Q's (Vitals,TF meds, "quick" head to toe)

[glovedgoddess]

Hi again its me with some more of my "queery" (lol) questions!:

1) I have done a few shifts and one thing I still have just NOT gotten straight is when to take vitals!! To me its makes sense to take them first thing in the morning when I go in to do assessment and than again later if needed. But when the nurses are doing report they say for ex. "okay vitals for this pt are TID"..than they write down 10:00 vitals on their sheets. I doesnt make sense to me to do a head-to-toe and resp assessment and everything and not even do vitals at the same time, I mean we are trying to be efficient here are we not? anyways...if someone could just clear this up for me I would be forever thankful:yeah:. Day shift (7-3): what are the vitals for: Routine? BID? TID? QID? q4h?...Evenings (3-11): Routine? BID? TID? QID? q4h? and Nights (11-7): Routine? BID? TID? QID? q4h?

2) Tube feed Med question: The other night I had to give a pt 2 meds (tablets crushed) thru his PEG tube. I have never given 2 so my question to the RN was "is it policy to give 2 meds together in the same syringe when administering thru a tube?". Sooo she said yes I could. I did this and later I was still thinking about it.. I was thinking okay well it's only going into the stomach anyways so why would it be a problem to give the 2 meds together?? But what if there were 3 or 4 meds to give, would I still mix all those together and draw them up in the syringe with water? (seems a little queery to me). So a couple days ago I was wondering if there was a policy or procedure book on the ward that would have stuff like this in it (you know like all the things that I as a student don't really know and it seems to be common knowledge among all the other nurses)..well turns out there's no such thing as this student saving book that I speak of!! hmmm.. well I did some detective work and I was on the hospital computer system that has procedures, pt education and stuff like that. I found tube feed meds and guess what it said in capital letters "DO NOT GIVE MEDS TOGETHER, give one at a time and flush with 5 ml between each one". Well there ya go! Do you see why I always question things:idea:?? I want to do things the right way not necessarily the easy way. SO my question is..does anyone know what the reason would be that you should not give meds together in same syringe into PEG tube (or any tube for that matter)? Is it because the consistency could be altered and possibly increase risk of clogging the tube easier?

3) What is meant by a "quick" head to toe? The RN told me to do this when a postop pt came back to our ward. I observed an LPN do an admission of another postop pt and she did a fast little check like bowel sounds and chest sounds (not listening to the pts back), asking about pain and N&V, checking dressing. Is this correct for a "quick" assessment or should I still be doing cap refill, edema checks, turning asking them to sit forward or turn over to listen to back resps (I think this is important, but is it acceptable to just listen to chest resps??), heart sounds. All that business.

Thank you for your responses:)!.. even if you only can answer one or 2 anything helps!

[kimmie4476, ASN, RN]

Wow! Lots of questions and sadly, there is no simple answers. Take your first question. Here our routine vitals (or QID vitals) are done at 06,12,18,and 21. In the real world, you most likely won't be the one doing the routine vitals, and these times are set up so that the CNA can keep their routine. Obviously, this only works for stable patients with stable vital signs. In the real world, routine pt's don't need an extra set taken with your head to toe. They do however need to be taken before giving blood pressure meds etc. or if they are unstable or feeling "differently".

Imagine you are a stable patient laying in the hospital bed and someone comes in at 06, wakes you up, takes your vitals, then you go back to sleep and the nurse comes in at 0730 (when our dayshift starts) does the head to toe, takes another set, then comes back at 09 for AM meds, takes another set, then the CNA comes back to take the routine vitals and so on..seems like a lot right? Now if your head to toe coincides with the time for the routine vitals, then yes it makes sense to take them then (you don't need to wait for the CNA to get them and they will be very grateful!) If, however, your instructor wants you to take them with your head to toe, then by all means, take them! (you need the practice while in school) as they are the ones grading you.

As for the tube feeding, maybe they want you to administer separately because some medication combinations can interact to clog the tube? Just a guess here, but I'm sure there are experts who can answer better than my limited knowledge of feeding tubes lol. (P.S. just reread your questions and saw that you came up with that too lol)

Anyways, question #3 another difficult one to answer simply as there are so many factors...remember that you are in school, so what applies in the real world doesn't apply to you right now..for now, you should always do a full head to toe because you need the practice in doing it correctly.

