Only Charting "The Good Vitals"?

Nurses Safety

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So I have a question for everyone.

The scenario: I had a patient the other day who was 88 RA and 78/49 with a HR of 92 at beginning of my shift. Came in for weakness and fever. The CNA put the patient on O2, sat the head of the bed up, and got a new set of vitals 92 on 2L, 102/68, HR 96 and only charted those last vitals and didn't tell me about the first set. When I assessed him after vitals were taken he was a little pale but had no s/s of anything, just tired.

At midnight I take his vitals because the CNA was busy and see a patient whose pale, diaphoretic, nauseated with BP 79/48, 90 on 2L, and 102 HR. The blood cultures come back with gram+ cocci 5 min later. I call the doctor and we get a Lactic Acid and send to tele with dx of Sepsis.

The CNA then tells me that they were told to only chart the good vitals and he didn't tell me what the first one's were because he got better ones and "it didn't matter."

Here's the question. Has this happened to anyone else?

I've had CNA's who take vital signs while the patient is on the bedside commode, while ambulating, getting temps just after drinking. Really?

Specializes in Hospice, ONC, Tele, Med Surg, Endo/Output.

Really hard to trust these CNAs. I'd report this one to management and insist that the CNAs be inserviced on taking vitals. The nurse is ultimately responsible for everything. I'm glad i no longer work in acute care. No more CNAs to deal with in my field. Praise God.

Really hard to trust these CNAs. I'd report this one to management and insist that the CNAs be inserviced on taking vitals. The nurse is ultimately responsible for everything. I'm glad i no longer work in acute care. No more CNAsto

deal with in my field. Praise God.

Well, I don't know if that's fair. I need my CNAs, my facility would collapse without them. They're great at the hands on care part of their job. I just wish they would

take the vitals more seriously. They treat it like just another task. Taking even a routine set of vitals takes *some* critical thinking, putting two and two together and whatnot. I just feel more comfortable getting my own vitals.

I really have a hard time getting why a med surg nurse, with six pts, would have a hard time getting her own vitals. It doesn't take that long. And you're in the room *already*, doing your assessment. I will admit, I've never been an acute care nurse, so maybe I just don't know....

Well here is the thing. I think it's important to document ANY intervention, you would chart the vitals but stipulate the patient was uncooperative, asleep, wrong size cuff etc. As far as calling a physician, in terms of critical thinking, you use your judgement. The is no need to automatically call an MD for an off vital unless you are absolutely sure the reading is accurate. I am an acute care nurse and it's baffling to me when I check back on my patients and see vitals recorded that are clearly abnormal with no explanation! If you get a low BP, consider orthostatic vs or a manual. It's also possible there just isn't the time to search for equipment or reassess, and that is unfortunate but true. I'd be lying if I said my hourly assessments didn't drift into the hour and a half or two hour mark. Sometimes it's just impossible.

Stooooopppppppp!!!! These aides are doing this crap because some someone told them to do it! Every single shift, there are a handful of nurses that tell me NOT TO CHART THE "BAD" VITALS. But I do it anyway. If I get wacky vitals then I retake them 2 times, write it all down, and then tell the nurse and give them everything that I have documented. There is a nurse that I work with RIGHT NOW that goes behind my I&O charting and crosses out my "bad vitals" and writes in something different so that she doesn't have to call the doctor. WTH? Ask these aides WHY they are doing this stuff, and explain to them why it's not a good idea. You'll be surprised at some of their answers. If someone doesn't know any better, then how can you expect them to do differently? Especially if someone has probably given them misguided direction.

This is why I do my own vitals most of the time. I do get behind because if it, but I just can't trust anybody (except for 1 aide). It's sad. The aide that I trust is phenomenal. I love working with this particular aide. Sorry this happened to you! I seriously feel for you that this happened.

Specializes in PACU, presurgical testing.

My experience with this has been limited by department. In the CV surgical unit, RNs did all the vitals, manual B/Ps, real one-minute apical pulses, etc., because of the nature of our patients' conditions. In the PACU, everyone is on a monitor, RNs track the vitals every 10 minutes and put them into the computer, and LNAs can take temps. When I was in clinicals on a med-surg floor, the LNAs did the vitals, and we were responsible to check them in the computer and follow up. We did not have LPNs in these hospitals.

The danger of just taking another reading and recording the "good" one has been well-explained in the above posts. Remember that even if you like the 2nd opinion better than the 1st, it's not necessarily more accurate, and you may need a 3rd! But also remember that repeated measurements under the same conditions tend toward the actual number, so if you do get a weird bp, it's worth testing again.

The oxygen issue gives me pause, though, because I was always taught that oxygen is an ORDERED MEDICATION, and as such, I would think that it could not be applied or adjusted by anyone but a licensed nurse. And I especially think that if oxygen is being applied by ANYONE, the O2 sat that prompted the intervention MUST be charted. By applying Os, you're saying that you believe the O2 sat to be accurate, and thus it must be charted.

