Published Jan 7, 2013
Do_Good
73 Posts
Hi...could use some advice...
Today I went into a patient room and discovered the patient with a respiratory rate of 28-30, O2 Sat of 88. In my note I documented it as dyspnea.
I got home and now I'm thinking this......Should I have used the word tachypnea instead? If so....should I correct my note the next time I go in using proper correction methods?
Thanks....
Orion81RN
962 Posts
The term dyspnea can refer to either bradypnea or tachypnea. As long as you entered the objective data (the resp rate) your documentation is accurate. If you only entered "dyspnea" then this can be interpreted as fast or slow breathing or difficulty breathing. If you entered the resperatory rate then changing the word to tachypneic is a little redundant. I personally don't like the word dyspnea because someone can be have tachypnea or bradypnea and not FEEL short of breath. Its open to too much interpretation.
This is also a good example if not relying soley on numbers for assessment but the overall picture. Was the patient struggling to breath? How did he/she look? Did they just overexert themselves getting up...Is this abnormal for him/her? Don't get me wrong. I'm not saying you specifically weren't relying on your keen nursing observations. I just thought it was a good example of looking at the entire picture for any nurse reading this. For myself as well, as this made me stop and think :)
Orion...thanks for your comments. You answered my question! This was abnormal for the patient. Extremities were mottled, Pt was almost panting, and very lethargic. First thing after the visual assessment was VS, then grabbed the O2. Then the subjective assessment. Numbers don't lie and so, I agree with you that one has to look at the whole assessment. If he had a RR of 28-30 but O2 Sat of 97% and he had orders for Ativan, I'd think he might be anxious.
proud nurse, BSN, RN
556 Posts
I think you were right to document it as dyspnea based on the O2 sat and what you assessed. If I read your nurses note, I'd know that a RR of 28-30 was tachypneic.
BostonFNP, APRN
2 Articles; 5,582 Posts
Technically speaking...
Dyspnea is a subjective symptom. Did you ask the patient if they were breathless or having difficultly breathing?
It sounds like you assessed a patient that was lethargic, mottled, hypoxic, and tachypnix with ?labored breathing.
That being said, I don't think maybe people would give you a hard time about it.
Pt was sent out....ended up being septic.
I'm sorry to hear the diagnosis is sepsis :/ I hope he/she recovers. Awesome nursing assessment though :) I had a similar situation my first night off orientation. I sent him/her out and diagnosis was PE. Resident was treated and OK. But, yikes, scared me, being my first night.
Thanks for that. One of the nurse's on that second shift said to me, "we'll take over from here. You did the best you could." I really needed to hear what you said, "awesome nursing assessment."
Karen01
1 Post
Thanks You for your information. Very helpful for me
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