Today, as part of my rapid response rounding, I spent an hour at the bedside of a patient who was having respiratory issues secondary to TB and exacerbated by CHF. The whole time I was there, the patient's O2 sat never exceeded 89% despite his being on Hi Flo NC at 100% FIO2 and 30L/min. I had a lovely argument via telephone with the brand new intern who claimed that putting patient on NRB would violate the patient's wife's wishes that he be a partial code and basically disallowed everything except for pressors in the event of a code. (The patient and his wife had no idea that they had apparently signed away their rights to an O2 mask!).
In any case, the doc at one point said, "I just checked his chart, and he looks like he's doing okay.". HUH??? I walked to the nearest computer cart and opened the patient's chart. Sure enough someone had charted the patient's vital signs as O2 sat of 94% on 50% FIO2--ten minutes ago! Up and down the halls I roamed searching for the person who had charted these vitals. The hour I spent in that room, not one other person had come in to take vitals or assess the patient. Apparently it was the CNA. CNAs are responsible for getting vitals on the patients on our med-surg floors. Unfortunately this is not the first time I have found the charted vitals to be completely divorced from reality. Every med-surg patient has a respiratory rate of 18 or 20 for some reason, and nobody's O2 sat is ever below 90 unless the patient is busy for some other reason (diarrhea for instance) and the floor nurses want her/him transferred to a higher level of care. I have noticed that assessments and vitals are especially fictional if the patient, like this one, is on isolation precautions.
I could not find the CNA, but the RN for the patient assured me that the charting must have been a mistake. She thought that the CNA must have charted another patient's vital signs in this patient's chart. I decided not to make a stink about it so as to maintain good relations with the staff on that med-surg floor, but the more I think about it the more I feel that the CNA made up those vital signs just so he wouldn't have to enter the room; the values were much too similar to what the vitals had been 4 hours previously.
What do you think? What would you do? Find the CNA and question him (he pretty much disappeared after that!)? Fill out an incident report. Contact the manager for that floor? I did put a note in the chart stating that I had been at bedside during the time the vitals signs were alleged to have been taken and charted the actual O2 sats and FIO2 on top of the erroneous values.
As for the CNA training/education regarding VS... The RN has legally delegated this responsibility to the CNA and therefore is responsible to validate their understanding. It only takes a couple of minutes to explain these types of things to your CNA as you move through your day. You can educate the CNA as you perform duties together such as bathing the patient. If you NEVER have a moment with your CNA to perform this validation, which is your legal responsibility, the option is to do your own work or work somewhere else.
Well...many of the RN's I know were once CNA's so with all the finger pointing at the aides I have to wonder how many RN's are also guilty of this. As a CNA, CHHA, ERT, and nursing student I know that this offense can be attached to every role from the bottom ALL THE WAY TO THE TOP, not just CNA's. Take action against this aide/situation (so that action will be taken) so that she/he will stop being part of the bad name given to a usually very hardworking member of the healthcare TEAM. Mistakes happen and the patient deserves the right for you to follow through with yur obvious gut feeling that something is amiss.
As a clinical instructor for student nurses (BSN and 2nd degree CNL's) I stress that everyone can make mistakes, and if they go to chart and realize they forgot to collect certain info (pain score, last BM- it could be anything) to make a list while finishing the rest of that particular flow sheet. Then go back to the patient and do whatever is necessary to collect the missing data. This is a sin of omission, and hopefully as they get more experience and are less anxious, they'll remember to do all of it the 1st time. What I won't tolerate is having anyone chart something that was NOT DONE- as in the example above, and students see that it happening all the time. I tell them on day 1 - falsifying a medical record is a failure for the day and could get you suspended/expelled. Part of the blame falls on peer-chart review, surprise visits from JCAHO/STATE H.Dept who are always searching through charts looking for "things that are missing." The patient/nurse ratio is dangerously high and the nurse doesn't have time to do everything and also to chart all of it - especially in 3 different places :-(. Since the written chart or EMR eventually gets reviewed, too many times the decision is made to meet the charting requirements by cutting corners on the actual delivery of care. Here is a place that looking for evidence can help; does all of this info really need to be collected/documented every (hr/shift/whatever time frame) or are we still collecting stuff because we always have, plus now we do 17 other things during that same hour? Does the new mom 2nd day after birth who delivered with no meds and has 0 co-morbidities really need her lungs listened to in 3 places? However, the PO day 1 c-section sure does, along with bowel sounds +-so we can advance her diet if she also + gas. We need to have charts that reflect what really needs to be done so that a critically thinking nurse can deliver evidence-based care, and a way to update/change what data is collected when the patient's status/risk factors change. When staff are asked to collect & document data that never seems to mean anything, they become complacent.
