Things to watch out for! Advice needed.

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    Hi Everyone! I am a relatively new nurse and was wondering if you would share with me a list of things to watch out for that indicate that a patient is becoming unstable. For example, if a patient has CHF and you hear wet lung sounds or gurgling, the patient is in respiratory distress. What are some other things I should be vigilant about? Please share!
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    Trust your gut. If you just have an odd feeling about a patient don't just blow it off.
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    Duplicate Threads merged........

    You are still within your first year after graduation/licensure......this is a tough year, give or take a few months. Coming out of school and suddenly you are responsible for everything can be overwhelming. It is impossible to begin to list things for each and every disease process and it is different for children.

    In general......there are subtle changes that might "tip you off". The patient might tell you that they don't feel well. They become restless, confused say thing like...something isn't right. The family might feel that the patient is acting oddly or not themselves......that again something isn't right.

    Know your patient and assess them frequently.....look at their baseline, "usual" vital signs of this, and past, admissions. Check your vital signs, B/P (both arms) HR Resp rate Sat% Glucose Temp, are the higher or lower that they "should be".....what is their output? One of the indicators of well being is end organ perfusion....a urine output of at a minimum 30cc/hr....it should be at least 1ml/kg/hour in the "normal" patient.

    Look at the cap refill, the patients color, nails beds, lung sounds.....are they different from earlier or are the different from what you were told by the earlier shift? Go over the list of symptoms, in your head or a quick google search on your phone, to know/learn what to look for.....I always look stuff up that I don't know....when I started out I spent many lunch hours at the hospital library learning my "craft".....for school gives the bare minimum. A ton of extra time was required after school/work to get to that Ah Ha moment when some of it finally made sense.

    There might be A little voice in your head, a nagging feeling, that tells you something isn't right. A general trending that the patient is no longer at their baseline. It does take time, experience and organization of that information. You need brain sheets.......here are a few.

    mtpmedsurg.doc
    1 patient float.doc‎
    5 pt. shift.doc‎
    finalgraduateshiftreport.doc‎
    horshiftsheet.doc‎
    report sheet.doc‎
    day sheet 2 doc.doc
    ICU report sheet.doc‎

    Why do you ask? Are you switching units? or just feel like you are still struggling to keep up.....I hope this helps
    loriangel14, tbehlow, prnqday, and 2 others like this.
  6. 0
    Big ones that often get missed by many: GI bleeds ( nausea , abdominal distention, drop in bp, increased heart rate ) right before it is completely obvious. Sepsis ( increased or very decreased temp, tachy, low bp, suspected or known infection) . The main thing you can do is assess your patients. Know how they were at the beginning of your shift and if possible before. I read at least the daily MD progress note. For changes report them to the doctor. urinary out put is one that gets missed even though it is easy to monitor. eventually you will have enough pts go bad that you will know what to watch for
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    Another tip: if an elderly person has sudden onset of confusion when (s)he is usually AAOx4 at baseline, they most likely have a raging urinary tract infection (UTI). Some healthcare workers don't take the new onset confusion too seriously and attribute it to other causes such as senility or dementia, even when the elder has no history of dementia.
    GrnTea likes this.
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    Always, always take your own vital signs, and do it manually. If a CNA takes them, you run the risk of having happen what I heard one day. About to round a corner, I heard a new CNA say to an experienced one, "I can't ever hear blood pressure very well. What do I do?" and the old one said, swear to God, "Write down 120/80, that's a good one." You will also note that the flow sheet has pretty much the same pulse and BP all the way down the page, and the same weight every day. NOBODY does this normally, and yet, we see charting like this all the time. Dinamapps have very specific operating instructions, which are rarely followed properly, and are lousy in arrythmias because they don't hear well. Use a manual cuff whenever possible.

    A gain of a pound or two overnight may not be a measuring error, it may be the first sign of fluid retention from incipient CHF, as the failing heart pushes less BP to the kidneys and the kidneys respond by retaining fluid (they aren't that smart and the first thing they think of is hypovolemia). Then you'll pay extra attention listening to lung sounds, not just at the beginning of the shift but every couple of hours.

    You will notice that the things that indicate trouble happening often, in retrospect, showed subtle changes in VS. A leetle increase in (but sustained) HR, a leetle drop in diastolic pressure -- these are compensatory mechanisms going on. Your alert mind would think, "Why?" "Why would we need to be compensating for anything? What kind of things could be happening?" and this will cause you to be extra-vigilant on that patient's behalf.

    If you can't always be present to walk your own patients or get them up, be present or do it yourself at least once a shift. Watch for slight increases in weakness, shortness of breath, a bigger "Whew!" when the chair is finally settled into.

    Bed baths are a great time to observe mobility, strength, symmetry, pulses, and endurance. Don't turf off the baths to your CNA all the time. S/he will likely not notice what you can.
    BrandonLPN and prnqday like this.
  9. 2
    The very first indication of pulmonary edema is patient restlessness. Before you can hear it or see it, the patient can feel it - though they may not realize what they're feeling.

    Any change in patient presentation needs to be monitored and explained... VS, skin color, behavior, urine output, mentation, etc...

    Typically, several hours before a patient actually crumps, have there been subtle signs of deterioration.

    Look for trends and step-wise changes (that is, things should generally change slowly, not abruptly... abrupt changes portend badness)

    BTW, it gets neglected sometimes but if you're starting to sense impending badness, get a second line *before* it's all bad, while they still have some BP. I had a patient with a sketchy line who was triggering my Spidey sense so I had someone place a bomb-proof line by ultrasound. When she crumped 30 minutes later and her original line failed, I patted myself on the back as we accessed her new line.

    Always try to think a couple steps ahead... if this happens, what will I do, what will I need... the time to your ducks in a row is BEFORE the patient dumps, not while they're dumping.
    anotherone and GrnTea like this.
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    I too am a new nurse.. thank you so much for posting your sheets. I will be starting my new job in a couple of weeks on the orthopedic floor. I am nervous and excited at the same time. The sheets you posted will help keep me organized.
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    Totally agree that nurses should get their own vital signs. I don't know when the culture shift was that shifted this from a "nursing duty" to a "CNA duty". Probably a long time ago. But it was a huge mistake. Seriously, how long does taking a set of vitals take?

    At my LTC facility, it is policy for CNAs to get all vitals on 1st and 2nd shift. On 3rd shift, it is the RN/LPN's responsibility. I am 100% convinced this policy is why so many more residents are sent out on the midnight shift. I catch so many fevers and raging infections on nights that go missed on days because of half-a**ed vitals by the aides. Poor technique with the tympanic thermometers drive me crazy. Temperatures are ridiculously low across the board when gotten by our CNAs. 94.1 degrees? Seriously?? When i see a CNA get a temp of 98, i have to assume the resident is septic. Blood pressures as low as 70/30 with no manual retake. And god forbid you want an accurate respiratory rate.......
    GrnTea likes this.
  12. 0
    That is very vauge.... Just trust your instinct, if something doesn't look right or sound right, act on it. You'll know what to do when the time comes.


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