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punishment advice.....please......

Posted
by Seamless LVN Seamless LVN (Member)

Specializes in Geriatrics.

Okay, So I'm a new nurse working on the Rehab unit of a geriatrics based healthcare center...

I noticed the Vital signs sheets were looking a little shady with ALL the residents respirations at 20 and 22 bpm's....I was given the authority to discuss the issue with the Cna's and hand out any write ups if need be....BECAUSE.....they are obviously falsifying some very important information. I approached the first CNA writing down his vitals and what do you know....20, 20, 20, 20 and 18 respirations for his 5 patients. I asked him if he knew what the normal resting respiratory rates were. what did he say? "18 to 20"...I couldnt help but laugh...the charge nurse took over from there and proceeded to lay into him. He stormed off in a RAGE.

20 minutes later i walk into the employee break room and there he was, still yelling about how we accused him of falsifying records. (a new orient cna told me NONE of the cna's were even counting resps !)

i sat down and over-apologized if we had embarrassed him, he interrupted me, insulted me, disrespected me and ACCUSED ME OF HASSLING HIM ON THE BASIS THAT HE WAS PHILIPINO.!!!!!!!!

yep, he pulled the race-card.

NOW................as a new nurse, i dont want to come in and alienate the entire cna staff. I want them to respect me, and i want them to do their jobs...correctly.

I am thinking of bringing the issue to the DON and writing him up...but I'm not sure how to handle this siuation. comes to find out, he has been a behavior problem before, so do I throw him under the bus already or give him another chance??

i need some advice....:o

joyflnoyz, LPN

Specializes in home health. Has 40 years experience.

Write him up, have a "plan of action" ready- how his conduct is to improve, perhaps have whomever is "over" the cnas do a general inservice for all the CNAs on what can happen with incorrect VS, perhaps do skills monitoring/testing/ updating

NO ONE should be yelled at. It's unprofessional, rude, and is insubordination.

Write up a statement as to exactly what happened, who said what, HOW it was said etc, and give a copy to the DON with the write up.

No slack...since you say he has a history

txspadequeenRN, BSN, RN

Specializes in ICU, PICC Nurse, Nursing Supervisor. Has 20 years experience.

what do you consider a normal respiratory rate?

=seamless lvn;2585736 i asked him if he knew what the normal resting respiratory rates were. what did he say? "18 to 20"...i couldnt help but laugh...

Seamless LVN

Specializes in Geriatrics.

what do you consider a normal respiratory rate?

18 to 20 is not abnormal per say....12-18 is what we expect. but....considering our pts are elderly, just out of the hospital and on some serious pain medications, the rr's are not all 20's........does that answer your question!!!???

On one of the units I worked as a traveler, every patient's respiratory rate was 20. Every one. I would walk in and find people in distress puffing away at 40+ per minute, but the chart would say '20'. Or I'd have a post-op with a RR of 10-14, yet the chart would say '20'.

I once stood across from an NA doing VS and she called out the numbers... minus the RR. When I asked, she said "20" and walked away. She had never looked at her watch or the clock. The rate was in the 30's, btw.

I don't think it's so much an issue of deliberately falsifying records as it is either not knowing how to count respirations or simply not wanting to take the time.

Chloe'sinNYNow

Specializes in Did the job hop, now in MS. Not Bad!!!!!.

On one of the units I worked as a traveler, every patient's respiratory rate was 20. Every one. I would walk in and find people in distress puffing away at 40+ per minute, but the chart would say '20'. Or I'd have a post-op with a RR of 10-14, yet the chart would say '20'.

I once stood across from an NA doing VS and she called out the numbers... minus the RR. When I asked, she said "20" and walked away. She had never looked at her watch or the clock. The rate was in the 30's, btw.

I don't think it's so much an issue of deliberately falsifying records as it is either not knowing how to count respirations or simply not wanting to take the time.

Hmmm...

help me out on this...are we really asking to place blame for improper charting of RR's or just under-valuing the purpose of counting RR's at all? This is a terrific post. I too have had issues with what seems like hapless or indifferent or just plain ignorant charting of RR's.

Quickie scenario: I had a post-op pt returned to her room that required q15 mins checks and the PCT assigned to her gave me grief about having to take care of her so often in addition to her other pts. So on top of my med passing, I tried to step in as often as I could. I'm still slow as a new grad...My PCT had her hooked to the Dynamap on a timer that would go off q15 mins and had a screen that showed her VS trend. She didn't go in at all, but after 45 mins she stepped in and wrote everything down, and when I asked for her RR's, she glanced at her for all of 2 secs!!! And said 20. (She was actually 12; she wasn't able to deep breathe, had just had a liver biopsy due to CA mets and was already in a terminal state of uterine CA)

So is it ignorance? Defiance? Or impatience? At the very least, 15 secs is not a long time to watch a pt to count their breathing, considering the brevity of knowing a pt's RR could be compensating for a very dire underlying condition. There's a reason they are considered a Vital Sign.