The observation about an 88% sat being normal for a person with COPD reminds me of another example where knowing the patient is very important. When I was pregnant the first time, my blood pressure at a visit was 135/88 or so. That was considered normal by the APRN who saw me, but I was instantly suspicious, because my normal bp is about 100/70 and had stayed low throughout pregnancy. A week later I was at 142/98 and ended up getting induced. (I think it was rechecked both times, BTW). A nurse should know what the patient's normal is and be able to compare VSs with what can be expected (i.e., are we not seeing high HR with pain or a circulatory problem because the patient is beta-blocked?). I think that is in the nurse's scope of practice and should not be delegated.

Specializes in Pediatric Cardiology.

Our techs get VS every 4 hours, it varies though so I could check for VS at one moment, nothing then get super busy and not get a chance to check VS for a while. Some techs don't let us know highs or lows which means I have no idea that patient A had a temp and patient B had a SBP of 165. We give Hydrazaline for SBP > 140 for our neurosurgery patients so it's annoying when I don't get a number until 2 hours later. I am trying really hard to check more often because I know MY license is on the line, not the techs.

well CNAs work their butts off! In some places like assisted living facilities they are overworked. To top it off they get paid very little to bathe, VS, and whatever else their told to do. I totally agree they need to be taught right. I think for some of them or i should say most of them hate their jobs. There are some very good CNAs out there, but yes sad to say i've worked alongside many of them when i was a caregiver and they pretty much just get by. Thank God for the wonderful nurse that teaches the and shows them the importance of this or the one that is willing to take the time to teach them or correct them. This is horrible. I still think to this day that there needs to be a CNA advocacy!

I use to work as a CNA many many years ago before I became an LPN. The nurses would "brush me off" when I would tell them I was worried about the condition of a patient. I remember one night at the hospital when I walked into a patient's room, looked at the patient and realized something was wrong immediately with him. I went to the nurse immediately to tell her and got the "brush off again."

I yelled at the nurse, "You need to stop what you are doing right now and go check that patient." That got her attention. She walked into the room checked him and 2 seconds later "Code Blue" was announced on the intercom.

So I have a question for everyone. The scenario: I had a patient the other day who was 88 RA and 78/49 with a HR of 92 at beginning of my shift. Came in for weakness and fever. The CNA put the patient on O2, sat the head of the bed up, and got a new set of vitals 92 on 2L, 102/68, HR 96 and only charted those last vitals and didn't tell me about the first set. When I assessed him after vitals were taken he was a little pale but had no s/s of anything, just tired.At midnight I take his vitals because the CNA was busy and see a patient whose pale, diaphoretic, nauseated with BP 79/48, 90 on 2L, and 102 HR. The blood cultures come back with gram+ cocci 5 min later. I call the doctor and we get a Lactic Acid and send to tele with dx of Sepsis. The CNA then tells me that they were told to only chart the good vitals and he didn't tell me what the first one's were because he got better ones and "it didn't matter."Here's the question. Has this happened to anyone else?I've had CNA's who take vital signs while the patient is on the bedside commode, while ambulating, getting temps just after drinking. Really?
I have seen lazy RNs instruct CNAs to only enter "good" vitals in patient records. I believe they encourage this so they don't need to perform/document any additional assessments themselves. I agree with previous posters that it is best to record both the abnormal and any retake values.
Specializes in family nurse practitioner.

WOW, only charting the good vitals aye? Thats interesting. I have not heard of that one before. I have had CNA's get crazy vitals with systolics in the 70s, and never even tell me or not recheck it. I think the CNA was right to recheck it manually because sometimes the automatic cuffs are off. Then you document both findings and which arm and which method. Then let the nurse know. Thats the whole purpose of obtaining vitals so we can gage changes in the patient ...hopefully earlier than later. And I have had aides put pts on oxygen after obtaining a low spo2, but they always need to tell you and record what it was and what it was after. And allow the nurse to go assess the situation for themselves. Its so hard to depend on some aides. I think they call themselves helping you out by only documenting good stuff. But the pts in the hospital for a reason. Not because they are in perfect health..ya know? It would be great to get your own vitals, but when you have a ton of pts and everyone is q 4 hrs, and some are sooner than that... that are having issues or receiving blood products ..its just not feasable. I think you just have to explain to the CNA your expectations for the pts you are responsible for. When I worked on the floor I told the CNAs to always let me know of any low or high vitals and blood sugars with in 10 minutes of taking them. It doesn't matter how busy I am, get my attention. I did that on a nightly basis and still had some CNAs that would not mention jack. Maybe speaking with the manager would help to change this practice :)

This is one of my BIGGEST pet peeves. Please do not give me an insane set of vitals if you haven't rechecked them MANUALLY. One of my CNAs told me the automatic BP cuff showed HR 206 and she rechecked it 3 times (all with the same cuff). When I asked if she took it manually she said she didn't know how. I showed her how to check HR manually (actually was 86) and explained to her reasons why the automatic cuff isn't a good option for some patients.

seriously?! people are so dumb. I am a CNA (hopefully only for another 3 weeks) and I would NEVER put that. and in my orientation a few years ago, we were taught how to do a manual bp. people are insane. However I know a few nurses who mainly do adult ed triage and triage peds patients with insane vitals (eg, 180/120, really?! no joke, even though we laughed at this for a while after finding the ACTUAL bp).

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