Vital Signs

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Groove

Groove

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Am I the only one dealing with nursing that seems incapable of obtaining and providing vital signs?

Almost every shift, I either go without temperatures for 1-2 hours on patients or some other set of VS. I think this all started when the powers on high determined to use only O2 sat and HR as the only necessary VS for ESI level appropriation and it all went downhill after that.

I counted yesterday and Pt1 went without Temp for 3 hours, Pt2 went without temp for 1H, Pt3 went with nothing but a HR and O2 sat on the tracking board for 2H, Pt 4 went without a temp for 45M.

What really pissed me off was catching one of the nurses yesterday back time stamping the vitals at the time of arrival. Meaning, she documented that they were available at 11:00 when in reality she accessed the chart to write them down for the first time at > 1400.

Can you imagine the liability caused by that kind of false documentation? If you got your chart pulled and it was brought to trial, it looks like the vital signs were all available to you minutes after the pt arrived, when in reality you didn't know about the say...temp of 102 until 2 hours later. There's no easy way to prove a nurse did that though in a chart audit situation with all the hundreds of documents printed out. Can you imaging being sued about delayed treatment for say...a meningitis and the plaintiffs lawyer asking why you didn't think about it with an arrival temp of 102, AMS and you're sitting there thinking ...."damn...they arrived with a temp of 102? What WAS I thinking?! Man, I must not have been on my A game that day." When in reality, the temp wasn't available until 2 hours later....but you're never gonna remember those kinds of details 3 years later when deposed on it.

Virtually all of my "stroke alert!" patients who come in and they page overhead for a physician to eval which could be almost anything from "dizzy" compliant to bell's palsy to whatever.....none of them have temps. I don't know about you but my AMS ddx shifts dramatically if I know the pt has a fever. Yet, all our code strokes go without until they go for CTA/CTP, etc.. and maybe...just maybe a nurse might get one an hour after they're well into their work up.

Anyway, It really pissed me off and I made a big deal about it to nursing leadership and our current physician leadership. I've been harping on nurses obtaining vital signs in a timely manner for over 2 years now and I'm sick of making an issue about it. This all seems to have started when they started obtaining O2 sat and HR (only) in the WR to triage pt's faster. Everyone thinks someone else is obtaining VS and the nurses have lost any sense of gravity as to why VS should be important to the physicians. It's driving me crazy. I have to take time out of my busy shift to run around and harass individual nurses about updating or taking VS.

Sorry, just needed to let off some steam.
 
Two things:

1. Epic chart audit will show what time they added it. If you're ever sued, have your attorney request a chart audit as quick as possible. That way you can see what time they added things and various things resulted.

2. If something is abnormal and was placed after the fact, document it. Just like I document discrepancies with triage (e.g., "patient noted by triage nurse to complain of chest pain; however, he adamantly denies chest pain and only complains of right lower quadrant abdominal pain"). This is where dictation makes this easy. Likewise, if a BP was 70/60, not available when you evaluated the patient, but then became available, then document the time it was available in your note.

We have changed our note templates so that when you open the note, the initial vitals available to you are there. They do not change. So if there wasn't a BP, HR, etc. when you opened the note, it won't be listed as "initial vitals" but will be listed in the sequence of vitals.
 
They will also chart grossly abnormal vitals and not alert the physician.

I think it comes down to whether or not you take pride in your work. No pride, no effort. They're too busy b******g about whatever the union issue of the day is
 
OTOH, I can't tell you how many times I've had to redirect nurses from trying to get vital signs on kids for things like suture removals.
Guys, they're talking and upright. If you never document them, they're never abnormal. Stop checking useless things on stupid complaints.
 
Even when vital signs are documented, I find them often frustrating.

Commonly, the RN will document whatever number shows up on the monitor even if it has nothing to do with the patient. Typically there is nothing close to a reasonable waveform but the monitor will state sat 77%. That goes in this chart and is scrutinized at chart review. Case review committees often ask why the hypoxia was not addressed for the first thirty minutes -- but there's nothing in the chart to say that the probe was resting behind the patient's pillow.

HH
 
Hamhock said:
Even when vital signs are documented, I find them often frustrating.