I also think that there is too much of this that does go on all over. I've written in previous posts about my own BP taken so poorly that it didn't even register w/ my current condition nor my lifelong trend. It was so off the wall incorrect! And a quickie 2 second glance is NOT long enough to count RR's!!

I think the bigger question to our OP is what can be done about the situation without creating a hostile work environment. In my case, I was dealing w/ a PCT 20 years older than me, much liked by the staff and lots of time served on the unit and in other places doing PCT work. She also liked to constantly challenge and test me. She didn't think she should be doing as I asked. Why? I'm not sure. But when I tt my charge nurse, she was not surprised. She said she was testing me. And eventually, after much griping, my assigned PCT said she'd get around to it. As a newbie to the floor, I thought that if she stopped yakking so much and taking time away fr her work to gossip and be a chatty cathy than she could have been able to do my pt's vitals as I needed. But I only thought this. I never said it.

So long post here, but it's a terrific thread and I'm on the bandwagon. I am not sure of the process for writing someone up, nor am I sure that PCT's are necessarily considered our subordinates. I always look upon them as co-workers. They are undervalued in my opinion. But that doesn't give this guy the right to get verbally abusive after negligence in his duties. I think the only way to tell if there was intent would be to validate him and audit him while he does his VS. Perhaps he needs training. Either which way, there's a written warning in there somewhere I'm sure.

Good luck!! I can' t wait to hear how this unravels

Chloe

CritterLover, BSN, RN

Specializes in ER, ICU, Infusion, peds, informatics. Has 22 years experience.

the hospital where i currently work apparently has an epidemic of patients that breathe 20 times per minute.

if you exclude the icus (where the nurses do their own vs), i would (probably conservativly) estimate that 70% of the patients have recorded rrs of 20.

it is to the point that i have to remind myself not to pay any attention to the recorded rr when i'm reveiwing charts to check on pt status.

i was asked to check on a patient a few months ago that was still a little sedated post-procedure. vss, i was told. rr was 20. i went in to assess him, and his actual rr was 8. i ended up counting it again to be sure. the second time around, i got 7.

why does this happen? i think it is a combination of lack of time, laziness, and (honestly) how they are taught. (way back when i was a new cna, my "preceptor" instructed me that, when getting a bp, to find the "top number" and then put it over the pulse. bad habits are sometimes passed on that way.)

part of the problem (at least where i work) is that rr is the one vs that the cnas have to do themselves -- the thermometer gives them the temp; the dynamap gives them the hr and bp.

i'm not in management, so i really can't offer suggestions on how to discipline. however, i would probably want to approch the issue through education, rather than discipline. if education doesn't work, then move to discipline.

UM Review RN, ASN, RN

Specializes in Utilization Management.

This is why I love monitored patients and in fact, why I wish all the patients were completely monitored, O2 sats and all. ;) Of course, LTC residents might protest the arrangement.

I think that the entire CNA staff needs a brief inservice on counting resps, the significance of the highs and lows, and the warning that if they are suspected of not counting the patient's resps accurately, they will have counseling and writeups.

The entire staff needs to be on the same page with this and the nurses need to be alert to the problem and agree on how to handle it.

sjt9721, BSN, RN

Specializes in Emergency/Trauma/Education.

This problem (inability to count, laziness, or whatever) isn't limited to the unlicensed.

I worked with an RN that frequently documented the RR as 11. Not 8, not 12, but 11! Now 11 is a prime number, meaning it's not divisible by anything...you can't tell me that she sat there for an entire minute for each patient and counted the respirations.

I found out (after I left the facility) that she was later fired for issues relating to T & A fraud because she was having someone clock her in before she arrived for work.

Here's what I do to get over this problem. I do my own RR when I'm doing my assessment. I then let the cna know I've done it already, let him/her know what the RR is so they can include it with their vitals charting.

For me, it kills 2 birds with 1 stone. It lets the cna know I'm aware of what the "real" RR is, and I'm covering my a.. by making sure the charting is a true reflection of what's really going on with the patient.

It's a win/win situation. I let the cna know I'm doing it to help him/her also.

Chloe'sinNYNow

Specializes in Did the job hop, now in MS. Not Bad!!!!!.

Here's what I do to get over this problem. I do my own RR when I'm doing my assessment. I then let the cna know I've done it already, let him/her know what the RR is so they can include it with their vitals charting.

For me, it kills 2 birds with 1 stone. It lets the cna know I'm aware of what the "real" RR is, and I'm covering my a.. by making sure the charting is a true reflection of what's really going on with the patient.

It's a win/win situation. I let the cna know I'm doing it to help him/her also.

But still not alleviating the bigger issue of copycat charting and ignoring the critical issues of properly obtaining, charting and reporting Vital Signs.

It will certainly keep you in good graces with the PCT's however.

Guess I am more insistent on the principle issue and having a cohesive working environment for the benefit and safety of the patient. Nursing school played a major consciousness raising factor on me.

But still not alleviating the bigger issue of copycat charting and ignoring the critical issues of properly obtaining, charting and reporting Vital Signs.

I agree wholeheartedly. For now, I just do the best I can to overcome the problem in the interim.

But you're absolutely right, the bigger picture needs to be addressed.

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