Charting when you are no longer able to obtain vitals.

FLArn · Jun 9, 2014

First, if you are unable to obtain a value for the particular VS state just that "unable to obtain BP" and then proceed with the rest of the values you are able to obtain. For example, VS BP UTO, P 98, R 20, T 99.4 F Ax.

Second, in my experience, O2 Sats are by MD order only and are rarely if ever ordered (generally only for peds cases). We treat respiratory issues by assessing the symptoms and patient reporting. For example, use of accessory muscles, cyanosis, restlessness, increased respiratory effort to name a few. The best way to chart is to record what your patient says and what you observe. The best way to know what to include in general is to chart to support the plan of care and document the progression of the terminal diagnosis.

SHGR, MSN, RN, CNS · Jun 9, 2014

A good rule of thumb is don't obtain vital signs that you would not act on. You don't need to get a blood pressure on someone who is dying. Maybe a respiratory rate to chart on (document cheyne-stokes or agonal breathing). But you're only treating symptoms, not curing. Document your observations, interactions with the family, interventions, evaluation. Hope that helps.

chopwood carrywater · Jun 9, 2014

A good rule of thumb is don't obtain vital signs that you would not act on. You don't need to get a blood pressure on someone who is dying. Maybe a respiratory rate to chart on (document cheyne-stokes or agonal breathing). But you're only treating symptoms, not curing. Document your observations, interactions with the family, interventions, evaluation. Hope that helps.

Very good advice!

I might chart by symptom mgt; are there s/sx of pain or anxiety and then what did I do to help to control or lessen them. Same goes for terminal secretions or agitation.

If they are hot then I might give Tylenol if I can do it without causing more distress than what I am trying to reduce; I would chart that I gave 650mg of Tylenol PR - or just a nice cool wet washcloth to their forehead or neck to try to cool them down.

If your charting is r/t a need to justify continuos care d/t active death, I might use HR and/or radial pulses: how fast, how weak, and how thready. How fast are the resps and have they transitioned to Cheyne or agonal.

Also, is there mottling present, dusky nail beds and cool extremities. And again, if it is a symptom that is causing discomfort, what was done to alleviate the problem.

You can also chart on whether family is present and if they are grieving appropriately.

I think that it is good that your organization has someone to be with the family assuming that it is not just a way to get continuos care pmts from CMS - and I am not assuming that.

trishmsn · Jun 9, 2014

I totally agree that monitoring V/S to get numbers is not important with those who are actively dying (and I do hate that term, like they are riding a bike in laps around the room, but until we come up with a better one-since I don't think CMS will take our southern usage of "fixin' to die".)

Chart any vitals you can get withOUT causing the pt. or family discomfort or grief, and then just chart what your eyes see, your ears hear, your nose smells, and your hands feel. For example, the BP cuff can cause agitation or pain, and if the last reading you got was 50 over palp....what difference does it make to check it again???

In all of nursing, but most especially in hospice, the question behind any test or assessment should always be "WHAT are we going to DO with this information?!?" In the OR, a dropping BP means fluids and pressors and maybe blood; in hospice it is just another sign that your patient is getting closer to leaving this world for another. :saint:

TammyG · Jun 10, 2014

Very interesting that your hospice does continuous care for everyone actively dying regardless of symptom burden. Any other hospices do this? We probably provide continuous care for less than 5% at end of life.

toomuchbaloney · Jun 10, 2014

Very interesting that your hospice does continuous care for everyone actively dying regardless of symptom burden. Any other hospices do this? We probably provide continuous care for less than 5% at end of life.

I am familiar with a large hospice provider in Florida that offers continuous care during the last 24 hours of life regardless of symptom burden. It is offered as support for the family as much as anything I believe.

RivetheadGirl · Jun 13, 2014

I work for a smaller hospice, and I know that we are one of only a few that do cc for the activity dying. As toomuchbaloney says, its usually as a respite for thr family so they don't have to worry about the pain of the family member during the last days.

