Assessing the Chart Versus Assessing the Patient

This week I had a nursing student share one of her clinical experiences with me and I wanted to share it with all of you. She had a 70 year old female patient admitted with pneumonia. After prepping for her patient and reading her chart she noted that many of the nurses had reported altered mental status and that the client had to be fed her meals by a nurse. After completing her morning shift assessment the student nurse reported the patient to be alert and oriented x 3 with her spouse sitting at the bedside. When she took the client's breakfast tray in, the student nurse asked the client if she would need assistance with her meal. The client reported she was fine and wondered why the nurses continued to try and feed her. After further assessment the student reported that after eating about 50% of her meal the patient became nauseated and did not want to continue to eat. When the student reported these findings to the primary nurse, the nurse informed the student that the patient needed to be fed due to her altered mental status. The student questioned the nurse regarding the prn medication of zofran and asked if she could give this to the patient. The nurse said she would give it, but she was too busy at the time, and 30 minutes later she still had not given the med.

It is obvious to me that the nurse was choosing to assess the patient chart rather than the patient. The clinical instructor was informed of the situation and the client did receive her medication, however I feel that if the student had not been with this particular patient that day this would have played out much differently.