Episode 4: What Your Patients Are Telling You (That You're Not Hearing)

Episode 4: What Your Patients Are Telling You (That You're Not Hearing)

2:00 AM. Post-op patient. Vitals totally stable. But Jennawè knew he was dying. This episode teaches you how to read your patients beyond the monitor—and catch deterioration before the numbers crash.

You'll learn:

• The 5 signs patients show before vitals change (altered mentation, skin changes, behavioral changes, respiratory changes, decreased urine output)
• Why looking at the monitor first is setting you up to miss deterioration
• How to do a visual assessment before checking vitals
• The difference between what students see and what providers see in the same patient
• Real case examples: "just confused" stroke, "just anxious" MI, "just tired" hypoglycemia
• How to calculate trends instead of just documenting numbers
• Why "resting comfortably" might mean your patient is dying

Timestamps:

 [0:00] The patient who looked stable—but was septic
 [3:30] Welcome to Think Like a Provider
 [4:00] Why students trust the monitor more than the patient
 [7:30] The language your patients speak
 [12:00] Case breakdown: what I saw vs. what students see
 [16:30] More examples: stroke, MI, hypoglycemia
 [20:00] How to develop this skill
 [23:30] Common mistakes students make

Clinical Pearls:

• Look at patient BEFORE monitor to avoid confirmation bias
• Altered mentation is earliest sign of deterioration (brain needs O2, glucose, perfusion)
• Urine output <30 mLs/hr = pre-renal failure/shock
• Vague complaints ("I don't feel right") = body's alarm system
• Trends matter more than individual values
• Touch your patients—skin temp/moisture/color tells the story

Hosts:

• Professor Jennawè, Nurse Practitioner & Educator
• Alice - Engaging Educator & Student Advocate

REFERENCES:

1. Kellett, J., & Sebat, F. (2024). Make vital signs great again: A call for action. QJM: An International Journal of Medicine, 117(1), 1-8.
2. Evans, L., Rhodes, A., Alhazzani, W., et al. (2021). Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Critical Care Medicine, 49(11), e1063-e1143.
3. Subbe, C. P., & Kinsella, S. (2024). Recognising acute illness: Respiratory rate and pulse oximetry. Clinical Medicine, 24(1), 100062.
4. Smith, M. E. B., Chiovaro, J. C., O'Neil, M., et al. (2021). Early warning system scores for clinical deterioration in hospitalized patients: A systematic review. Annals of the American Thoracic Society, 18(3), 548-556.
5. Winters, B. D., Weaver, S. J., Pfoh, E. R., et al. (2022). Rapid-response systems as a patient safety strategy: A systematic review. Annals of Internal Medicine, 168(6), 417-426.

Transcript

SPEAKER_01 0:00

It was 2 a.m. on a med surge floor, and I was three patients into my night shift when I walked into room 417. 72 years old male patient. For the sake of this episode, we will call him Mr. Peterson. Post op day two from a bowel resection. Surgical history uncomplicated. Vitals stable all day. I pulled up his chart before I went in. Everything looked fine. Blood pressure 128 over 76. Heart rate 84. Respiratory rate 18. Temperature 99.2. Oxygen saturation 96% on room air. Pain well controlled. Incision clean, dry, intact, bowel sounds present, foley catheter draining clear yellow urine. On paper, this patient was doing great. But the second I walked into that room, I knew something was wrong. What did you see? He was lying in bed, awake, eyes open, staring at the ceiling, not watching TV, not on his phone, just staring. And when I said, Hi, Mr. Peterson, how are you feeling tonight? He didn't look at me right away. There was this pause, like a two second delay, and then he slowly turned his head and said, I'm okay. But his voice was flat, monotone, no inflection. I walked closer. His skin looked different. Not pale exactly, just off, kind of greyish, dull. I touched his hand. Cool. Not cold, but cooler than it should be. I asked him, Are you in any pain? He said, No, I'm fine.

SPEAKER_00 1:31

But he wasn't fine. The vitals said stable, but everything about his presentation said something's wrong.

SPEAKER_01 1:38

Everything. And here's what most students would have done in that moment. They would have looked at the monitor, seen normal vitals, assumed the patient was okay, maybe charted, resting comfortably, no acute distress. And moved on to the next patient. But I didn't move on. Because my gut was screaming at me. So what did you do? I did a full head-to-toe assessment. Not the quick version, the real version. I checked his pupils, equal and reactive, but his eyes looked tired. Sunken almost. I listened to his lungs. Clear bilaterally, but his respiratory rate felt like it was on the edge, like he was breathing just a little faster than comfortable. I palpated his abdomen. Soft, non-tender. Incision looked good, but when I pressed on his lower quadrants, he winced, just slightly. He didn't say anything, but I saw it. I checked his urine output. The Foley bag had maybe 30 milliliters in it, and it had been hanging there since 6 p.m.