Commonly, the RN will document whatever number shows up on the monitor even if it has nothing to do with the patient. Typically there is nothing close to a reasonable waveform but the monitor will state sat 77%. That goes in this chart and is scrutinized at chart review. Case review committees often ask why the hypoxia was not addressed for the first thirty minutes -- but there's nothing in the chart to say that the probe was resting behind the patient's pillow.

HH
Click to expand...

Or the HR of 140 that they put in the chart when the monitor is double-counting? Don't get me started on METRIC weights for kids.....
 
Since when is BP not as important as O2 or HR? I would rather have, if a gun pointed was pointed to my head....elevated HR with a normal BP in the waiting room that a low BP in the waiting room.

We are generally pretty good except RR. Also, for peds vital signs, I do HR and RR myself almost reflexively now. Takes only 30 seconds and gives the impression that you are really doing something special as you are looking at your watch.
 
thegenius said:
Since when is BP not as important as O2 or HR? I would rather have, if a gun pointed was pointed to my head....elevated HR with a normal BP in the waiting room that a low BP in the waiting room.

We are generally pretty good except RR. Also, for peds vital signs, I do HR and RR myself almost reflexively now. Takes only 30 seconds and gives the impression that you are really doing something special as you are looking at your watch.
Click to expand...

Dude, I have no idea. My director came up with the idea a few years ago and I think it was to expedite direct bedding and he used some study to justify the safety that I seem to remember it not being very well powered but I couldn't find it again after that. It may be an Apollo thing... It's incredibly frustrating. All it does is teach techs and nurses that there are "important" vital signs such as O2, HR and "non important" VS....everything else. It also splits the responsibility of obtaining them among multiple people and they all blame each other when they aren't entered. I had a hypothermic myxedema coma (bad sick) about a year and a half ago on pressors that I admitted to the ICU and didn't have a temp until they were on their way up and almost had a conniption fit.
 
Super frustrating. Our ER does a pretty good job at documenting all initial vitals, but the nurses suck at repeating them.

Last week I had a lady come in with acute pancreatitis and she was very tachycardic, in the 150s. She was obviously on cardiac monitoring so I could pop in the room and see her heart rate was going down. When I admitted her four hours later - NO REPEAT VITALS had been documented. Seriously?

Same thing happens with crazy high blood pressures. I probably won’t do anything about that 194/100 but I certainly don’t feel like discharging the patient that way so CAN YOU RECHECK IT, PLEASE!

Today I had a lady with lightheadedness upon standing with a syncopal episode. I ordered a liter of fluids and ordered “orthostatic vitals - now and after fluid bonus administration.” (I know orthostatic vitals are considered useless in some docs’ eyes, but this is besides the point). I noted two and a half hours later this still had not been done. Put “ortho vitals” in the comment. Three hours later, nothing. I try to track down the nurse… Something that I genuinely did not have time for today. I couldn’t find her. I told the nurse sitting next to her, and she stated she would have it taken care of. At the four hour mark the nurse comes up to me and says “When are you discharging the patient? She needs a work note.” I said “How were those orthostatic vitals?” She said “Oh, I didn’t know you wanted me to get those.” Really! An order! A reminder from your colleague and “ORTHO VS PLS” written multiple times in the comments? It’s insane.

My favorite is when you get protests for repeat vitals. I had an old man come in today with a temporal temperature of 102.0F. I started a huge work up and asked the nurse to confirm with an oral temperature. You could tell that for some odd reason (laziness?) he didn’t want to do it. Then the nurse comes up to me a half hour later and said, “Okay, so I put in EMS vitals and didn’t check them myself, and the guy does not have a fever. It’s 98.7F.” I said, “Oh, oral temp?” He says “No, temporal.” DIDN’T I ASK YOU TO CHECK AN ORAL TEMP? It’s this kind of stuff that drives me absolutely crazy because it’s a little thing I should not be having to worry about or nag the nurse about.

I suppose I could learn how to document vitals in the chart… There’s not an obvious way to do this. But at the same time, why....

