Questioning yourself...

Nurses General Nursing

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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!

Originally posted by canoehead

You can have an experienced person double check your assessments, but in a very short time you will learn to trust your own eyes and ears. Unfortunately sometimes the previous shift sometimes charts what the shift before did...and the error compounds. I don't know if they just don't look, or if they don't trust THEIR assessment skills. Use the previous assessment as a guide for possible trouble spots, but know that patients can and do turn on a dime, and your job is to catch them at it.

What is said up above, plus, who the heck can can say that a major change did not occur? I document what I assess period, regardless of what I was "told or charted", if I notice a change, I might say "here come look at or listen to this, what do ya think?"

but bottom line, you assess it you chart it, once you're comfortable you won't question the prior documentation... but I have also used this as a usefull tool to go back and re assess, and see if I missed something. Nothing wrong with that.

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Originally posted by canoehead

You can have an experienced person double check your assessments, but in a very short time you will learn to trust your own eyes and ears. Unfortunately sometimes the previous shift sometimes charts what the shift before did...and the error compounds. I don't know if they just don't look, or if they don't trust THEIR assessment skills. Use the previous assessment as a guide for possible trouble spots, but know that patients can and do turn on a dime, and your job is to catch them at it.

What is said up above, plus, who the heck can can say that a major change did not occur? I document what I assess period, regardless of what I was "told or charted", if I notice a change, I might say "here come look at or listen to this, what do ya think?"

but bottom line, you assess it you chart it, once you're comfortable you won't question the prior documentation... but I have also used this as a usefull tool to go back and re assess, and see if I missed something. Nothing wrong with that.

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You'll gain confidence over time panda..until then trust your OWN eyes and ears..and as other posters have said: when in doubt you can always get another nurse to assess with you when unsure :) I've been nursing for 13 years and still doubt myself sometimes when it comes to breath sounds...esp.when prior shift has charted something wayyyy off from what I am hearing....2 heads...or ears in this case, are better than 1 ..lol

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You'll gain confidence over time panda..until then trust your OWN eyes and ears..and as other posters have said: when in doubt you can always get another nurse to assess with you when unsure :) I've been nursing for 13 years and still doubt myself sometimes when it comes to breath sounds...esp.when prior shift has charted something wayyyy off from what I am hearing....2 heads...or ears in this case, are better than 1 ..lol

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Specializes in Interventional Pain Mgmt NP; Prior ICU and L/D RN.

This happens to me on several occasions. The previous shift will chart pulses where the pt has no legs, sometimes even radial pulses on a pt that has no arms. And yes, clear urine on a pt that is anuric!! This are obvious incorrect charting "bloopers"....but the other things, lung sounds, edema, heart sounds, etc...Pt status changes...I note how the pt was earlier, but chart MY FINDINGS!! I will notify the MD of any differences that need to be reported. ie) clear lungs on days, but on my shift fine crackles are heard....

It is not wrong to double check your assessment "just to be sure", but always chart your findings!! Doubt is natural, I will always double check just to be sure:)

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Specializes in Interventional Pain Mgmt NP; Prior ICU and L/D RN.

This happens to me on several occasions. The previous shift will chart pulses where the pt has no legs, sometimes even radial pulses on a pt that has no arms. And yes, clear urine on a pt that is anuric!! This are obvious incorrect charting "bloopers"....but the other things, lung sounds, edema, heart sounds, etc...Pt status changes...I note how the pt was earlier, but chart MY FINDINGS!! I will notify the MD of any differences that need to be reported. ie) clear lungs on days, but on my shift fine crackles are heard....

It is not wrong to double check your assessment "just to be sure", but always chart your findings!! Doubt is natural, I will always double check just to be sure:)

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If the patient's assessment is going to be the same throughout their entire hospital stay, why bother assessing them?????

They change.... if you assess something different, so be it. Don't doubt yourself. IF it something the doc needs to know, let them, and go on with it. :)

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If the patient's assessment is going to be the same throughout their entire hospital stay, why bother assessing them?????

They change.... if you assess something different, so be it. Don't doubt yourself. IF it something the doc needs to know, let them, and go on with it. :)

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Originally posted by jmtmom

Hi!

Follow your own judgment. I'm a new nurse myself (1 year). You would be surprised how many nurses simply chart what the previous nurse charted.

For instance, I had a patient with bilateral draining leg ulcers with dressings. Three shifts for the previous THREE DAYS charted that skin was normal. By the way, the dressings were placed when the patient was on another floor days earlier. Three shifts of nurses for three days had not noticed his leg ulcers, leg ulcers were not charted, dressings were not changed.

If you don't hear wheezes, don't say that you do. If lungs sounds are diminished in the bases when YOU listen, then that's what you chart. When we chart an assessment, we chart what WE see (or hear or smell or feel) at the time that we perform the assessment.

Wheezes can come and go. It may have been there, but no longer present when you listened. Especially if wheezes were mild to begin with.

I have another story: I was assessing a patient's pupils as they reacted to light. One pupil was non-reactive to me. Previous nurse charted 2+ pupils bilaterally. So I went back again. Still no reaction. I thought "I'm a new nurse, maybe I'm just not seeing the reaction to light". I look at the history in the chart. Guess what. The patient had a prosthetic eye!

Don't ever feel as if your assessment must agree with previous assessments. Some people just chart and don't truly assess.

Believe in yourself. I'm sure you're doing great!:kiss

I have to agree, trust your assessments. Many times, I have also had assessed/ausculated/ etc.......something totally diff. from the previous nursing notes. When it came to lung sounds, I would go back and listen again..........chart on what you hear/see/ etc.........

Unfortunately, some do look at previous entries and write the same............even had a nurse admit to doing so in order to save time??????????? Sure wouldn't want her for a nurse. Thankfully, she was fired soon after because she wasn't giving out all of her meds.........and she was signing for them. Everyone was wondering how she was getting done so quick with her med passes. The sad part, is that when she got caught, she told administration that when she oriented, 2 of the nurses told her that they sometimes skipped the colace/senokot/tylenol/vitamins etc......esp when they were having a "hard day"..........Scary huh?

Anyways, always use your own assessments, only chart on what you see/hear.......if you have doubts, it's ok to ask a coworker or supervisor to take a look at the pt............never ever make up or go by previous entries in the chart.

Never ceases to amaze me what people do.

JUDE

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