What to do?

[middlekane]

I'm a PCA on a surgical floor and a nursing student studying for the nclex. I had a patient who when I took noon vitals on, got a bp of 80/36 and O2 sat of 88. She felt fine, wasn't dizzy, nauseus, or short of breath. I did her other vitals, then retook her pulse and BP and both were still low. I then told her nurse about it.

At the end of my shift, I am logging in her next set of vitals and I see that the nurse has crossed out, with an x, the set of vitals I took. She had taken her own vitals and logged them at 2 pm. This really pissed me off. One, I know how to take accurate blood pressures. I take my time, go slow, and do it twice if I get a funny reading. Plus, it's falsifying the medical record. If she had gone in, taken her own vitals right after mine and got something different, I wouldn't have minded. Patients can change and they can do so quickly. But taking them 2 hours later and crossing mine out? Who knows what had been going on with her, she might have been having a bad rxn to BP meds or something else entirely.

What should I have done? I'm newish, so I didn't want to make a fuss, but it made me feel so uncomfortable.

[gitterbug]

Speak to the nurse and ask her why she did this. If she does not have a good explanation, talk to the NM. Do not expect too much action on this unless your facility is nurse poor. I think she just did not want your vitals recorded as primary and no notes to show she talked with the MD regarding the patients condition. You will find this more and more as your time in nursing goes on, just do the best you can do.

[meownsmile, BSN, RN]

Its NEVER acceptable for one nurse to change documentation of another nurse. Dont care if it is a CNA/RN or anything else,, even a nurse manager or DON only has the right to add a new entry with clearification information or followup even if it is to correct something from a previous nurses note.

The nurse could have followed up with a note regarding monitoring the patient and add the new set of vitals and it would have been completely appropriate. She was covering her behind for not following up on a low BP IMO.