It is horrifying when the nurse discharges someone With significantly abnormal vital signs and doesn’t tell you. Once I had a patient who came in with nausea, vomiting, and abdominal pain, and was slightly tachycardic. Everything was looking good and the patient was improving, so I put in the discharge order. I was on my way out the door and had logged out when the nurse ran out and said that the patient was requesting another dose of nausea medication before I go. I told them they could give the patient another dose of Zofran, but to repeat a fluid challenge before the patient leaves (the patient was waiting for a ride). I specifically stated that if there are any abnormal vital signs or if the patient continues vomiting, to alert the night MD. I let the night doc know the scoop and left. I log in when I get home and see the nurse discharged my patient with a heart rate of 139 bpm and didn’t tell anyone. Just sent the patient home that way.How does a discharge heart rate of 139 hold up in court?
 
Last edited by a moderator:
ERCAT said:
It is horrifying when the nurse discharges someone With significantly abnormal vital signs and doesn’t tell you. Once I had a patient who came in with nausea, vomiting, and abdominal pain, and was slightly tachycardic. Everything was looking good and the patient was improving, so I put in the discharge order. I was on my way out the door and had logged out when the nurse ran out and said that the patient was requesting another dose of nausea medication before I go. I told them they could give the patient another dose of Zofran, but to repeat a fluid challenge before the patient leaves (the patient was waiting for a ride). I specifically stated that if there are any abnormal vital signs or if the patient continues vomiting, to alert the night MD. I let the night doc know the scoop and left. I log in when I get home and see the nurse discharged my patient with a heart rate of 139 bpm and didn’t tell anyone. Just sent the patient home that way.How does a discharge heart rate of 139 hold up in court?
Click to expand...

Where I am, nurses have protocols for when to notify the MD. I think it's >160 / > 90. So as one might think, I regularly get notified.
 
ERCAT said:
Same thing happens with crazy high blood pressures. I probably won’t do anything about that 194/100 but I certainly don’t feel like discharging the patient that way
Click to expand...

You won't do anything about it.... but you don't want to discharge them that way? I'm confused. Just tell them that their BP is high and they need to see their PCP.
 
ERCAT said:
Super frustrating. Our ER does a pretty good job at documenting all initial vitals, but the nurses suck at repeating them.

Last week I had a lady come in with acute pancreatitis and she was very tachycardic, in the 150s. She was obviously on cardiac monitoring so I could pop in the room and see her heart rate was going down. When I admitted her four hours later - NO REPEAT VITALS had been documented. Seriously?

Same thing happens with crazy high blood pressures. I probably won’t do anything about that 194/100 but I certainly don’t feel like discharging the patient that way so CAN YOU RECHECK IT, PLEASE!

Today I had a lady with lightheadedness upon standing with a syncopal episode. I ordered a liter of fluids and ordered “orthostatic vitals - now and after fluid bonus administration.” (I know orthostatic vitals are considered useless in some docs’ eyes, but this is besides the point). I noted two and a half hours later this still had not been done. Put “ortho vitals” in the comment. Three hours later, nothing. I try to track down the nurse… Something that I genuinely did not have time for today. I couldn’t find her. I told the nurse sitting next to her, and she stated she would have it taken care of. At the four hour mark the nurse comes up to me and says “When are you discharging the patient? She needs a work note.” I said “How were those orthostatic vitals?” She said “Oh, I didn’t know you wanted me to get those.” Really! An order! A reminder from your colleague and “ORTHO VS PLS” written multiple times in the comments? It’s insane.

My favorite is when you get protests for repeat vitals. I had an old man come in today with a temporal temperature of 102.0F. I started a huge work up and asked the nurse to confirm with an oral temperature. You could tell that for some odd reason (laziness?) he didn’t want to do it. Then the nurse comes up to me a half hour later and said, “Okay, so I put in EMS vitals and didn’t check them myself, and the guy does not have a fever. It’s 98.7F.” I said, “Oh, oral temp?” He says “No, temporal.” DIDN’T I ASK YOU TO CHECK AN ORAL TEMP? It’s this kind of stuff that drives me absolutely crazy because it’s a little thing I should not be having to worry about or nag the nurse about.

I suppose I could learn how to document vitals in the chart… There’s not an obvious way to do this. But at the same time, why....

