What are you most vigilant about?

[lynns75]

What things do you watch your patients for more vigilantly now after having missed before? Or maybe it is just because you have seen it happen more often or have seen another nurse have a problem because they didn't monitor something they should have? For example, I had a nurse tell me during an OB rotation that she is more vigilant about having patients empty their bladder sooner than later after delivery because most of her hemorrhages have occurred because of full bladders.

[elemenRN]

Awesome question! I feel like I have a lot! My biggest one is probably making sure DNR/DNI orders are active, signed within the correct time frame and by the appropriate people. My others mainly have to do with respiratory emergencies. I'm anal about making sure my seizure patients have suction that is set up, working and ready to go. Same for trached patients or those with respiratory issues. For my trach patients, I always make sure I have extra inner cannulas, trach tubes (same size and smaller), and sterile suction kits readily available.

My biggest fear is having a patient in respiratory distress. No other emergencies really evoke such anxiety in me. I think respiratory distress is about as instant "critical thinking" as it gets. It wasn't even my patient, but I'll never forget the look of pure fear in one patient's eyes as I walked in on her literally starving for oxygen. She was begging for me to fix it with just her eyes. Horrific! Her hands were gripped so tightly around my forearm that I couldn't even peel them off to intervene. That's what my nightmares are made of.

[ChristineN, BSN, RN]

Wow, Q4 for post ops seems too little. We have to do Q1x4 for post ops and put them on continuous pulse oximetry monitors.

I have never seen post op vs done this often unless the pt is still in PACU or is transferred to ICU. And not every post op needs pulse-ox

[anon456, BSN, RN]

Making sure emergency equipment is at the bedside and working. That includes an ambubag and suction for every single patient (I work peds critical care and stepdown). Trach patients make sure there is an obturator, two spare trachs (right size and one size smaller), suction catheters, and other emergency trach equipment. Also an extra pulse-ox probe in or near the room to grab in case there is a doubt about that one not working correctly. I usually carry one in my pocket. For a chest tube patient you want the clamps, vaseline gauze, and foam tape. For a patient with a central line you want hemostats. For a patient with an arterial line you want sterile gauze and foam tape. And so on. Make sure the equipment is kept in a visible place, like hanging from the IV pole or taped on the wall above the bed. And don't forget the code sheet!

Always, always make absolutely sure arterial bleeding stops completely before walking away (after ABG's, line removal, etc.) If the patient has a newer AV fistula and cannot be trusted to leave it alone, take action immediately. Exsanguation is not pretty.

Wasn't my patient but CLS drew ABG on a guy in the AC without following up with pressure.

HUGE hematoma... entire upper arm blew up like a balloon... bordered on compartment syndrome...

Dude would've been d/c'd home that day... ended up staying for another week...

If patient is ALOC, restrain their hands... fully inflated Foley balloons do a number when pulled out of the urethra...

And the horror of seeing a patient with an SBP of 65 with his central line and PIVs x3 laying on the floor is enough to get soft wrists on all your patients...

And for heaven sake, before you let them transfer a patient off the EMS gurney onto yours, you or someone reliable should have the sole mission of ensuring that the EMS PIVs survive the transfer... Patient comes in under CPR and the single field start gets pulled out because an intern caught the tubing... Emergent sphincteritis for the nurse.

And if you have to run pressors in distal PIV's (and I've had no choice), watch 'em like a hawk... an infiltration can cost the patient a limb and cost the nurse a job and/or license... same with CaCl pushes... it had better be in the vein or it's all bad for all involved.

And there's always time -- ALWAYS TIME -- to confirm a verbal order with the med/dose/route **BEFORE** the med goes in -- ALWAYS TIME

And ALWAYS watch their teeth and their nails

And never forget... the single highest priority in what we do is the safety of yourself and the others around you... If it can't be done safely, it can't be done at all.

Making sure anybody who is there for psych is undressed and gowned with their stuff given to security and security aware of their presence.

We had a reeeeal bad elopement situation with a violent psych patient who still had street clothes and, as it turned out, a knife, and who managed to walk out because nobody in security knew what was up.

^^^ this ^^^

We had something like that except it was a loaded semiautomatic pistol... in the gurney with the patient... who was brought in by EMS for having been deemed a risk to himself and others... gee, ya think?

[imintrouble, BSN, RN]

I always check VS before giving meds that might impact those VS.

It's pretty basic and simple, but I've lived through the sinking feeling of pushing Lasix on a patient with a SBP of 80 or below..

[amzyRN]

Blood sugars most definitely. I've had three patients become hypoglycemic. Cardizem drips with beta blockers are sometimes a bad mix and I am always cautious when they are prescribed together.

[BigGoose62]

I'm a stickler for restraints. I've only been on the unit 15 months, but I've never had a self extubation...and don't plan on one anytime soon. I don't care if my pt is sedated, unresponsive, or fully cooperative. Bilat wrist restraints are in place, secure, and don't offer any slack. Of course, I perform ROM and release them at every turn. Only time I leave an intubated pt unrestrained is if they're being paralyzed, and even then I have the restraints hanging ready on the bed.

[GingerTravelRN]

blood pressure

[RainMom]

Hmmm, VS of course & a lot of the above but also I like to make sure my post-op pts TURN! Seems like 9x out of 10 when I offer to help a pt turn they'll make a statement that they didn't think they were allowed...smh.

[annie.rn]

Checking drug levels prior to administration. Also, checking any labs that go hand in hand w/ certain meds (i.e., Lasix/K+ levels). As a new nurse I saw a 20 year old post-knee arthroscopy pt. end up on dialysis after receiving several doses of Gentamycin after a critically high trough had been overlooked. I had always been quite vigilant but that cemented my habit.

Stopping to look up drugs I don't know no matter how much of a time crunch I am in.

There's others but that's the one that comes to mind immediately.