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?