Among my CNA's I'm the "good" nurse to work with..why..because I NEVER give them vitals to take with the exception of the monthly routine vitals. Why? Because I didn't trust that I would get accurate vitals. Too many of them would make numbers up (not all but most).
My first time asking for vitals for a resident showed me I could not trust all of them. I had asked 'Mary' to get vitals on so and so. She got all huffy and walked away. I noticed as she stomped off that she had not taken the automatic vitals machine nor a stethescope. She came back with some numbers to give me. When I asked how she took a BP with no stethescope she got an odd look on her face and said "oh, those aren't hers..oops..those vitals are for Nancy Nurse's patient" She grabbed the scope and marched off. Came back with a number and walked off. I didn't like the look of the numbers..just too perfect for this particular pt. I grabbed the same cuff and scope and went to take the BP myself.
Lo and behold..I could get no BP because the cuff was broken! Found Mary and said you took so and so's BP right? And this is the number? She nods. I said, do me a favor..do it again because I think they are off a little. Again, she grabs the same scope and cuff that I had just attempted to use (broken, you could not inflate the cuff at all). she came back and said..."See, I know how to do it ya know I'm not stupid, her numbers are almost the same.."
May not be stupid but she was a liar. Wrote her up. No way in hell she took any BP with that cuff.
The next time that showed me I cannot trust all of them, I was in the room with a different CNA while doing an admit..asked her to grab the vitals on the new residents roommate. I didn't really trust this one. I watched from a distance and then said..got those numbers for me? nope..I watch a little longer..she looked terrified..i again asked..numbers? No response. I walk over and ask what was wrong..she said i think there is something wrong with these things. Can you try and see if you can get them? I did..all the "things" worked fine. I told her let me see how you are doing it.
Wow! She finally admitted she had NO idea how take a BP..or even a pulse! I was floored..she had worked there for quite some time and no one had ever known (or at least ever said anything) that this CNA could not do vitals and had been making up numbers all along. she was fired not to long afterward for things unrelated to the making up of vitals.
Any vitals for anything other than the monthly routine ones..I do them myself. With the exception of one or two of the CNA's I work with who have proven their honesty AND skills at taking vitals. Yes, I make ALL the CNA's who work my floor with my residents that they know how to properly do them. Call me a B but it is what it is.
I am a CNA/PCP on the Pediatric floor. I have heard of a few CNA's in our hospital that have been caught faking vitals. I don't know what has happened to them but I would hope that they have at least received a write up. This is very dangerous as many of you have said and in my opinion a crime. I also do blood sugars, blood draws, and set up for EKG reads. I take my job seriously and if I was in the original posters position I would at least run it up the chain of command to my shift leader if not to our manager.
Nursing assistants have been "making up" respiratory rates for as long as I can remember. I can remember on one occassion when all 28 patients on our unit were breathing at a rate of 20/min. By the way, that would make them all tachypnic. Normal resps are 12-16/min. When I encountered this issue I always addressed the CNA directly with the understanding that if it happened again I would write an incident report.