It is horrifying when the nurse discharges someone With significantly abnormal vital signs and doesn’t tell you. Once I had a patient who came in with nausea, vomiting, and abdominal pain, and was slightly tachycardic. Everything was looking good and the patient was improving, so I put in the discharge order. I was on my way out the door and had logged out when the nurse ran out and said that the patient was requesting another dose of nausea medication before I go. I told them they could give the patient another dose of Zofran, but to repeat a fluid challenge before the patient leaves (the patient was waiting for a ride). I specifically stated that if there are any abnormal vital signs or if the patient continues vomiting, to alert the night MD. I let the night doc know the scoop and left. I log in when I get home and see the nurse discharged my patient with a heart rate of 139 bpm and didn’t tell anyone. Just sent the patient home that way.How does a discharge heart rate of 139 hold up in court?
Click to expand...

It holds up for the plaintiff who is now 3 million dollars richer...crazy stuff
 
I used to work part-time at an urgent care.

Me: Hey, does that 2 year old really have a RR 16?
MA or RN: Yes
(I see the child who is happily sucking on a lollipop that urgent care has in a big bucket by the check-in desk, breathing comfortably at an age-appropriate rate. I manually count about 12 breaths in 30 seconds)
Me: That child does not have an RR of 16.
MA or RN: Yes she does.
Me: If she has a RR of 16, then I'm sending her to the ER.
MA or RN: But that's what I counted!
Me: Look, can you just change it to 24? A toddler should not have a RR of 16. For liability reasons, it would look bad if we discharged a kid with a RR of 16.
MA or RN: (begrudgingly does so)

This is literally my conversation. EVERY. TIME. I don't care if you write 16 for all the adults who aren't in respiratory distress, but can you please f-ing understand some basic pediatric physiology? And don't lie. But this is apparently too much to ask.

Needless to say, this is one of the many reasons I don't work there anymore.
 
JAFERD_MD said:
I used to work part-time at an urgent care.

Me: Hey, does that 2 year old really have a RR 16?
MA or RN: Yes
(I see the child who is happily sucking on a lollipop that urgent care has in a big bucket by the check-in desk, breathing comfortably at an age-appropriate rate. I manually count about 12 breaths in 30 seconds)
Me: That child does not have an RR of 16.
MA or RN: Yes she does.
Me: If she has a RR of 16, then I'm sending her to the ER.
MA or RN: But that's what I counted!
Me: Look, can you just change it to 24? A toddler should not have a RR of 16. For liability reasons, it would look bad if we discharged a kid with a RR of 16.
MA or RN: (begrudgingly does so)

This is literally my conversation. EVERY. TIME. I don't care if you write 16 for all the adults who aren't in respiratory distress, but can you please f-ing understand some basic pediatric physiology? And don't lie. But this is apparently too much to ask.

Needless to say, this is one of the many reasons I don't work there anymore.
Click to expand...

I feel you. I'm logged into work at my desk and count 33 pts in the ED. All of them have a RR of 18 or 20.

This jogged my memory. Last week I had a pregnant female >24w with minor trauma (fell on her bum at the mall) c/o back and and abd pain, getting assessed by yours truly before sending her to L&D for obs per our hospital protocol. This girl was fine. She has completely normal VS. Right before I'm about to send her up the nurse comes up and asks "She's hypotensive! Her pressure is 84/59! I re-cycled it twice! Do you want to give her fluids?!" I walk into the room and see a completely comfortable pt texting on her phone with a steady HR of 75. Strong radial pulse. I go "Look, there's no way this girl has a pressure of 84/59, take a manual before we flood this pt with fluids and generate an additional 3K of workup that she doesn't need." She goes and gets her "trainee" and they connect the cuff to the manual pump on the wall with analog decriments of 10 on the blood pressure dial. I lean against the door frame and think to myself "This should be entertaining." For starters, the nurse turns the valve the wrong way and its wide open while she starts pumping up the cuff which is deflating faster than she can pump it. It quickly zips back down and she pumps it up again and thank God she locks the valve in the correct position this time, but she still opens it too fast and man that thing flies....zipping back down to zero. She looks intensely focused and pulls her stethoscope off and goes "81/49!" I literally started laughing at both of them. I go "81/49?! Really? For starters, it's in decrements of 10 on this Moses old manual cuff dial. How on earth are you able to see an 81 or a 49 for that matter with the release valve wide open? Gimme that." I take a proper blood pressure and it's 110/70. 110/70! These nurses can't even take a manual blood pressure! I was flabbergasted. I can't count how many times I've asked them to take a manual pressure and just trusted them to be able to do it competently. Now, both these nurses are new but still....do they not teach them how to take manual blood pressures in nursing school?!
 
