment results when I read the previous shift's results in the chart.

I'm so glad to hear that I'm not alone, and the importance of trusting myself and asking for validation from an experienced nurse when appropriate.

Love this board!

Rose