Most sources say 12-20 is considered normal. This whole issue has me wondering and thinking about a lot of other issues that might be going on. Tip of the iceberg kind of thing. Disturbing.
No point in falsifying vitals when it is your most important job as a cna. I myself go with the 16,18, 20, 22, 26 etc respirations, i dont always count them but i am very good at visualizing quickly.
You do not count you just visualize uhm I am not believing a nurse does not actually count rather than to trust your eyes this is absurd. I do my vitals using all my senses not just visual but touching and listening as well never would I simply rely on visualizing any of the vitals too important to me---this is just to weird to wrap my head around it really is
By the way, that would make them all tachypnic. Normal resps are 12-16/min.
Normal is when a patient has no pain. Resperation rates go up when a patient has pain so in most cases when the patient has pain their resperation rate will go up. I work with children in the pediatric unit and their resperation rates always seem slightly higher than the so called normal. When working with the kids nothing seems normal from the adult world.
That being said, I know they study a lot about anatomy and illness, they get tested on vitals and what is normal, but I am really not sure if there is an emphasis on how the vitals relate to the illness and how meds are titrated according to vitals. I will talk to my friend who teaches the program. Maybe I will show her this thread. It might give her new insight as to her teaching.
i'm not certain if they need to know how vitals relate to particular illness.
i would think just knowing why high/low bp, pulse, temp, resps are concerning, and what ea vital can do to one's body, i.e., bp affects cardiac ouput, and can do x, y, z to body.
keep it simple in layman's terms...yet very generalized.
You do not count you just visualize uhm I am not believing a nurse does not actually count rather than to trust your eyes this is absurd. I do my vitals using all my senses not just visual but touching and listening as well never would I simply rely on visualizing any of the vitals too important to me---this is just to weird to wrap my head around it really is
this concept really needs to be reinforced.
always, always, always count.
i believe most of us can assess a heart rate or resps, to be wnl...
yet it may not be normal if it's not pt's baseline.
and yes, never just look at the numbers.
you need to assess pt presentation...diaphoretic? using accessory muscles? restless?
and never ever go by pulse ox.
do you know how many times i've gotten 90+, yet pt critically ill (pulm edema, chf for examples)
i've had nurses tell me to "look at the ox number" and at times such as these, i immediately respond, "look at the damned pt!!"
please, accurate vitals...they are our most assistive tool.
and, it's the first question dr's ask of us when trying to make decision about pt.
i'm not certain if they need to know how vitals relate to particular illness.
i would think just knowing why high/low bp, pulse, temp, resps are concerning, and what ea vital can do to one's body, i.e., bp affects cardiac ouput, and can do x, y, z to body.
keep it simple in layman's terms...yet very generalized.
I think if they do not understand that a deviation is a symptom and is important then they will not see the reason to be accurate. I am not saying they need to know everything in a med-surg book, but they need to understand why they are counting the respirations, not just how to do it.
Now that I see that it is not just CNAs who are doing this I am unsure what to think. I was thinking it was because they did not understand, but if other health care workers do this too then what does it mean?
I was visiting my mother in the hospital not long ago and the male nurse could not get the automatic BP cuff to work. He went and got another one and still was having problems. There was one on the wall behind her bed and I suggested he try taking it manually. Maybe they just were not sensing her for some reason. He looked at me like he did not understand. I thought - don't people even take BPs manually anymore? I had to leave so I am not sure what happened. I wondered if he even remembered how to take a BP with a regular cuff.
Are we all on autopilot these days? Too much information overload?
kindaquazie
73 Posts
As for the CNA training/education regarding VS... The RN has legally delegated this responsibility to the CNA and therefore is responsible to validate their understanding. It only takes a couple of minutes to explain these types of things to your CNA as you move through your day. You can educate the CNA as you perform duties together such as bathing the patient. If you NEVER have a moment with your CNA to perform this validation, which is your legal responsibility, the option is to do your own work or work somewhere else.