Groove said:
I feel you. I'm logged into work at my desk and count 33 pts in the ED. All of them have a RR of 18 or 20.
Click to expand...

I am one of the few nurses who charts the true RR. Unfortunately it makes it appear as though the pt is in respiratory distress when the RR jumps from 18 to 27... then somehow magically returns to 18 at shift change.
 
Happened again today. Received the pt in respiratory distress - O2 sat 56% on room air, RR 33. Seen by RT, placed on NRB mask, stat CXR, CT PE, the works. What was the RR documented by the oncoming nurse at shift change? 20.

Sorry, had to share. This bugs me to no end.
 
Groove said:
I feel you. I'm logged into work at my desk and count 33 pts in the ED. All of them have a RR of 18 or 20.

This jogged my memory. Last week I had a pregnant female >24w with minor trauma (fell on her bum at the mall) c/o back and and abd pain, getting assessed by yours truly before sending her to L&D for obs per our hospital protocol. This girl was fine. She has completely normal VS. Right before I'm about to send her up the nurse comes up and asks "She's hypotensive! Her pressure is 84/59! I re-cycled it twice! Do you want to give her fluids?!" I walk into the room and see a completely comfortable pt texting on her phone with a steady HR of 75. Strong radial pulse. I go "Look, there's no way this girl has a pressure of 84/59, take a manual before we flood this pt with fluids and generate an additional 3K of workup that she doesn't need." She goes and gets her "trainee" and they connect the cuff to the manual pump on the wall with analog decriments of 10 on the blood pressure dial. I lean against the door frame and think to myself "This should be entertaining." For starters, the nurse turns the valve the wrong way and its wide open while she starts pumping up the cuff which is deflating faster than she can pump it. It quickly zips back down and she pumps it up again and thank God she locks the valve in the correct position this time, but she still opens it too fast and man that thing flies....zipping back down to zero. She looks intensely focused and pulls her stethoscope off and goes "81/49!" I literally started laughing at both of them. I go "81/49?! Really? For starters, it's in decrements of 10 on this Moses old manual cuff dial. How on earth are you able to see an 81 or a 49 for that matter with the release valve wide open? Gimme that." I take a proper blood pressure and it's 110/70. 110/70! These nurses can't even take a manual blood pressure! I was flabbergasted. I can't count how many times I've asked them to take a manual pressure and just trusted them to be able to do it competently. Now, both these nurses are new but still....do they not teach them how to take manual blood pressures in nursing school?!
Click to expand...

Pretty sure that nursning school requires you to post funny clips on YouTube about putting in a foley catheter as a graduation requirement, rather than doing anything useful.

I have one of these RN students rotating thru my department right now. He seems more intent on YouTube'ing things than doing patient care.

He will make a *GREAAAT* nurse practicioner one day.
 
RustedFox said:
15 seconds. Count 'em. Mutiply by four.

Its not hard.

THANX, RNS... PLEASE, MAKE MAOR NPS.
Click to expand...
In high school I tutored a few nurses in math and to be honest I'm not sure all of them could multiply by four.
 
penpenclown said:
In high school I tutored a few nurses in math and to be honest I'm not sure all of them could multiply by four.
Click to expand...

Right-on.

This skinny fugger 'has said straight-out" "I want to eventually become a nurse practioncer."

Like, this was his career goal. I want to skirt nasty things like standardized exams, and other academic rigors and eventually have some academic respect.


Nope.

 
Before anyone asks: Ryu was my homeboy.

Ryu.
Iori.

Only after you understand evil can you do good.
 
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Our profession is taken over by people who are less driven and less educated than us... What is wrong with us?
 
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