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?

We can tell the pt to straighten their arm; but we couldn't actually touch the buttons on the pump. I understand what you are saying though. We didn't do dressing changes either.

We could do vitals, baths/change bed linen, at the time we did foleys and such; but when I finished clinical there, I noticed they changed the policy, we could get specimens,empty foleys, d/c foleys, chart, bladder scan, feed pts unless they were speech pathologist's people/swallowing problems, collect trays, calorie counts (unless it's like tube feeding), turns, empty drains and take the pt out when discharged. We could also ambulate them as long as it was not the first time getting up (nursing judgment)

We couldn't give meds, do dressing changes/wound care, start/stop pumps, do anything with oxygen, do blood sugar checks, etc.

I got ya though. I do think they are using techs/UAP/CNAs for too much now. Definitely think they need LPNs and RNs to do that stuff.

Right, I hear what you are saying. How did you find out about the initial VS? We recently laid off RNs and replaced them with RPNs. It's been a very difficult transition and I really preferred an all RN floor. So, I hear your frustration because I have felt it myself.Another question, if a patient was unstable and say desatting in the 70's, can a CNA put O2 on then? I'm from Ontario and we have RPNs (registered practical nurses) who it seems have a much wider scope of practice. If a patient became unstable they would intervene but then a RN would assume care.Was it a positive outcome for the patient?

Specializes in geriatrics.

There are only a handful of CNA's who I trust to check vitals. Even after educating some people, they either don't care or want to learn. So guess what? Those CNA's don't take vitals for me...ever. Sorry, but I need to know if I'm potentially facing a code situation ASAP, not because someone chose not to report abnormal vitals.

Specializes in PDN; Burn; Phone triage.

Are the "good vitals" the ACCURATE vitals? For instance, if a CNA was taking an automatic b/p on a patient and that patient happened to start thrashing his arm around wildly, I would assume that they would re-take the b/p and not give me the original, wildly hypertensive b/p. Is the CNA placing the saO2 probe on a cold finger or one with an extra long fingernail?

Specializes in Med/surg, Quality & Risk.

I used to get low b/p's all the time on night shift and when I woule retake them they would be fine. They were using the narrow, long cuff on everyone because they were lazy. I told my manager and she said "yeah it's long, but it wraps all the way around." ?!??!?!?!! Um I seem to remember something about 80% of the bladder encircling the arm, and I figure there's a purty good reason we use different lengths, but okay then, it's your floor.

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?

Our policy is that is a vital is questionable (somebody who is alert and looks well having a B/P of 60/40 when it's been "normal" for days, for example) then it is not charted, but must be checked manually and the manual B/P charted. Most times it turns out to be a machine error. Of course, if the manual is still 60/40, we chart it, but if it was manually 105/50, we would chart that one and chalk it up to the machine.

I 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.

"Cringing" is not the correct response.

Write up the CNA... in order to assure he/she gets the additional training required to perform their JOB.

In the meantime, I would take my own vitals.

Specializes in Emergency, Telemetry, Transplant.

I don't know that 'writing up' the aide is always the best choice....maybe some education is in order. Education may make them do it correctly the next time, while a write up might lead to unnecessary angst between aides and nurses. If this is a repeat offender even after education, then a write up is the way to do.

Either way, only charting good VS is a silly policy for the reasons others have already mentioned.

I've had times when the aide/tech informs me of a 'bad' BP, say 72/39 (with the machine). I go in to do a manual BP and I get something reasonable. Makes you wonder that if the machine incorrectly gives 'bad' BPs that it also gives incorrect 'good' BPs (i.e., the real BP is actually either too high or too low, even though the machine tells you it is 118/58).

Now, this is next part is not meant of a criticism of aides/techs--they are trained in how to take VS (usually with a machine). The aides do not have education in how to interpret the VS, assess the pt, and evaluate the VS in the light of the entire clinical picture. For example, take pulse ox. Aides might be aware that sats should be above 90%. Now suppose they take a pulse ox on a COPD pt and the sat comes back at 88%. Likely totally acceptable for this pt, but for someone without education on the subject, this pt needs supplemental O2 (in reality they do not). Point is, the RN must be aware of VS taken by aides, and aides need to be aware that sometimes the VS will be bad--don't feel the need to 'buff up' those VS--notify the RN and the RN goes from there.

I'm an ex PCT. RN as of July.

Kind of the opposite, nurses used to irritate me. They didn't want me to chart that systolic over 160 or under 80. They would come check it themselves and it would magically be 150 or 90 or something.

It was funny how my manual BPs were very similar to the Dinamap's but the nurses were within a range that wouldn't make the system put up a flag.

On the O2 note, nurses let me do cannula but I always told them.

Its quite amusing to read nurses discuss the importance of charting the first vital set when not a single place I have worked at including hospitals and supervisor staff has said anything more than "chart the best vitals you got and monitor". So many nurses do not seem to discuss what is commonly done in real world nursing as compared to textbook nursing. Not saying the above practice is right, but many of you live in a fairytale world were this is not common practice.

Also, if the first set the aide gets is way out of whack and I recheck right after and get a more normal set, it's safe to assume the aide used improper technique. Lots of times they get crazy low BPs because they use an automatic cuff while the pt is laying on his side. Or they get a temp of 95.5 because they only use those stupid tympanic thermometers. Or they write the "magic 20" respers on everyone, whether their respers are 12 or 32. Why would I chart any of those vitals?

Its quite amusing to read nurses discuss the importance of charting the first vital set when not a single place I have worked at including hospitals and supervisor staff has said anything more than "chart the best vitals you got and monitor". So many nursesdo not seem to discuss what is commonly done in real world nursing as compared to textbook nursing. Not saying the above practice is right, but many of you live in a fairytale world were this is not common practice.
I don't get how "charting both sets" would work logistically in a hospital setting. Say the aide gets a BP of 71/39. Obviously, you would go recheck manually. You get 94/52. If you charted the 71/39, and it's there in the computer, don't you have to call the doctor? And if you told the doctor, "well I rechecked manually and it was 94/52" wouldn't the doctor be pi**ed that you wasted his time? The first set was clearly bogus. So why not just disregard it an chart only the good set?
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