SPEAKER_00 2:39

Wait, so in eight hours he only put out 30 milliliters of urine.

SPEAKER_01 2:44

In eight hours, that's less than 4 milliliters per hour. Normal urine output is 30 milliliters per hour minimum. This patient was barely making any urine at all. And that's when I knew. I looked at his chart again. Temperature earlier in the day, 98.6. Current temp 99.2. Heart rate earlier 72. Current heart rate 84. Blood pressure earlier 118 over 68. Current blood pressure 128 over 76. Nothing alarming, everything within normal limits. But everything was trending in the wrong direction.

SPEAKER_00 3:22

This is compensation. Just like the postpartum hemorrhage case from episode 2. The body is working harder to maintain stability, and the vitals are just barely starting to reflect it. Exactly.

SPEAKER_01 3:35

And if I had just looked at the numbers without looking at the patient, I would have missed it. I called the hospitalist, I said, I'm concerned about sepsis. Vitals are currently stable, but he's showing early signs. Altered mentation, cool skin, decreased urine output, low-grade temp climbing. The hospitalist came up, ordered labs, lactate was 3.2, white count was 18,000. Blood cultures came back positive two days later. We caught it early, started antibiotics, fluids. He went home a week later. But if I had trusted the monitor instead of my assessment, he would have been in septic shock by morning.

SPEAKER_00 4:15

And this is what students don't learn in school. They learn to chart vitals and document assessments. But they don't learn to read the patient, to see what the body is telling them before the numbers catch up.

SPEAKER_01 4:28

And that's what this episode is about. What your patients are telling you that you're not hearing. How to see beyond the monitor. How to trust your clinical assessment even when the vitals say everything's fine. Because the body always tells the truth. You just have to learn the language. Welcome to the Think Like a Provider podcast. I'm Gennaway Whitley, nurse practitioner and educator. Here we don't memorize, we understand. Each episode we break down clinical reasoning system by system so you walk away thinking and acting like the provider you are meant to be.

SPEAKER_00 5:01

And I'm Alice, here to help connect the dots and ask the questions you're probably thinking.

SPEAKER_01 5:06

So let's break down what actually happened with Mr. Peterson. Because this isn't just about one patient. This is about learning to see patterns of early deterioration that students miss every single day.

SPEAKER_00 5:19

And the scary part is, these patients look fine on the monitor. So if you're only looking at numbers, you're going to miss them until they crash.

SPEAKER_01 5:28

The problem. Students trust the monitor more than the patient. Here's what happens when you're a new nurse or a nursing student. You walk into a patient's room, you look at the monitor first, you see normal vitals, and your brain says, okay, they're stable. And once your brain has decided they're stable, it's really hard to see evidence that contradicts that. This is called confirmation bias. You've already decided the patient is fine. So you unconsciously filter out information that suggests otherwise.

SPEAKER_00 6:00

So even if the patient looks off, even if something feels wrong, your brain dismisses it because the monitor says they're fine.

SPEAKER_01 6:09

And this is why I teach my students. Look at the patient first, then look at the monitor. Not the other way around, because if you look at the patient first, you form an impression based on clinical assessment. Then you use the monitor to confirm or question that impression. But if you look at the monitor first, you're already biased.

SPEAKER_00 6:27

So with Mr. Peterson, if you had looked at the monitor first, BP128 over 76, heart rate 84, suggesting normal vitals, you might have walked in expecting to see a stable patient. And then you would have missed the altered mentation, the cool skin, the decreased urine output. Exactly.

SPEAKER_01 6:48

Because your brain would be looking for evidence to confirm stable, not evidence to suggest deteriorating. But because I assessed the patient first, I saw the clinical picture didn't match the numbers. And that mismatch is what made me dig deeper. The language your patients speak. So let's talk about what patients are actually telling you. Because here's the thing patients don't walk up to you and say, hey, I'm septic. They don't announce, I'm going into shock. They show you with their body, with their behavior, with subtle signs that most people miss. And if you learn to read those signs, you can catch deterioration hours before the vitals crash.

SPEAKER_00 7:31

So this is like learning a new language. The body has its own way of communicating distress, and most students don't speak that language yet.

