Only Charting "The Good Vitals"?

[whitecat5000]

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?

[SarcasticLVN]

I spent my lunch break a few weeks ago just talking to one of my cnas and he was telling me about a resident who was declining quickly and the nurse asked him to get vitals stat and he said it was weird for him to take a bp cause it had been almost a year so I said well you do vitals on my patients when there is Jo light duty and he just gave me this oh crap I got caught look.. Now I always do my pts vitals. I tried to tell him how important they are and we gp by these vitals for serious conditions.. I mean it doesn't take that long to do it!

[anotherone, BSN, RN]

i HATE THE only chart the good vitals. Because then you, the next shift and the DRS have no clue that there was evidence of a desat or change in condition. all of a sudden your pt is down hill. Didn't the aide tell you he/she put the pt on O2? if so did you ask what the vitals were? Not that you should have to , but if you work in a place like I do you would every time lol. I once heard an assistant manger tell the aide to NEVER CHART 65% on room air. ***. yes that should be charted and the next one should be what it was after intervention. I spoke up and had the assitant manager go off on me thinking she was correct. No. Wrong. Not just have 95% on NRB appear out of no where. In the case of manuals, I get them myself most of the time because I do not trust most of the aides to get an accurate one . And if the manual is 75/42 I do not want interventions to be based on someting that may or may not be correct. 78/49 and 102/68 is a huge difference. How far apart where these obtained? manual bp cuff ever? or just the machiene?

[Been there,done that, ASN, RN]

The CNA acted on the results of the initial vitals signs. That is beyond the scope of their practice.

No... in 30 years of nursing.. that has never happened.

Of course you need to immediately report the CNA's actions.. so this can be evaluated and NEVER happen again.

As far as the overall inaccuracy of obtaining vital signs that you described... if you have been observing this ... you needed to report and attempt to correct it .. before this sentinel event occurred.

Really

[tigerlogic]

As a CNA when I get a low O2 sat, the nurse will tell me to instruct the pt to take some deep breaths and then ONLY chart that number. Um... Great, I guess, except if someone has been at 88% while sleeping the last 4 hours that shouldn't also be charted?!! I also think only charting the good one is bad practice but it seems encouraged, sadly. My old job at a nursing home definitely told CNAs to only chart normal vitals. The rational was that if anything was wonky a nurse should retake and then chart as abnormal. If your CNA is good or has the potential to be good, just let them know your expectations! Too often we work with nurses who want normal vitals so they don't have to do anything more. Have an honest discussion rather than assume they are incompetent. They might be. Their instructor might have been. They might have loads of room for improvement.

[whitecat5000]

The patient was an admit about 30 minutes before change of shift. So the report from days was understandably lacking. They didn't even know where the IV was, let alone if the patient was on oxygen.

So I go into the room and the patient is on oxygen. I think that the nurse did it and maybe forgot to mention (it happens) because I KNOW that CNA's can't do that legally. And even though those vital signs aren't great, they are still within normal limits.

Wow. Scary, I mean you don't mention a temp with the first assessment but clearly the patient was sick. I'm shocked the first concern wasn't sepsis....

I don't remember what the temp was. I was thinking sepsis, but without ANY documentation of proof the doctors think I'm an idiot. My last sepsis, I called the doctor 16 hours before they caught it saying, "They just aren't right. Something is wrong, and I can't say what, but I think they need to go to PCU." Totally ignored.

That's why vital signs are so important. And all the CNA's here (in Arizona) have to have a license (unless they got grandfathered in) and I would think that how to take correct vitals signs would be covered in class.

I guess I'm just frustrated. It was a whole SNAFU and it didn't need to be. And the patient wasn't safe at all. I felt horrible for him.

[BuckyBadgerRN, ASN, RN]

Not this nurse!

I did this all the time as an aide in the hospital. Of course, I'd always tell the nurse I did so. I also would tell the pt to straighten out his arm and then restart a beeping pumpthat had stopped when the pt bent his arm and occluded an anacub IV. I did always check to make sure the IV hadn't gone subQ before restarting it. All technically against the rules, but we all did it. The nurses expected us to.

[BuckyBadgerRN, ASN, RN]

So a CNA in AZ is "licensed" to do what? Everything I find on the AZ nursing board website talks about certificates for CNA's, not licensure?