I do my best not to cause the patient pain and discomfort, but, vitals arr one of those requirements for my company's charting. I think you hit the nIl on the head for me chopwood. Often it feels that im charting to show proof of active death in the patient.

RivetheadGirl · Jun 13, 2014

Flarn, and shgr, It seems a bit strange to me to need thrse things on an hourly basis when tjey are used more for charting then for any type of symptom resolution besides pain management, but its what my company wants me to include. ?

chopwood carrywater · Jun 13, 2014

Sometimes more is less:

Taking VS q hourly is more about details and less about giving comfort.

I think that doing all of that vs assessment - especially every hour - interferes with the nurse's and the family's ability to be "present in the moment". Many of us are unfamiliar with how to be be present around someone who is dying, and this gives us a task and having a task gives us some 'distance' from the event, from the person who is dying, from the people who are gathered there. It may also create a barrier to the people who are gathered there to vigil and be with the pt.

I can be pretty unobtrusive getting a radial pulse, getting resps, and touching BUE and BLE to assess for warm and dry or cold and damp, but putting a bp cuff in and pulling a stethoscope out q hour over a period of 4+ hrs seems a bit much.

I would attend to symptom mgt and then gently ask if anyone has any questions about what is, or will happen as the person gets closer to death. If needed, I model ways to be be around the dying person.

I usually start off by explaining the need to try and keep the level of stimulation down (with allowances for cultural differences and traditions), I give them the analogy of the pt being like a young child who's been sick and miserable for several days and has finally gone to sleep; you want to be there and reassure the child that you're in the rm, but then it's times to keep the lights down, the tv off, conversations in the rm should be soft. I recommend that if they are going to talk to the dying person, they should talk with a gentle tone; talk low and slow - take pauses to allow time for the person to process to whatever level of understanding they can. This is generally not a time for asking questions as the ability of the dying person to understand what is being said may create undue stress. I talk and show ways of touching the dying person, I tell them not to stroke or rub too much - that is typically more about our own anxieties - it's an understandable human reaction, but it may not be what's best at this time. And I always make sure to say that these are guidelines, not rules.

I tell them I only have 2 rules:

If they are doing something and it's working to make the pt feel better, keep doing it - if it doesn't, stop.

And, try not to make the nurse cry.

.

SHGR, MSN, RN, CNS · Jun 13, 2014

Oh, HOURLY??? Somehow I missed that detail. That is just awful. Chopwood Carrywater hit it perfectly. If I was a family member, having a supportive nurse present- really present- would be wonderful, but I'd be that family member that refused the vitals. Hourly vitals are for fresh postop patients.

toomuchbaloney · Jun 13, 2014

No way I would do hourly VS on an actively dying patient.

I don't do a lot of VS even during my routine care when the patient is doing well. To clarify, I do them, once a week or so, unless there is some problem we are addressing which has an aspect reflected in those numbers.

The goal of hospice is not to record and chase numbers. The goal of hospice is to address the patient's perception of their overall comfort and quality of life and/or the family's perception of that. If VS help us to make these people more comfortable, or they are a tool to qualify or quantify another observation or recommendation, fine. Otherwise they are a task without real value in the setting in many a case.

During a routine visit I will listen to the chest, abd, and feel a pulse while I am asking the patient about their status. I listen to the heart tones and note if the rate is fast/slow/regular/etc. I record a Pulse and Resp number. I take their BP if they want me to or if they have a problem with their BP. I check POx only if needed at recert, etc or if pt is anxious and depends upon that number (must of those people check their own POx frequently, so) or if there seems to be a clinical finding which really demands on some professional level that I look at that number.

If your Hospice has a requirement of hourly VS I would recommend having a talk with your medical director about that. It is not in keeping with a hospice philosophy.

Don't get me wrong, there is value in VS in the hospice patient. It is simply important to remember that the VS are not the priority they are in acute care or other settings.