[Tait]

I am a proprietor of patient safety AND comfort. I work 12 hour nights, I love to let stable, D/C am patients sleep as much as possible.

I understand that by making an autonomous decision to let my patient sleep through a set of vital signs I am putting myself at risk. Risk that something could go wrong, risk that my patient may bottom BP randomly (though I hope I am through enough to see something like that coming way before deeming them "Q4 VSS while awake".)

My question is when marking on the graphic I have three options.

"Pt Refused"
-nothing-
and what I generally put lately "Pt Stable, VSS deferred"

Now I have a hard time lying so putting "Pt refused" to me is a blatant error on the chart, unless they really are being a crabby person about being worken up.

Putting nothing makes it look like I didn't even think about vitals, or they were missed all together. Once again, negligent.

So for me "Pt Stable, VSS deferred" means "I assessed the patient, they are stable, I am letting them rest and monitoring"

Anyone ever mulled this over before?

Tait

PS. Just to clarify I will be asking my supervisor this same question.

[carebearRN08]

Yes, I am in the same boat and usually put "Pt. sleeping, did not wish to be disturbed" which if I ever have to defend myself says "This pt was stable enough to not need midnight vitals taken and did not want to be woken up. If I felt the pt. needed closer monitoring, bet your bottom dollar they would have been awakened regardless". Hopefully the people reading my charting understand that I would wake the pt up if they were in a condition that needed that close of monitoring, or even if I gave a bedtime beta-blocker.

[mom4josh]

I, too, absolutely hate to wake people up for MN VS, only a few hours after they have taken a sleeping pill and pain pill, are finally off in dreamland without pain, and here comes the clunky, noisy b/p machine rolling into their room startling them out of their minds!

It's bad enough when there is an 0200 antibiotic for which you must go in, flush their heplock, hook them up, turn on the machine, only to wait for it to beep in 30 minutes and wake them again, flush their line, unhook them, and tell them to go back to sleep... just to wake them for 0400 VS? Gimme a break! It's no wonder our patients get grumpy after a few nights of this!

I'm curious to read other replies as well.

[RN-Cardiac]

At my last job we were required to do Q1hr rounds. The RN was required to do this as well as the aid/tech,..this means that twice an hour a staff member was to walk into the pts room and ask if they needed anything "because I have time". We of course also had pts on Q4hr VS. I worked 7p-7a and often got comments from pts and family members about not being allowed to get even a few hours of uninterrupted sleep. After waisting my breath with our nurse manager about giving an ambien at 2100 and having to physically touch a pt to wake them at 2200, 2300, 0000, 0100 etc I decided to take a different approach. At the beginning of my shift I would introduce myself,.explain that I would be their nurse until 7am. I would then explain that it is our floor policy to have two staff members, indepentent of each other, walk into the room to make sure your needs are being met. "I see that you requested a sleeping pill last night, are you having trouble getting back to sleep when we wake you?" Of course many pts would look at me like "of course,.why do you think I asked for the sleeping pill?!!"
I would then review the VS for the last 24 hrs and discuss any med changes etc,..if appropriate I would then say "your VS have all been normal for the last 24hrs,.you do have the right to request that you not be awakened from sleep,.if you would prefer I can just peek my head in the door and if your asleep I won't wake you." If that is what the pt wanted I would then chart at 2000 "pt requests not to be awakened from sleep tonight." I would chart every hour "pt sleeping, snoring noted, respers even and unlabored, per pt request pt not awakened at this time".

[carebearRN08]

We also do the Q1 hour rounding, but it becomes Q2 hours between 2200-0600 and our manager doesn't expect us to wake up the patients to ask if they need anything! That's ridiculous!!!!

[herring_RN]

I work 12 hour nights. I tell my patients when I need to take their vital signs and draw their labs in the morning.
I ask them to use the call light if they wake up to turn over or use the urinal. That way I can take their vital signs and avoid having to wake them up right after they get back to sleep.

[Tait]

Well this thread got a wee bit off topic, but anyway.

The answer I got from my supervisor regarding the "charting", or technically the "lack of charting" for a Q4VSS deferred for sleep in stable patients was as follows:

"Put something in your notes about "pt viewed, stable, no distress R/R regular, VSS deferred. I would rather there be a blank line on the flowsheet for the vitals than something that will draw attention to an investigators eye."

In addition, per our floor policy, if patients are stable they can be Q8 as well.

Tait

[suzanne4]

Originally Posted by Tait

Well this thread got a wee bit off topic, but anyway.

The answer I got from my supervisor regarding the "charting", or technically the "lack of charting" for a Q4VSS deferred for sleep in stable patients was as follows:

"Put something in your notes about "pt viewed, stable, no distress R/R regular, VSS deferred. I would rather there be a blank line on the flowsheet for the vitals than something that will draw attention to an investigators eye."

In addition, per our floor policy, if patients are stable they can be Q8 as well.

Tait

Sorry, but I do not agree with your supervisor at all. Even if you do not obtain the vital signs every four hours, something must be written there as to why not. Leaving it a blank is more of an issue if one knows how things are looked at by the state or any other agency, or even legal. Leaving it blank means that nothing was even attempted or that the patient did not wish to be disturbed and that is an honest thing to put there.

If a physician has written vital signs to be done every four hours, then that is what is expected, unless you get an order to change them. Floor policy does not override a physician's order. Floor policy only takes effect if nothing was written or if the physician writes per unit protocol.

[Tait]

Originally Posted by suzanne4

Sorry, but I do not agree with your supervisor at all. Even if you do not obtain the vital signs every four hours, something must be written there as to why not. Leaving it a blank is more of an issue if one knows how things are looked at by the state or any other agency, or even legal. Leaving it blank means that nothing was even attempted or that the patient did not wish to be disturbed and that is an honest thing to put there.

If a physician has written vital signs to be done every four hours, then that is what is expected, unless you get an order to change them. Floor policy does not override a physician's order. Floor policy only takes effect if nothing was written or if the physician writes per unit protocol.

Well as with all great internet commentaries, there are few details missing from my story, that as this topic gets longer apparently needed to be added.

Our "physician" policy on most of our patients, particularily our cardiac cath patients is "VSS per floor routine if stable" hence my comment about our floor policy. Of our population our cardiac cath patients are primarily our most stable, and the other half of our population is a GI group that refuses to send thier patients to any other floor than ours, hence the nurses have a great deal of autonomous desicion making.

Your first comment fits perfectly with my argument for putting "Pt stable, VSS deferred" in the flow sheet space, and then in addtion I suppose one could put a note in the nurses notes as well stated the patient was visualized.

[nelcoy4]

I feel bad if I have to wake up my pt to do vs @0400, but I do it. I tell the pt what I have to do to them in the beginining of my shift. I ask him/her to keep a arm out so I can just slip on the BP cuff @ 0400. If they don't wake up while I'm doing vs, then I will take ax temp . If they wake up, I will take po temp. The patients get more upset when we take 11pm vs because they just got to sleep and then staff comes in about vs.
At my hospital we do Q1 checks. If they are sleep, I just make sure they are breathing. It's funny that management keeps getting on us bc pt complain about not getting enough sleep during the ngt, but then they keep having us do things to wait them up. (Ex Q2 turns on a pt that walks!!!)