CNA with a question.. ocd on the job.. afraid someone will die because of me

klone, MSN, RN · Nov 8, 2022

You should ALWAYS document what you actually see. What you are witnessing is a culture of sloppiness and laziness. Do not give in to it. But also, be prepared that your coworkers are not going to make your life easy. You are doing the right thing.

Also, it's quite possible that people don't read your notes. If the expectation is that the RR goes in the RR field, put it there. Don't put it in a note.

Also, if someone dies, it will be because of all of them, not because of you. Charting the actual vitals is not what kills people. What kills people is ignoring the vitals, or lying in one's documentation.

Anxiousandafraid · Nov 8, 2022

Thank you. I’m going to just step down and leave my job. I again LOVE what I do. And can totally understand the frustration the nurses share. I would too be annoyed with someone charting 8 and having an alert next to it for someone who is other wise fine … I thought leaving the note would still give me some peace as to not try to totally omit the RR… now I feel guilty. I feel so much responsibility whenever someone is discharged and think “they will die because you didn’t chart 8 although while they were watching tv, on the phone … alert and awake all night “

JBMmom, MSN, NP · Nov 8, 2022

If you enjoy your job, this is not a reason to leave. NO ONE is going to die, ever, based on charted vitals. It's inaction based on those vitals that could lead to problems, but as you point out, these patients are not in distress. You are charting an observed value and you are right to chart it. The average respiratory rate when people are awake is generally accepted as 14-20, but clearly people breathe slower than that while asleep or awake. Anyone working in the field should know that and no one should be giving you a problem.

There's a chance that a nurse could have a PRN medication, such as a narcotic, that has parameters to hold administration for a respiratory rate less than 10, to minimize the likelihood of respiratory depression. But all they have to do is chart the rate that they observe at the time of administration.

I hope that you can find a way to balance your concern with the desire to do the job. And remember, healthcare is a TEAM approach. If you documented a rate of 8 and the patient was in distress, you would probably go right to your nurse and let them know, correct? A rate of 8 when the patient is not in any distress, is alert and oriented, is NOT an indication of impending doom. And you are the not the only person to see this patient, so unless you find someone not breathing or without a heart beat and you don't act on it, you are not ever going to be responsible for someone dying by recording vital signs. I hope you find something that's a good fit for you!

Anxiousandafraid · Nov 9, 2022

On 11/8/2022 at 6:45 AM, klone said:But also, be prepared that your coworkers are not going to make your life easy. You are doing the right thing.

Also, if someone dies, it will be because of all of them, not because of you. Charting the actual vitals is not what kills people. What kills people is ignoring the vitals, or lying in one's documentation.

Thank you. And this is the part causing me mental torment. I have tried to find a way to be truthful but also not annoy the nurses. I can understand their frustrations honestly. I wasn’t trying to lie in my charting but left a note instead of a value because I know the nurses treat patients and it numbers and the nurse had already send the patient and determined he wasn’t in distress but my Literal thinking is always “did you see this number … chart that “ and the nurses are freaking out like “nooooo. They would be in ICU with that “

Anxiousandafraid · Nov 9, 2022

18 hours ago, JBMmom said:

NO ONE is going to die, ever, based on charted vitals. It's inaction based on those vitals that could lead to problems, but as you point out, these patients are not in distress. You are charting an observed value and you are right to chart it.

Thank you so much ...my ocd has had me STRESSED for the past two days obsessing and feeling so much guilt. It's funny I went to the Dr yesterday...literally held my breath and they charted 18...anyway I love your response the problem I'm having is that I DIDN'T chart the 8 ...I only left a note and explained patient not in distress. I was a coward and didn't chart the value allowing it to turn red (in out system an 8 is a possible sepsis)...so I put a note in the value field ..later I went and recounted when patient was sleeping and obtained a 10 and charted that value ...other than leaving a note to possibly assuage my guilt of leaving a trail of the numbers I honestly obtained but also NOT frustrate the nurses with vitals in the system for patients obviously not in distress I haven't found a solution ...I ALWAYS aim to be honest...I have black and white thinking ...and my ocd has been saying "im sure that patient is fine ...they've been discharged ...BUT then again ,you left a note instead of charting that 8 ...maybe they're suffering now and you could've prevented that”….

I know a RR is one of the first indications of something “brewing” … how long usually between the time of noting abnormal vitals or RR does those other signs appear ? If I saw patient Thursday night … and close to 24 hours later they were being discharged would something else like other signs had presented themselves by then before they left ?

avo_921 · Nov 12, 2022

I am also a lowly CNA and here to tell you that you aren't doing anything wrong. One of the worst habits in all of HC and EMS is charting every RR as 16 or 18. Say you are going to chart a number that looks bad, check a few more times. Does something else not look right? Does the patient appear comfortable or in distress? Are they using accessory muscles to inspire? Add comments like "sleeping," "post-ambulation," "RN notified," "c/o SOB; RN notified." Your job is to chart the truth and notify the nurse, and you may get push back for it. You seem to be experiencing too much anxiety for the given situation.