The patient was an admit about 30 minutes before change of shift. So the report from days was understandably lacking. They didn't even know where the IV was, let alone if the patient was on oxygen.

So I go into the room and the patient is on oxygen. I think that the nurse did it and maybe forgot to mention (it happens) because I KNOW that CNA's can't do that legally. And even though those vital signs aren't great, they are still within normal limits.

I don't remember what the temp was. I was thinking sepsis, but without ANY documentation of proof the doctors think I'm an idiot. My last sepsis, I called the doctor 16 hours before they caught it saying, "They just aren't right. Something is wrong, and I can't say what, but I think they need to go to PCU." Totally ignored.

That's why vital signs are so important. And all the CNA's here (in Arizona) have to have a license (unless they got grandfathered in) and I would think that how to take correct vitals signs would be covered in class.

I guess I'm just frustrated. It was a whole SNAFU and it didn't need to be. And the patient wasn't safe at all. I felt horrible for him.

[jadelpn, LPN, EMT-B]

CNA's should document WHATEVER their first vitals are, (in a perfect world after informing the nurse) which is an indication that this is the patient that needs to be assessed first. (and they should be re-educated if past practice has been otherwise). Then nurse can take the second set, intervene per MD orders, then another set after interventions. I don't like the idea of CNA's getting the second set of vitals, cause if the first ones were wonky, then I need to assess this patient. It is hard to explain to the Dr that the CNA got vitals not WNL, I asked her to take a second set, and then in fact the CNA intervened, and I have not a clue the patient was put on O2........when your CNA's tell you that someone's BP is in the toilet the first time, then that becomes the nurse's priority to follow up immediately.

And to the above poster who says that as a CNA when an IV shows "occlusion" that you push the start button (after doing your own assessment of the site)???? Please don't do that. The nurses are responsible for the outcome of an infiltrated IV. So we need to know, so that we can determine that this is not the case, and to perhaps talk to the patient about rotating the site.

In any event, CNA's gather important info for nurses. They often know patients better than others, and can detect even the smallest change in condition. That is information to take directly to the care nurse to intervene from then on. When your CNA tells you that "something is not right" I listen and respond accordingly.

[BrandonLPN, LPN]

Not this nurse!

Well, I was told to. When the pump beeped "distal occlusion" I was told to have the pt straighten out his arm, check for infiltration, and then push 'start'. It wasn't until much later that a nurse told me "well, technically, you're not supposed to do that". I did many things on that floor that the nurses weren't really supposed to delegate. I changed many ostomies. I did all the bladder scans. I was handed suppositories and told to administer them. I did manual removal of feces in pts that were impacted. I'm not saying it was right. But they were they RN and I was the aide, so I did what they told me to.

[BrandonLPN, LPN]

And I'd like to add that all of this improper delegation that happens all the time in hospitals is a direct result of the abandonment of team nursing and the elevation of UAP to "nurse tech" status. I mean, how do you know where to draw the line? A tech straight cathing a pt doesn't require nursing judgement, but giving a suppository *does*? Its okay for a tech to change a non-sterile dressing, but resarting an occluded pump is going too far? Is it any wonder nobody knew what could be delegated and what couldn't??

[wish_me_luck, BSN, RN]

Brandon, here, techs used to do in and outs and foleys but then the facility woke up and smelled the coffee and realized that that was not within the tech scope of practice (not here atleast). High risk of UTI if sterile technique not followed. We couldn't touch the IV pumps or give suppositories.

Techs can't do anything with O2 either, not even checking to make sure it is at the right flow rate (that's actually a nursing judgment).

[BrandonLPN, LPN]

Right, but when you start saying *some* formerly "nursing only" skills are okay for UAPs to do and others aren't, you've opened the floodgates. Why is inserting a foley "okay" but restating an occluded IV "not okay"? Why are clean dressing changes "okay" but giving a fleets enema "not okay"? Heck, I know for a fact that, on our burn unit, the techs did the vast majority of the dressing changes. So who can keep track of where the line is for each and every skill? Hospitals made their own bed when they replaced LPNs with glorified UAPs who seem to do everything short of giving meds or calling the doc. Now they have to sleep in that bed and deal with the consequences....