question answered

cherrybreeze, ADN, RN · Feb 28, 2010

Actually, I do disagree with you. The BP may have been higher than that pt's norm, but it still was their BP at that time. Yes, circumstances may have caused it to be higher, but again.....it was, what it was. I think you're making too big of a deal out of it. If it was a pain issue, administer the med, and chart a follow up BP wherever you chart a med follow up (I am not sure what your documentation looks like, but we have separate areas for charting medication follow ups). Subsequent blood pressures may again follow the patient's norm, or they may not....I don't think you can say for sure that that one was due to pain (although it could have been). What if they were starting to trend upwards? I think the CNA's charting was fine. It was higher, yes, but not freakishly so.

roser13, ASN, RN · Feb 28, 2010

I guess I don't understand the issue. All VS are valid and should be documented, whether they are normal or not. I strongly believe that the first set of vitals should have been documented, you noted them, addressed the issue (patient's pain) and then documented the 2nd set as returning to the patient's baseline.

You can't just document patient information that meets your approval or your patient's baseline. In my opinion, failure to document when you were informed of the abnormal VS could be considered to be derelict on your part.

SharonH, RN · Feb 28, 2010

Our nursing assistant takes a set of VS at 1600. BP is 157/80. This is unusual for the patient. Pain turns out was in pain. I ask the assistant to recheck in 30. She states that this is the BP she is going to chart regardless of what the results are later. She states this is what she was told, to chart first set taken. I was SO upset. As the RN, I get final word in what VS get charted right? I mean, I sign off on it, i'm the one with the license. Worst of all, the chart that the doctors see each day have very limited space. I then asked if she could chart the before and after then on the doctor's chart that way they can see the difference. she said "I can't", due to limited space I suppose, she writes big. So she charted the high BP instead. I also had to go back and explain in the nursing notes about the discrepancy when the first set of VS really shouldn't have been taken anyway. Its redundant and more work. If VS are within the same first half of the hour, what is the problem with taking the more baseline set when the patient was obviously in pain when the high set were taken.
I am the RN, I am the one who has to explain whatever is documented. I feel I get to make the final decision. By the hospital supposedly telling the assistants to chart the first set always is allowing them to judge the appropriateness of time/patient condition to gather VS. That in itself is a nursing decision. Am I wrong here?

Well yes, you are wrong. She should chart the blood pressure she gets. There is nothing worng with you documenting "BP per nsg assistant, 157/80. Patient reports back pain 8/10. Medicated with Percocet 1 tab PO." Then 1 hour later, you might document, "patient now reports pain 4/10. BP 136/78." But personally I don't think I would have bothered to recheck that BP unless the next routine set of vitals was more than 4 hours away. Why did that upset you so much?

Also, I've never heard of the RN getting to decide what the aide can and cannot chart. They document their findings. You document yours. That's it.

allnurses Guide · Feb 28, 2010

I agree with cherrybreeze and roser and sharon.

"Abnormal" or not - that was the bp. Just because we are RN's doesn't mean we get to tell the aide what to chart. That is almost like fraud.

That bp gives the docs some information - it was high - the patient stated they were in pain - pain med given - bp down.

It is a good thing! Follow up that initial bp with the other bp in your nurses notes.

steph

Virgo_RN, BSN, RN · Feb 28, 2010

The aide is correct to document the vitals that she obtained. As the RN, you are responsible for following up on any abnormal VS, and to document your assessment, interventions, and the results. There is absolutely nothing wrong with doing this in your narrative, if there is not enough room on your flowsheet or whatever you use to document multiple sets of vitals.

You could write something like "BP 157/80. States pain score 8/10, "back aching". Medicated for pain per MD orders. BP at 1700 120/80, pain score 2/10. Left resting quietly with call bell within reach."

I'm not understanding why this is a problem.

holdensjane · Feb 28, 2010

Thanks for answering the question!

Virgo_RN, BSN, RN · Feb 28, 2010

I was always taught that things like pain, cold/hot water within ten minutes, laying on the side, strenous activity, etc, would falsely portray true VS. Ideally, you wouldn't take VS under these conditions and would come back later to do them. Otherwise doctors who only see those sets of VS would medicate based on those numbers, which would be inaccurate.

This is why you follow up on any abnormal VS and document your assessment, intervention, and the patient's response in your narrative. The doctors are supposed to read the nursing notes, too.

casi, ASN, RN · Feb 28, 2010

Nursing assistant's job is to observe and chart. Your job is to follow up and assess that. Not charting something because the nurse says not to is potentially getting the aides butt in trouble in the future.

roser13, ASN, RN · Feb 28, 2010

I was always taught that things like pain, cold/hot water within ten minutes, laying on the side, strenous activity, etc, would falsely portray true VS. Ideally, you wouldn't take VS under these conditions and would come back later to do them. Otherwise doctors who only see those sets of VS would medicate based on those numbers, which would be inaccurate.
I mean, by the same token if the patient was drinking hot coffee @ 1600 and the the PCA decided to take a temp anyway and it came back as a fever. I would not consider that something worthy of being documented. I would come back later in 15 minutes and retake it. If it was normal by then and the patient has been normal all day, I would consider that my 1600 temp. How is that fraud?

I haven't read anyone's post that mentioned fraud. Of course those things that you note have an impact on VS. That's why ideally, VS are not taken under any of those conditions. But the VS were taken under one of those conditions and thus needed to be documented.

After all, if I read your post correctly, the increased BP was the only indication you had that the patient was in pain. Thus, taking/documenting that BP assisted you in your nursing assessment/intervention.

allnurses Guide · Feb 28, 2010

Taking an oral temp after drinking something hot or cold is not the same as taking a bp when someone is in pain.

Blood pressure tells you something - regardless of whether the patient is in pain or nervous about the doc coming in or tired or angry.

You telling an aide not to chart a legit vital sign - is tantamount to telling her to lie. And that is wrong.

A bp during pain IS a legit bp.

steph

Virgo_RN, BSN, RN · Feb 28, 2010

I mean, by the same token if the patient was drinking hot coffee @ 1600 and the the PCA decided to take a temp anyway and it came back as a fever. I would not consider that something worthy of being documented. I would come back later in 15 minutes and retake it. If it was normal by then and the patient has been normal all day, I would consider that my 1600 temp. How is that fraud?

In a circumstance like this, I would allow the aide to chart their VS, then follow up and recheck in a few minutes and document those results. I would chart "Temp rechecked at 1615 by RN, 36.8." or "Pulse rechecked at 1615 by RN, 68BPM at rest." or "BP rechecked at 1615 by RN, 120/80 supine." The doc is going to give your result more credibility than the previous one by the aide.

What's the big deal? There are so many things to get frustrated about in nursing, but I don't see this one as a hill worthy of dying on.

It is your job to assess, intervene, and evaluate, not the aide's. The aide is correct to stay within her scope and just record her observations. Any observations that are outside the norm for that patient are your job to investigate.