Only Charting "The Good Vitals"?Register Today!
This is a discussion on Only Charting "The Good Vitals"? in Nursing Issues On Patient Safety, part of General Nursing ... So I have a question for everyone. The scenario: I had a patient the other day who was 88 RA...by whitecat5000 Sep 6, '12So 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?
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- Sep 6, '12 by roser13Not only that, but since when does a CNA place O's on a patient of their own accord?I'm curious as to whether the CNA can identify who gave the curious "good vitals only" instruction. Possibly the same person who gave them leeway to initiate oxygen?
- Sep 6, '12 by LiveandLearn88Some days it's a miracle to even get vitals in a timely fashion and sometimes you have to wonder if they're not made up when you see the condition the patient is in. I would educate the CNA on the importance of reporting ALL vitals even if they improve after interventions are implemented.
- Sep 6, '12 by FLICURNI had a CNA hand me my morning vitals one morning with a BP of something like 69/32. I asked her was this a retake and how the pt was as I am already headed towards this room. She said no she didn't retake it. I asked her you got a BP like this and #1 you failed to retake it, #2 you didn't come straight for me? She answered, he seemed ok?!? At least the recheck of the BP was completely WNL. So yes I have had to work with a CNA like that and I cringed everytime I saw her name with my pts.
- Sep 6, '12 by LiveandLearn88This 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.
- Sep 6, '12 by RNewbieI don't know why but I have noticed that some CNAs do not record abnormally high or low vitals. I think they are trained to recheck them, so sometimes after rechecking them they get "better" results and record those. The ones I work with always notify me in a timely manner of abnormals ( I then assess and recheck vitals myself) but I notice that sometimes the original abnormal is not documented if better results are collected afterwards.
- Sep 6, '12 by sapphire18I've run into this too. I don't understand it.
- Sep 6, '12 by KelRN215Quote from roser13Uhhh this is my response to reading the OP too. Since when do CNAs have the ability to assess when a patient is needed oxygen and to start it without an order?Not only that, but since when does a CNA place O's on a patient of their own accord?I'm curious as to whether the CNA can identify who gave the curious "good vitals only" instruction. Possibly the same person who gave them leeway to initiate oxygen?
- Sep 6, '12 by BrandonLPNI know it's not always feasible, but this is why it's best for nurses to check vitals themselves. The temps the aides get really bug me. Febrile pts with normal readings 'cause they check right after the pt drinks some ice water. Or they just kinda lay the tympanic thermometer on the ear. And half of our routine temps come back as 95. Or less. Really??
- Sep 6, '12 by BrandonLPNQuote from KelRN215I did this all the time as an aide in the hospital. Of course, I'd always tell the nurse I did so. I also would tell the pt to straighten out his arm and then restart a beeping pumpthat had stopped when the pt bent his arm and occluded an anacub IV. I did always check to make sure the IV hadn't gone subQ before restarting it. All technically against the rules, but we all did it. The nurses expected us to.Uhhh this is my response to reading the OP too. Since when do CNAs have the ability to assess when a patient is needed oxygen and to start it without an order?