How Often Do You Check...?

Red Kryptonite · Mar 23, 2015

I'm still in school and so therefore fully willing to admit there are things I don't know, but there are several blood pressure and cardiac medications whose instructions include checking BP before every dose. Are there others that do not require that?

RescueNinjaKy · Mar 23, 2015

For certain medications such as for hypertension, it's important to check v/s prior especially for beta blockers in the event that their pulse is low. It's generally good to check their bp/pulse again 30 min after to see how well they tolerated and whether it has the therapeutic effect but that can be hard with high patient ratios

CTnewgrad826 · Mar 23, 2015

Blood pressures before every blood pressure medication...what happens if their blood pressure was 80s/40s and you gave them the med without checking? Pretty sure your patient just tanked...

Fingersticks before every meal and bedtime if diabetic, potentially every 6 hours if NPO, on steroids or a couple other circumstances. Again, you give their before meal time insulin without checking first? Into a coma that hypoglycemia patient goes...

Sats are only checked at scheduled times during vitals unless patient seems SOB, new onset confusion, decreased consciousness, etc.

I'm confused by your post honestly. Are you a nurse?

heron, ASN, RN · Mar 23, 2015

I am a nurse x 40+ years and I think the checks described in the OP are a bit overboard, too. Obviously, there would be exceptions, but on the whole, LTC deals with chronic conditions and long-term meds. If a res has been taking the same dose of metformin for thirty years and her A1c is stable, then what's the point of frequent CBGs? Ditto for long-term cardiovascular meds and BPs.

Consider what effect this kind of intrusive checking has on the residents's quality of life. Consider also the effect that chart-buffing busy-work might have on the ability of the nurse to spot subtle changes that might need real attention.

LittleCandles · Mar 23, 2015

It sounds like your new DON is trying to keep people alive by not giving them insulin when their BS is low and BP meds when their BP is low. It sounds like it's working bc you had to hold those a few times.

You should like you don't want to do the extra work. Sorry but unless you have a magic Chrystal ball that will tell you it's safe to give that BP med without checking you should check.

heron, ASN, RN · Mar 23, 2015

Nope, I disagree. Of course, the OP has not described the level of acuity of her unit, but for the usual LTC resident I still think that a little critical thinking is in order regarding some of these rituals. Let's face it, we can get just a little self-important and overly dramatic at times.

The issue is one of balance. Sure, do the frequent checks on known brittle diabetics, with sliding scale coverage or those starting a new med or who are clinically symptomatic - but as far as I'm concerned, blanket orders as described in the OP are neither medically appropriate nor cost effective.

Btw, the hypoglycemic resident is much more likely to faint, seize and progress to a code than go into a coma.

Here.I.Stand, BSN, RN · Mar 23, 2015

I am a nurse x 40+ years and I think the checks described in the OP are a bit overboard, too. Obviously, there would be exceptions, but on the whole, LTC deals with chronic conditions and long-term meds. If a res has been taking the same dose of metformin for thirty years and her A1c is stable, then what's the point of frequent CBGs? Ditto for long-term cardiovascular meds and BPs.
Consider what effect this kind of intrusive checking has on the residents's quality of life. Consider also the effect that chart-buffing busy-work might have on the ability of the nurse to spot subtle changes that might need real attention.

This. Of course if someone is on sliding scale insulin they need to have BG checked. Or if it's a new med, definitely prudent to check more frequently. But in most cases, these residents are in their home. Most people in their homes don't check a BP before taking every single dose of their BP meds, and definitely don't re-check the BP at every single dose's peak action time to evaluate its effectiveness. Many (if not most) people on BP meds at home don't even own a BP cuff.

How much experience does this newish DON have in the LTC world? I do remember in nursing school, being drilled into our heads that a BP and apical pulse must be checked before every dose of beta blockers, and hold for SBP

flashpoint · Mar 23, 2015

Yes, I am a nurse. I am a nurse with almost 25 years experience, about half of that in LTC. I work in an LTC (which is why I posted in the LTC forum) with stable residents, many who have been on the same medication at the same dose for years. It just seems strange to me that we are suddenly checking blood pressures, blood sugars, and pulse oximetry several times at day on stable residents. Very few diabetics check their blood sugar four times a day unless they are on a sliding scale. Why stick a lancet into the finger of a stable, asymptomatic diabetic four times a day? Sure, if their sugars are unstable or we are changing medication, but otherwise, it doesn't make sense to me. Why check pulse oximetry four times a day on someone who is stable and has been on the same dose of oxygen for ten years. I can sort of see the frequent blood pressure, but when they asked for parameters, several of the doctors gave hold parameters of things like 80/40. One doctor gave orders NOT to check blood pressure more than one a week unless nursing judgement sees the need for a PRN check.

flashpoint · Mar 23, 2015

Blood pressures before every blood pressure medication...what happens if their blood pressure was 80s/40s and you gave them the med without checking? Pretty sure your patient just tanked...
Fingersticks before every meal and bedtime if diabetic, potentially every 6 hours if NPO, on steroids or a couple other circumstances. Again, you give their before meal time insulin without checking first? Into a coma that hypoglycemia patient goes...
Sats are only checked at scheduled times during vitals unless patient seems SOB, new onset confusion, decreased consciousness, etc.
I'm confused by your post honestly. Are you a nurse?

Some of the blood sugars we are checking four times a day are on residents who only get 5 units of Lantus at night. I have been around the block a few times...often enough to question why we are doing things more often than are sometimes done in an acute setting. I have worked in ER and ICU too and honestly have rarely checked blood sugar on stable patients four times a day.

flashpoint · Mar 23, 2015

It sounds like your new DON is trying to keep people alive by not giving them insulin when their BS is low and BP meds when their BP is low. It sounds like it's working bc you had to hold those a few times.
You should like you don't want to do the extra work. Sorry but unless you have a magic Chrystal ball that will tell you it's safe to give that BP med without checking you should check.

I don't object the the extra work. I do object to doing things that are not necessary for stable residents. We have had to hold B/P meds three times on four months...it isn't like we are holding them daily or even weekly. I go to church with one of the doctors and we talk about work sometimes before services start. She told me she was surprised when we started asking for hold parameters on people who are quite stable. She only gave parameters and orders to check before dosing because we asked.

heron, ASN, RN · Mar 23, 2015

@flashpoint: it would be an interesting exercise to add up the minutes spent on all these checks x your salary to ballpark the cost in nursing time. CBG test strips tend to cost ~$1+ retail, too. This kind of overkill can get expensive.