SPEAKER_01 7:39

And here are the most important words in that language. Sign number one, altered mentation. This is the earliest and most important sign of deterioration. The brain needs three things oxygen, glucose, and perfusion. If any of those are compromised, you see mental status changes. And I don't mean full-blown confusion or unresponsiveness. I mean subtle changes. A patient who was chatty yesterday is now quiet. A patient who made eye contact now stares at the wall. A patient who answers questions immediately now has a two-second delay.

SPEAKER_00 8:13

And students miss this because they're not assessing baseline. They walk in, ask, how are you feeling? Patient says, Fine, and they move on. They don't notice the patient's voice is flatter, or their responses are slower, or they're just not quite right.

SPEAKER_01 8:29

Yes, precisely. You have to know what normal looks like for that patient, because altered mentation is often the canary in the coal mine. Sign number two, skin changes. Your skin is a window into your perfusion status. When the body is in trouble, it shunts blood away from the skin to protect the vital organs. So you see, pale or grayish skin, cool extremities, mottled skin, especially in severe cases. Delayed capillary refill, more than two seconds. Clammy or diaphoretic skin.

SPEAKER_00 9:02

And again, students miss this because they're not touching their patients. They're charting from the doorway, looking at the monitor, and never actually laying hands on the patient to feel if their skin is cool or clammy. Precisely.

SPEAKER_01 9:15

You have to touch your patients, feel their skin, check capillary refill. Notice if they look different than they did two hours ago. Sign number three, behavioral changes. Patients who are deteriorating often show behavioral changes before vital sign changes. Restlessness, anxiety, agitation, or the opposite, lethargy, withdrawal, apathy. Mr. Peterson wasn't agitated, but he was flat, disengaged, staring at the ceiling. That's the body's way of saying, I'm using all my energy just to stay alive. I don't have anything left for normal behavior.

SPEAKER_00 9:50

So if your normally pleasant, chatty patient suddenly seems irritable or withdrawn, that's not just a bad mood. That's a clinical sign.

SPEAKER_01 9:59

Yes, definitely something to be concerned about. Sign number four, subtle respiratory changes. Not full-blown respiratory distress, subtle changes. Respiratory rate creeping up from 16 to 20. Breathing that looks slightly labored even though oxygen sat is fine. Nasal flaring, using accessory muscles. These are signs the body is working harder to maintain oxygenation or blow off CO2.

SPEAKER_00 10:23

And students miss this because they count respirations for 15 seconds, multiply by four, chart it, and move on. They're not watching the quality of breathing. They're not noticing the patient is working harder than they should be. Precisely.

SPEAKER_01 10:38

Respiratory rate is important, but quality of breathing is more important. Sign number five, decreased urine output. This is a massive red flag that students almost always miss. Your kidneys are perfusion dependent. When the body is in trouble, blood flow to the kidneys decreases. Urine output drops. Normal urine output, 30 milliliters per hour minimum, about 0.5 milliliters per kilogram per hour. Mr. Peterson was putting out less than 4 milliliters per hour. That's prerenal failure. That's shock.

SPEAKER_00 11:12

And students don't catch this because they're not calculating hourly urine output. They just see there's urine in the bag and assume everything's fine. Unfortunately, yes.

SPEAKER_01 11:23

You have to do the math. Look at the last time the bag was emptied, measure the output, calculate the hourly rate. Because by the time urine output drops to zero, the kidneys are already failing. Case breakdown, what I saw versus what students would see. Let me walk you through exactly what I saw with Mr. Peterson and contrast that with what a student would typically see. What the student would see walks into room, looks at monitor, blood pressure 128 over 76, normal. Heart rate eighty four normal. Respiratory rate eighteen normal. Temp ninety nine point two, slightly elevated but not fever. STO two ninety six, acceptable. Asks patient, how are you feeling? Patient, I'm okay. Student charts. Patient resting in bed, vitals stable, denies pain, no acute distress. Moves on to next patient. What I saw. Before looking at monitor, I assessed the patient. Flat affect, delayed responses, altered mentation, grayish skin tone, poor perfusion, cool hands, peripheral vasoconstriction, minimal urine output over eight hours, prerenal failure, subtle winds with abdominal palpation, possible source of infection. Then I looked at vitals and I looked at trends, not just current numbers. Temp trending up 98.6 to 99.2 over eight hours. Heart rate trending up 72 to 84. Blood pressure increasing 118 over 68 to 128 over 76. This is vasoconstriction, not just a good enough blood pressure. Pattern recognition, early sepsis, body is compensating.

