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Used wrong word in documentation

Nurses   (3,785 Views 11 Comments)
by Do_Good Do_Good (Member) Member

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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....

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Orion81RN has 7 years experience.

787 Posts; 8,029 Profile Views

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.

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Orion81RN has 7 years experience.

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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 :)

Edited by Orion81RN
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68 Posts; 3,735 Profile Views

Orion...thanks for your comments. You answered my question! :yes: 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.

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proud nurse has 15 years experience as a BSN, RN and specializes in Medical Oncology, Alzheimer/dementia.

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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.

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BostonFNP specializes in Adult Internal Medicine, Hospitalist.

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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.

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Orion81RN has 7 years experience.

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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.

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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." :yes:

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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 You for your information. Very helpful for me

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Orion81RN has 7 years experience.

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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." :yes:
That's a shame, that would have been a great learning opportunity. I've had situations come up where a nurse somewhat takes over but keeps me involved telling me what to do and why. Some of it, I already knew what to do, some of it I didn't so I just soaked up the pertinent info and learned. But don't let anyone take from you what you DID. You saw the patient. You assessed 'something's wrong' and did a further assessment leading to your patient getting the help they needed :)

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