Things to watch out for! Advice needed.

Trust your gut. If you just have an odd feeling about a patient don't just blow it off.

Big ones that often get missed by many: GI bleeds ( nausea , abdominal distention, drop in bp, increased heart rate ) right before it is completely obvious. Sepsis ( increased or very decreased temp, tachy, low bp, suspected or known infection) . The main thing you can do is assess your patients. Know how they were at the beginning of your shift and if possible before. I read at least the daily MD progress note. For changes report them to the doctor. urinary out put is one that gets missed even though it is easy to monitor. eventually you will have enough pts go bad that you will know what to watch for

Always, always take your own vital signs, and do it manually. If a CNA takes them, you run the risk of having happen what I heard one day. About to round a corner, I heard a new CNA say to an experienced one, "I can't ever hear blood pressure very well. What do I do?" and the old one said, swear to God, "Write down 120/80, that's a good one." You will also note that the flow sheet has pretty much the same pulse and BP all the way down the page, and the same weight every day. NOBODY does this normally, and yet, we see charting like this all the time. Dinamapps have very specific operating instructions, which are rarely followed properly, and are lousy in arrythmias because they don't hear well. Use a manual cuff whenever possible.

A gain of a pound or two overnight may not be a measuring error, it may be the first sign of fluid retention from incipient CHF, as the failing heart pushes less BP to the kidneys and the kidneys respond by retaining fluid (they aren't that smart and the first thing they think of is hypovolemia). Then you'll pay extra attention listening to lung sounds, not just at the beginning of the shift but every couple of hours.

You will notice that the things that indicate trouble happening often, in retrospect, showed subtle changes in VS. A leetle increase in (but sustained) HR, a leetle drop in diastolic pressure -- these are compensatory mechanisms going on. Your alert mind would think, "Why?" "Why would we need to be compensating for anything? What kind of things could be happening?" and this will cause you to be extra-vigilant on that patient's behalf.

If you can't always be present to walk your own patients or get them up, be present or do it yourself at least once a shift. Watch for slight increases in weakness, shortness of breath, a bigger "Whew!" when the chair is finally settled into.

Bed baths are a great time to observe mobility, strength, symmetry, pulses, and endurance. Don't turf off the baths to your CNA all the time. S/he will likely not notice what you can.

The very first indication of pulmonary edema is patient restlessness. Before you can hear it or see it, the patient can feel it - though they may not realize what they're feeling.

Any change in patient presentation needs to be monitored and explained... VS, skin color, behavior, urine output, mentation, etc...

Typically, several hours before a patient actually crumps, have there been subtle signs of deterioration.

Look for trends and step-wise changes (that is, things should generally change slowly, not abruptly... abrupt changes portend badness)

BTW, it gets neglected sometimes but if you're starting to sense impending badness, get a second line *before* it's all bad, while they still have some BP. I had a patient with a sketchy line who was triggering my Spidey sense so I had someone place a bomb-proof line by ultrasound. When she crumped 30 minutes later and her original line failed, I patted myself on the back as we accessed her new line.

Always try to think a couple steps ahead... if this happens, what will I do, what will I need... the time to your ducks in a row is BEFORE the patient dumps, not while they're dumping.

I too am a new nurse.. thank you so much for posting your sheets. I will be starting my new job in a couple of weeks on the orthopedic floor. I am nervous and excited at the same time. The sheets you posted will help keep me organized.

Totally agree that nurses should get their own vital signs. I don't know when the culture shift was that shifted this from a "nursing duty" to a "CNA duty". Probably a long time ago. But it was a huge mistake. Seriously, how long does taking a set of vitals take?

At my LTC facility, it is policy for CNAs to get all vitals on 1st and 2nd shift. On 3rd shift, it is the RN/LPN's responsibility. I am 100% convinced this policy is why so many more residents are sent out on the midnight shift. I catch so many fevers and raging infections on nights that go missed on days because of half-a**ed vitals by the aides. Poor technique with the tympanic thermometers drive me crazy. Temperatures are ridiculously low across the board when gotten by our CNAs. 94.1 degrees? Seriously?? When i see a CNA get a temp of 98, i have to assume the resident is septic. Blood pressures as low as 70/30 with no manual retake. And god forbid you want an accurate respiratory rate.......

That is very vauge.... Just trust your instinct, if something doesn't look right or sound right, act on it. You'll know what to do when the time comes.

I am relatively new to nursing, in fact, I am a nursing student still. That does not mean that I am not new to patient care. I have approximately 7 years experience doing patient care, primarily in the field. There seriously is just too much to be able to list everything that you could possibly look for in what happened with patients as they start to deteriorate. There is just too much to list.

Probably the biggest thing you can do is make sure that you do an assessment yourself as early on in the shift as you can so that you can monitor for changes as the shift goes on. The next thing you need to do is to seriously just "trust your gut." Many times that will be an indicator that something is just not right. It's something that you might not be able to put your finger on at first, but it's something that tells you that this patient has something going on that you need to keep an eye on.

I cannot tell you how many times I have seen patients that just did not look right but otherwise appeared to be fine and later developed some more obvious signs that something was amiss.

Seriously, do not dismiss that gut feeling. The other thing that you should do is to always listen to your patients. Often times they will be able to tell you, in not so many words, but something is wrong. They may not know what it is, but they know that something just is not right.

As far as delegating out certain tasks, like vital signs, you will eventually learn which aides will do a good job and which ones will not. While it may seem like you are doing double duty at first, take your own set of vital signs. Do your own assessment. Compare the values that you got with that of the aides that you work with. They will also begin to understand how you are as a nurse and whether or not they can get away with things. When I was working in the field, I had to do the same thing with my EMT partners. There were some that were exceptionally good at what they did and I trusted them completely and implicitly. There were others that I had to, for lack of a better word, babysit the entire time.

Getting to know which patients are going to have a problem and which ones are going to be fine is a skill that will not be developed overnight, rather, it takes time. In that previous life, after several years of doing it, I had developed a rather accurate knack for very rapidly assessing patients and figuring out what was going on with them. Prior to nursing school, it has been many years since I have worked with patients, and upon returning to doing patient care, I have found that I still have some of that process still going on. From the moment I laid eyes upon my patient, I still look for signs that my patient is not doing well. When I see that, it might not be something I can put my finger on, but I know that something is not right and will do a MUCH more thorough assessment.

But that's just something that I have found that I still do as a habit. I'm not even really all that aware of it. On the nursing end of things, I'm still learning to apply those things and become better at being a nurse. I know I've got a long way to go before I would consider myself a good nurse. Good student, yes. Good nurse? Not yet.

Keep on going because you will get the knack for it!