SPEAKER_00 13:14

So the student sees a snapshot and thinks stable. You see a trend and think deteriorating. That's the difference between novice and expert pattern recognition.

SPEAKER_01 13:24

Exactly. And this is a learnable skill. It's not magic, it's not intuition, it's trained observation. More examples. What patients are telling you. Let me give you a few more examples because once you learn this language, you'll see it everywhere. Example one, the just confused stroke patient. Patient is 68 years old, post-op day one from hip replacement. Overnight the nurse notices the patient is a little confused. A student response, they just had surgery and anesthesia. Confusion is normal in elderly post-op patients. Provider response, wait, what does a little confused mean? Are they oriented to person, place, time? Can they follow commands? Is their speech clear? Do they have any facial droop or arm drift? Turns out the patient had a stroke overnight, but it was dismissed as post-op delirium because no one did a focused neuroassessment.

SPEAKER_00 14:24

So confusion isn't a throwaway observation. It's a clinical sign that requires investigation. What's causing the confusion? Is it hypoxia, hypoglycemia, stroke, infection, electrolyte imbalance?

SPEAKER_01 14:39

That's right. The patient is telling you their brain isn't getting what it needs. Your job is to figure out why. Example 2. The just anxious MI patient. Patient is 62 years old, diabetic, admitted for cellulitis. Overnight, they keep pressing the call light. They're restless. They say they feel anxious. I just don't feel right. Student responds, you're okay, just try to rest. Do you want something to help you sleep? Provider responds, tell me more about this feeling. Where do you feel it? Any chest discomfort, shortness of breath, nausea. When did this start? Turns out the patient is having a silent MI. Diabetic neuropathy means they don't feel classic chest pain, but their body knows something is wrong, so they feel anxious and off.

SPEAKER_00 15:29

So when a patient says, I just don't feel right or something's wrong, that's not anxiety. That's their body's alarm system going off. And you need to take it seriously.

SPEAKER_01 15:40

Yes, patients know their own bodies. If they say something feels wrong, something is wrong. Your job is to figure out the what. Example three, the just tired hypoglycemic patient. Patient is diabetic on insulin. Mid afternoon, family member mentions the patient seems really tired. They've been sleeping all day. Student response, they're in the hospital, they're probably just catching up on rest. Provider response, when did they last eat? When was their last blood sugar check? Are they sleepy or are they lethargic? Can you wake them easily? Turns out blood sugar is 42. They're not tired, they're hypoglycemic.

SPEAKER_00 16:21

So sleeping a lot in a diabetic patient isn't rest. It's a potential hypoglycemic emergency until proven otherwise.

SPEAKER_01 16:30

That's right. Context matters. A diabetic patient who's suddenly sleeping all day, check the blood sugar, a post op patient who's suddenly confused, rule out stroke, a patient with risk factors who says, I just feel anxious. Rule out MI. The body is telling you something. You just have to listen. How to develop this skill. So how do you actually train yourself to see these things? Because I know what you're thinking. That sounds great, Genoa, but I'm not there yet. I don't have that clinical eye. And you're right, you don't. Not yet. But here's how you build it. Step one, do a visual assessment before you look at the monitor. Every time you walk into a patient's room, before you glance at the monitor, look at the patient. What's their color? Are they alert or lethargic? Are they breathing comfortably? What's their body language? Form an impression first, then check the vitals.

SPEAKER_00 17:28

So you're training your brain to prioritize clinical observation over data. Over time, that becomes automatic. Precisely. Step two.

SPEAKER_01 17:38

Touch your patients. Feel their skin. Is it warm or cool? Dry or diaphoretic, flushed or pale. Check capillary refill. Press on their nail bed. Release. Count how long it takes to pink up. Should be less than two seconds. This gives you information the monitor can't. Step three. Ask open-ended questions. Don't just ask, how are you feeling? And accept fine as an answer. Ask, tell me how you're feeling today compared to yesterday. What's different than usual? Is there anything that feels off even if you can't quite put your finger on it?

SPEAKER_00 18:17

Because patients often know something's wrong before the vitals reflect it. But if you don't ask the right questions, they won't tell you. Yes.

SPEAKER_01 18:27

Step four. Calculate trends, not just document numbers. Don't just chart BP 128 over 76. Chart BP trending up from 118 over 68 at 6 p.m. to 128 over 76 at 2 a.m. Heart rate increased from 72 to 84 over same period. Because trends tell a story that single values don't. Step 5. Trust your gut. If something feels off, it probably is. Even if you can't articulate what's wrong. Even if the vitals look fine. If your gut is telling you something's not right, dig deeper.

