Is change a BAD thing? (MS nurses doing vitals)

[ClaraRedheart, BSN, RN]

My whole floor is changing in one day, apparently according to our last meeting. It seemed to go down like a lead balloon. Everyone, including those who didn't voice their opinions went out with solemn/scared faces.

Our techs are NOT going to be doing their first 0700/1900 rounds, or shift report. They will get report from the nurses. Instead, they will be responsible for ADL's like going to the bathroom, walking, and ambulation. The nurses will be responsible for vitals and blood sugars from EVERY patient. (1900 and 0400 for MY shift, unless the physician specifies q4 vitals. which most do anyways We HAVE to follow the orders if they do that... (I think I will call them in the middle of the night to change that if I must for a patient with stable vitals. )

This all seems great, except that, as a MS nurse... usually during/after report, I get several requests for pain meds, where I give all scheduled meds at the same time. Sometimes during that, I get calls from PCT's who are tasked with taking vitals... and they get critical ones, so I must shift my focus from pain to the basic ABC's.

I will not have these quick vitals now, and I'm kind of worried. Maybe, before med-pass I should do a quick sweep through of vitals. The patients who need the MOST help are the ones who WON'T push the button and I'm so scared that I won't notice because I have 5 other patients who need emergent ADL's or pain meds to deal with. The blood pressure or quickly dropping O2 sat could EASILY go overlooked if they have not called and have to wait until 2200 to be assessed.

6 is our max, but I've had 2-3 crash on me at once, and I don't want that to happen again. I know we're med-surg and NOT acute care, but more often than not, Critical Care patients end up on Med-Surg floors.

We're not LOSING our techs, but... gosh darn it, we NEEDED them, and worked closely with them before this change.

I know that we cannot change others (management) but we can change our own practice. I usually work 3 days in a row, SMT. I plan on showing up at 1730 on Sunday (even though I don't get paid until I clock in at 1838) and checking vitals. If ANYONE shows any question of crashing, then I will view and assess and medicate them first.

What kills me is that MOST of my patient's in MS will have to, during report, ask to SLOWLY ambulate to the bathroom each time you see them. That takes OVER 20 minutes. And, usually, I've got 1-2-3 (6 total) patient's waiting while they're crawling to the bathroom needing pain meds for 9/10 pain every time. I slowly take them to relieve themselves. In the meantime, my 2100 (9:00) meds are LATE for all other patients. So... my scheduled heart/blood pressure meds for my other 5/6 patients get pushed back, my rounding just DOESN'T happen. My 2100 meds tend to happen at 2200 sometimes already even though I try to mitigate it the best that I can. Gah... I'm so stressed about this change, and I can't even imagine how my manager thought that it was a GOOD thing

[Levitas, BSN, RN]

That seems to be a growing trend. More work, less staff, big wigs save money, we reap the consequences.

Our hospital sometimes has a low enough census where we do total care, vitals, etc. Usually, they'll allow us up to 5 patients to total, but we've had 6-7 before (yes, I know that's not safe, it's just the way it is).

As a night shift nurse myself, most evening meds aren't due until 2100-2200, so that leaves an hour after getting on (half hour usually, due to receiving report immediately) to grab vitals, and it's not so hard.

In fact, I like to do the first set of vitals. It gives me a chance to check their fluids, pain level, any other complaints, and start my assessment. It also gives me a chance to introduce myself right away so they know who's caring for them that night.

What I don't like is doing the 2nd and 3rd set, because you almost always have to wake up the patient, which I despise doing.

That being said: Vitals are the least of your worries, I would think. When you have total care, and patients who cannot move, control their bowel/bladder, feed themselves, etc., then it starts to really get hairy.

Then again, that's bedside (MS) nursing. Large patient loads, tons of objectives, and building invaluable time management skills. I've gotten so used to the chaos, when it's quiet, I'm usually bored out of my mind. Fortunately I've gained enough wisdom to enjoy the boredom... Because I know admissions are waiting around the corner :)

[ClaraRedheart, BSN, RN]

That was my managers argument when she introduced the concept in the meeting yesterday morning. Too many times, apparently, critical vitals are either being NOT reported to the nurse or overlooked and patient's crash. In this scenario, we will take them ourselves, so we will know them first-hand BEFORE we give meds. It seems great, but every med-pass is already a 20 minute ordeal or more, and when we have a 6 patient load, and LOTS of meds to give to some, it takes even more time. Sometimes, during the time it takes to ambulate Ms. Jones (recent back surgery patient) to the bathroom after I gave her her nightly ditropan and atorvistatin, pepcid and colace, I get calls for pain meds from patients. I usually see them next, but then I get a call from the tech that another patient's vital is abnormal, so it usually takes priority. What scares me is that now I WON'T know my patient's vitals. I will just take call in order to receive. If vitals are late, then... well. They're too late. I plan on going into this experiment doing my best and with a positive attitude, but with 6 patients, and this added responsibility... I'm honestly kind of worried.

[Levitas, BSN, RN]

Good, keep vigilant, it will serve you well.