When I worked Med/Surg, I called nurses all the time to report vitals. They were annoyed with me but never voiced it. At that hospital, we HAD to notify the RN for any "out of range" vital that was "in the red." That practice had more to do with the hospital trying to look good than anything else. If the nurse is nearby, you can tell the nurse before charting it. Tell them that you didn't put it in yet, they appreciate that.

Build up a good reputation and foster a trusting relationship with your nurses. If the unit is toxic and you keep running into issues with charting real vitals, consider getting the experience you need and moving on. You are a second set of eyes and if you see something that does not look right, do not be afraid to voice it in a calm and collected manner. Aim to be calm and collected in every situation.

If I get a very high temperature on a patient or see an odd acute change, 95% of the time I will tell the nurse before documenting that specific thing. If the patient is awaiting an organ and has spiked a fever, now they are off the waiting list. Keep in mind that this is in a specialized ICU setting so things are different. I have found IV sites in use that were infiltrated that no one had noticed. I've found Levo running dry, which was the only thing supporting the patient's BP. You can be useful in spotting things here and there.

If you work nightshift, always do safety rounds (and chart them) because many floor/Med/Surg patients are not on telemetry/cardiac monitoring. If they go down, they may not be found in time to get a pulse back. If you find someone pulseless and unresponsive, yell, press the code button and start compressions. Don't run around frantically into the hallway, I have seen that on more than one occasion. Generally, be on the lookout for patients who are trying to pull out IVs or climb out of bed (put on the bed alarm) and let the nurse know.

Anxiousandafraid · Nov 12, 2022

2 hours ago, avo_921 said:

I am also a lowly CNA and here to tell you that you aren't doing anything wrong. One of the worst habits in all of HC and EMS is charting every RR as 16 or 18. Say you are going to chart a number that looks bad, check a few more times. Does something else not look right? Does the patient appear comfortable or in distress? Are they using accessory muscles to inspire? Add comments like "sleeping," "post-ambulation," "RN notified," "c/o SOB; RN notified." Your job is to chart the truth and notify the nurse, and you may get push back for it. You seem to be experiencing too much anxiety for the given situation.

I guess my problem is I’m very very literal. So for instance I can be in a room with a patient that is VERY calm , watching TV and not in distress at all … but all I can count for them is 8 RR … I get stressed KNOWING the system will turn red for them and the nurses will be annoyed BUT then I’m also annoyed with myself because I know it looks bad and there’s no one in distress

mtmkjr, BSN · Nov 12, 2022

3 hours ago, avo_921 said:

At that hospital, we HAD to notify the RN for any "out of range" vital that was "in the red." That practice had more to do with the hospital trying to look good than anything else.

I would disagree that the purpose of communicating out of range vitals is to make the hospital look good. You report them to the nurse because further assessment is needed and possible action needs to be taken.

As for your other comments, I'm sure your nurses appreciate your observation skills, all things that you have learned through experience and asking questions. You are certainly not a lowly CNA!

Anxiousandafraid, I would suggest to that you ask questions. When you get a RR of 8, report the value to the nurse before documenting, but go ahead and ask if there is any concern, or what you should be looking for with that particular patient that would assure that they are not in distress. You could ask the nurse to check the RR to verify. In fact every time you get a set of vital signs where something is out of range the nurse should double check. You are not responsible for the status of the patient. If they decline the nurse is ultimately responsible for action that needs to be taken. You are there to assist with tasks but as long as there's good communication and good reporting of anything that doesn't seem right, you are doing your job well.

The more you understand about the significance of different vital signs the more confident you can be. You fear because you don't have good understanding - never feel embarrassed about asking because that's how you learn. You will find there are certain nurses who are better teachers, seek them out. Take caution around those who would put you down, it's not you it's a character fault of some sort.

Even with all the good advice you have received here it really does sound like you would be well served to have a good therapist to help with your thought processes. I hope you do learn some strategies to cope with these feelings, and I'm wishing the best to you in working through all that.

mtmkjr, BSN · Nov 12, 2022

And by the way my RR right now is 10 ?

I don't know how 18 got to be the standard RR for everyone. I believe that is too high at rest and especially during sleep. A sick person, especially with fever, metabolic, cardiac or other issues would obviously run higher but as the RR is usually documented it is not a very useful part of the overall assessment (I'm talking about when it's always 18)

Editorial Team / Admin · Nov 13, 2022

38 minutes ago, mtmkjr said:

I don't know how 18 got to be the standard RR for everyone

Same. I mean, even rescue breathing is only 8-10/minute.

Been there,done that, ASN, RN · Nov 13, 2022

I appreciate your diligence. An accurate respiratory rate, either high, or low can indicate a problem. It's too bad your accuracy kicks off a red flag in Epic.. that make more work for the nurse. Nurse then has to do a complete respiratory assessment.. which they should have done in the first place.

Keep up the good work.