When I get a patient back from surgery, I do a quick "head to toe" which sounds a lot like what you saw the LPN do. I will consider chest ascultation ok in this situation IF I already know the patient and have already listened fully to lung sounds before the operation and do not hear anything out of the ordinary on the chest (of course if the pt is at risk for breathing problems ie. CHF COPDer etc. always assess the back also). But the main thing I'm assessing for in an immediately post surgery pt., is their wound and then i'm looking for after-effects of anesthesia. The last thing to wake up from general anesthesia is usually the bowel, so remember never to give anything to eat or drink until bowel sounds are present. Depending on where and what the surgery was, you may have to check circulation in the distal area and so on... I know this is confusing, but I said it wasn't going to be easy to answer lol. And you also have to remember that you are always assessing your patients, so even if it doesn't look like the LPN did much, I'm going to copy and paste a response that I wrote to another student who asked about head to toe assessments to give you an idea of how fast and thorough an assessment can be without looking like much..

Here's my general head to toe; walk in the room, look at the patient (assessing skin color, diaphoresis, flushed, edema etc.) talk to the patient introduce myself, ask what's going on, try to make them smile (observing speech, slurring, orientation, facial drooping, etc.) Listen to heart, lungs, (making the stethescope leave a ring to check cap refill time) bowel sounds (ask about last bm and urine and any problems) have patient squeeze hands bilat (assess ROM and strength). Look at legs, assess pedal pulses (both at the same time also assessing edema and you could also do cap refill here) then, while my hands are still on top of the feet, have pt pull toes up, then move hands to the bottom and have pt push. Done. It takes less than 5 minutes on a relatively healthy patient. If you find something wrong, then you investigate further, like if your patient doesn't answer questions appropriately, then you need to find out why and do a full neuro, if there's a wound, then you assess that etc.

[JBGC4]

Tube feedings: We've been told YES, give meds together when they are compatable. The rationale is that they all end up in the stomach together. Is your question based on the fact that you are giving crushed and dissolved pills and are wondering about the patency of the tube? I still think you could mix them together and give them. It's been awhile since I looked at those details, (summer break and all). YES, it does say in the text to give meds one at a time, and that is what you would put as an answer for NCLEX.

Head to toe: I learned from a very experienced ICU nurse show me how she does her quick head to toe. She actually did her assessment, then told me which was crazy b/c I didn't see her do anything, she was that good! While she was asked some questions she casually had her hands on the womans feet checking pps etc. It was amazing!!! I think w/ experience you will learn which head to toe assessment aspects are vital at the time pertaining to the patient needs. I think as students, we are so afraid to miss a thing and are just learning, but that someday, we too will get there.

Vitals- I believe this is hospital policy and/or dr's orders. The hospital that I have done clinicals for are q4hrs. However, we need to vitals and assess every time we give a med.

[glovedgoddess]

Thank you both for your helpful replies! I'm still shaky on the Vitals ahh! but i'm sure I will sooner or later get the hang of it.

[glovedgoddess]

Kimmie - By the way the head to toe in 5 mins is a keeper!! I like that this has a good flow to it, I'm trying it out next shift :-P

[VickyRN, MSN, DNP, RN]

Always follow the official policy and procedure in a facility. Always take the time to check the official policy and procedure manual. Always. The staff nurses will often tell you something that is not according to official facility policy, out of ignorance or in an effort to save time.

Medications are given separately through an enteral tube with a small flush of water (or saline, depending on the provider's orders) in between, before and after. This is because some oral medications are simply not compatible when mixed together or they may clump in the tube, rendering the tube useless. Also, if a patient coughs suddenly and the contents come back up the tube or vomits, you at least can keep track which medications were given. It also gives the nurse or nursing student a chance to assess a patient's reaction as each medication goes down.

Be careful also to check compatibilities with any enteral feeding formula and medications. Some medications cannot be given with enteral feeds.