After some time, it'll just be another part of your schedule, and you'll handle it no problem. You'll always have nights where objectives are seemingly endless, and piled up, but you'll get through them. Your instincts will kick in, and you'll prioritize efficiently, and everyone will go home safe, albeit some of us stressed, haha.

Three ways I see to handle this:

1.) Find another job.

2.) Petition your managers/collaborate with co-workers to figure out if this new policy is safe, and in the best interest of the patients.

3.) Weather the storm. This option will either make you, or break you, I imagine. If you can handle it, you'll become stronger. There will be little you can't handle. This experience will aid you immeasurably in your career ahead. That's how I see it, anyways, when I'm assigned a hectic load. :)

[ClaraRedheart, BSN, RN]

I think I'm going with #3 Just stressing about it... I'm just coming up on my 1 year mark as a new nurse, and finally feeling confident about my job and now I feel that everythings just shaken up. I'm sure I'll come up a better nurse as a result... I really DO trust my managers judgement. I like her... she hired me :)

Just one question... Do you take the vitals of ALL of your patients before beginning to pass out meds?

[FurBabyMom, MSN, RN]

One of the places I worked as a med surg/stepdown nurse had no techs. We compromised and the off-going shift made rounds about 1845 (or 0645) and got 0700 vitals then while the oncoming shift looked patients up, we gave report/introductions and you still had a "fresh" set of vitals. Obviously we could re-assess them and might have to by the time we got to pass 0900 meds on patients... I handled this by, after introductions, assessing my patients who were going off the unit (testing, OR, etc) first, then basically saw everyone else by acuity (I'd already done a eyes-on once over/check IV infusions when we did shift change introductions). Is this something that might be worth bringing up for your unit to try?

I have to admit, when I worked nights elesewhere with techs, I did my own vitals. We always had 1 tech for up to 31 patients, and it takes a LONG time to get vitals on 31 patients. I just did 1900 vitals with my assessment, and grabbed my 2300/0300 ones myself because I generally had time (unless I didn't have the time/had some other situation and the tech was super helpful to me because we shared the work well). And many of my patients on this unit were q2 neuro checks and vitals and/or had "critical meds" (according to our facility) that required q1, q2, q4 (depending on dosing, titration, etc) vitals and tele strips.

[Levitas, BSN, RN]

Just one question... Do you take the vitals of ALL of your patients before beginning to pass out meds?

If I'm doing primary care, yes. If we have a PCT on the floor, I still wait for my vitals to pass meds... Unless they only have something like Protonix, or Insulin. But pain meds, cardiac meds, etc., definitely.

In fact, we had to primary 5 patients a piece last night (I had an admission as well). Admissions while doing primary care is even worse, because you have to do everything: Vitals, weight, inventory, tele (if they need it), plus all of the nurse stuff - The works.

I obviously survived, but it was busy for sure. I had two total care patients, one in which I was constantly suctioning to prevent from aspirating. With talk of snow coming tonight, I'm not really excited about waking up to go in tonight :) At least I'll already know my patients, and my assessments will be that much easier.

[Larry3373]

Transfer to ICU. Vitals are done automatically, lol.

[Farawyn]

Back in the day we did our own vitals.

"We also walked uphill to school in the snow, both ways, and we were thankful to do it!"

(Yes, I just quoted Bill Cosby)

[anh06005, MSN, APRN, NP]

What if they adjusted the times vitals were taken so the nurses could do assessments, check charts, pull meds, then go through and, in one sweep, check vitals and give meds then move on to next patient?

As PP's (and OP) have said there is logic to it but it seems like it might be more time effective to just do 2 tasks at once in one big sweep.

[thenightnurse456]

In my country nurses always do their own vitals and ADLs. A nursing assistant was more used to... assist with patients who needed more then one nurse to transfer/bath etc.

My question is, if your tech/CNA takes an unstable set of vitals and forgets to tell you or they didn't think it was a big deal... Who is responsible? Who loses their job/license? Wouldn't it be you? That's a huge level of trust your putting on someone.

The idea of techs/CNA doing vitals/BSL checks in the US has always perplexed me. It's my assessment; and vitals make up a huge part of that assessment. Seems weird to let someone else do that part of my job.

And since when is Med/surg not acute care?

My suggestion would be to cluster my care on your shift whenever safe to do so. I wouldn't come in that early to start work when your not gonna get paid for it! You'll get the hang of it.

[tokmom, BSN, RN]

Med/Surg is acute care and sometimes borders on PCU with the overlooked sick people.

I think once you get used to the new way of doing things you will do ok. I have never had a CNA do my blood sugars or vitals. They primarily do the toileting/bathing. I wouldn't trust them doing vitals for the meds that I was about to give anyway, unless you can trust them a 100%. I'm a firm believer of walking rounds to get a feel of the patient and then going back with a VS machine, grabbing vitals, getting pain meds etc and going from one patient to the next. If you have anyone that looking worrying, hopefully the walking rounds would bring that to the forefront and you can start there. I would also pull in the CNA and have them be your second ears and eyes for any upcoming requests. No reason why they can't tell you that Mr. Smith needs pain meds and you could have them with you when you get to his room.

Can you approach your manager after a month of the new routine and have a check and adjust if it's not going well?