By Shawn Kennedy, MA, RN, AJN editor-in-chief
We recently had a lot of feedback to a question we posted on our Facebook page: “We know old habits die hard and nursing has a lot of them. What old habits do you think we should kill? NPO after midnight? Routine temps on every patient?”
We got several good responses:
– Waking patients up at 4am for blood drawing, routine vital signs
– Measuring intake and output on every patient
– Taking routine temps
– Giving dorsogluteal IM injections
– Doing a skin prep for an IV by swabbing the site in a circular motion, inside to out (some manufacturers of products are instructing that skin prep be done by a scrubbing motion)
– Enemas before childbirth
– Double documenting
– Rushing to give medications right on time (which makes one prone to error)
– NPO after midnight
Choosing from the above, we then asked this: “Survey question #1: Do you routinely wake patients up at night to check their vital signs? If not, when would you?”
This question received many comments, from “Of course not” and “only when necessary” to “If a doc orders q 4 vs and you don’t do it and something happens to the patient, that would not be good for you AT ALL.” Also this: “Orders are orders which we must follow.”
Commenters cited several stories of recent postoperative patients (who, I agree, should have vital signs frequently monitored) who could have suffered grave consequences had the nurse not woken them to check their vital signs or level of consciousness. I do like what one response noted—“critical thinking.” This is key, regardless of what the physician order may be—if the physician order is “q4h” but a patient’s condition may warrant more frequent checks, we would all hope the nurse wouldn’t stick to q4h.
Of course, for those working in ICUs or in postanesthesia units, the answer is simple: the patients are there precisely because they need close monitoring. As one responder indicated, “If you don’t check, you don’t know. I don’t want to be that nurse!”
Our next question was this: “When you give IM injections, what site do you most often use: dorsogluteal (upper outer quadrant of buttocks), ventrogluteal (lateral hip), or deltoid (upper arm)? Why?” Weigh in here or on our Facebook page.
I am a nurse with 38 years last 20 in ccu. I have every monitoring system there is.But I still love bedside nursing…I also have worked nights the last 20 years and unless there is a reason to wake someone up I will not allow my patients to be awakened. This is patient advocacy…
we actually will tell the patient when they will be woken next, and we tell them why. when we wake for VS we also do everything else possible at that time: foley, iv check, PCA check, etc.
To Sean, as an RN who has also been an inpatient after several surgeries—-there is a way to quietly come in and take a patient’s vital signs. But I cannot understand 4 am weighing! That is an old tradition that serves no purpose in my opinion.
In my most recent O.R. position, as an RN, many of the younger, more up-to-date Anesthesiologists/ CRNA’s allowed patients to have BLACK COFFEE up until time for surgery. They were, of course, basing this on information from their journals/ seminars. It makes sense to me: many people get “caffeine headaches”, and being NPO simply causes more dehydration, anxiety.
In may last position as an L&D/perioperative RN, NO ONE, per hospital standard, gave enemas pre-labor/childbirth. Why add to discomfort/ cramping, etc? However, on a lighter note, we had a small shower room for those patients who REALLY needed a shower/hairwashing. Some of the country people, here in the South, of all ethnicities, had been taught NOT to shower or bathe throughout pregnancy. Some of them had lice as well. We presented this to them as something “routine”.
I also had a first hand experience in a different hospital, when a young woman came in to the hospital in labor, second baby, first had been delivered by C/S. A resident ordered an enema. He did not realize her C/S had been LATERAL on the uterus, though her scar was in the usual “bikini” region, or, horizontal…..no notes covered this.
The young woman fainted in the bathroom, due to uterine rupture, and her full term, healthy baby died. In other words: you can’t always be sure HOW a C/S was done just by observing where the scar was. She also fractured her arm when falling….altogether a terrible tragedy.
Last—and I don’t know how to “fix” it either—many studies have shown that people who rotate shifts have their health permanently damaged. High blood pressure, stress, being less alert….yet so many hospitals still insist on everyone rotating, no matter what. If possible, people should be on standardized shifts of their choice….if that is not possible, then I don’t know how to get around it. The attitude “we’ve always done it this way” is the single worst problem in the Nursing Profession, in my opinion, and one that drives out many younger people.
I would like to see an end to inefficent paperwork and processes. Why when I want to take a nursing course do I have to register the same information over and over again? So, it is not just a complaint that plagues our patients (i.e. filling out the same form over and over again) – it plagues all of us. From a nursing academia perspective – it is just nutty sometimes what we have to do – which of course (just like inefficient clinical processes) spawns all sorts of very creative (and sometimes dangerous) workarounds. Sheesh! We should adopt workflow engineering principles and cut the waste and giant “time eaters” out of what we do.
Yes, I would have to agree “If you don’t check, you don’t know”. Then again, I’m and ICU nurse who always thinks in the ‘worst case scenario’ mode.
There can and should be a fine balance though between monitoring need and the patient’s need for rest.