SPEAKER_00 19:04

And this is where students hesitate. They think, I don't have enough experience to trust my gut. But your gut is pattern recognition happening at a subconscious level. Your brain is picking up on things you haven't consciously registered yet.

SPEAKER_01 19:19

That's right. So when your gut says something's wrong, listen to it. Call for help. Get a second opinion. Do a more thorough assessment. You might be wrong, that's okay, but you might be right. And if you are, you just saved a life. Common mistakes students make. Before we wrap up, let me tell you the three biggest mistakes I see students make when it comes to reading patients. Mistake number one, relying on the monitor more than the assessment. The monitor is a tool. It gives you data, but it doesn't tell you the whole story. If your assessment says the patient is deteriorating but the monitor says they're stable, trust your assessment. Because the monitor lags, the patient's body doesn't.

SPEAKER_00 20:01

And this goes back to confirmation bias. If you look at the monitor first and see normal, your brain will filter out signs of deterioration because it's already decided the patient is stable.

SPEAKER_01 20:14

Exactly. Mistake number two, accepting vague complaints at face value. Patient says, I just don't feel right. Student charts patient reports feeling unwell. Reassured. No, dig deeper. What doesn't feel right? Where do you feel it? When did it start? What makes it better or worse? Vague complaints are often early warning signs. Don't dismiss them.

SPEAKER_00 20:39

Because the patient is trying to tell you something's wrong, but they don't have the medical language to articulate it. Your job is to help them translate that feeling into clinical data you can act on.

SPEAKER_01 20:51

Yes. Mistake number three, documenting patient resting comfortably without actually assessing. This is charting by exception. You walk in, patient has eyes closed, you assume they're sleeping, you chart resting comfortably and leave. But are they resting or are they lethargic? Are they comfortable? Or are they too weak to call for help? You don't know unless you actually wake them up and assess them.

SPEAKER_00 21:17

So resting comfortably should only be charted if you've actually verified the patient is alert, oriented, and comfortable, not just because their eyes are closed.

SPEAKER_01 21:27

That's absolutely right. And I see this mistake kill patients because a patient who's resting comfortably at 2 a.m. is found unresponsive at 4 a.m. And everyone's asking, What happened? What happened is no one actually assessed them. They just looked fine from the doorway. Here's what I want you to take away from this episode. Your patients are always talking to you. Always with their skin, their breathing, their behavior, their mentation. But if you're only looking at the monitor, you You're not listening.

SPEAKER_00 22:01

And the scary part is, by the time the monitor shows a problem, the patient has often been deteriorating for hours. You've missed the window for early intervention.

SPEAKER_01 22:11

So you have to learn to read the patient, not just the numbers. Look at them before you look at the monitor. Touch them. Feel their skin. Notice the details. Ask open-ended questions and actually listen to the answers. Calculate trends, not just individual values. Trust your gut when something feels off. Because the body always tells the truth. You just have to learn the language. And that's a skill, which means it can be learned. Which means you can learn it. But you can't learn it from a textbook. You can't learn it by reading about assessment techniques. You learn it by practicing, by paying attention, by training your clinical eye to see what others miss.

SPEAKER_00 22:49

And that's exactly what clinical reasoning is: seeing patterns, recognizing early signs, and acting before the crisis happens.

SPEAKER_01 22:57

And that's why I created Think Like a Nurse and Think Like a Provider. These are clinical reasoning systems designed specifically to help LPN, RN, and NP students develop the necessary skills to excel in clinicals and at the bedside. Not just vital sign interpretation, not just charting templates, actual assessment skills, actual pattern recognition, actual clinical reasoning that catches deterioration before it becomes a code. You can find the link in the show notes. And if you're looking for community, a place where you can practice this kind of thinking with other nursing students who are serious about becoming excellent clinicians, be on the lookout for the Think Like a Provider School community. It's a community that's going to change the way you think, understand, and do nursing. We work through real cases together. We practice reading patients. We build the skills that save lives. The link to join the wait list is in the show notes as well.

SPEAKER_00 23:52

Everything you need to start reading your patients like a provider is right there. But for now, I want you to try this.

SPEAKER_01 23:59

The next time you're in clinical, walk into a patient's room and don't look at the monitor first. Look at the patient. Really look at them. What do you see? What do you notice? What what feels different? Then look at the monitor and ask yourself does this match what I'm seeing?

SPEAKER_00 24:16

Because that mismatch between what the patient looks like and what the monitor says, that's where you catch deterioration early. Thanks for listening. I'll see you next week. See you next week.