Stop! Is that Assessment Really Necessary?

While playing with my 3 year old daughter today, I had an opportunity to reflect on an issue that deserves more attention among nurses: Why do we do the interventions and assessments we do? Are they always necessary, or even appropriate? Nurses Announcements Archive Article

Stop! Is that Assessment Really Necessary?

My daughter declared that her toy horse Jack had "died". She was very carefully checking him over and giving him "medicines" with her toy vet kit. I asked her if Jack was going to come back to life, to which she replied, "No mommy, Jack is dead" My immediate thought was why are we attempting to treat Jack at all if he is beyond help?

I immediately thought of an issue that had been annoying me at my current job. Recently I began working nights at a postpartum unit, after working days on a telemetry unit. One of the biggest challenges has been learning to group my cares and work around the patient's preferred schedules; after all, as my unit is low risk and my patients are generally young and healthy, they do not require the same frequency of a nurse's presence as the patients on a telemetry unit. Moreover, there is a lot of emphasis placed on our patients getting enough rest and sleeping according to their baby's schedule.

Sure there are exceptions: the fresh c-sections, the preeclampsia patients, the late preterm babies. But generally speaking, far less is needed from me on an average night than at my previous job. Still, many of the senior staff members insist on doing interventions and assessments that are completely unnecessary. There is a consensus on following "rules" because "we have always done it that way". To me, this means these nurses are not using critical thinking and are not individualizing their care plans based on what a particular patient actually requires.

A perfect example is the "order" that babies that weigh less than six pounds automatically require every four hour vital signs-even if their birth weight started out above six pounds. As this is my first OB job, I did not question this practice at first. But as I began to become more comfortable and knowledgeable, it began to trouble me.

Carrying out every four hour vital signs often meant that I was going into a room at 0400 and waking up mom and baby for no specific reason. Often these babies were term, AGA, low bilirubin level, had no body temperature issues, and all other systems had been WDL; sometimes these frequent vital sign checks were occurring at 0400 when the mom and baby were scheduled to discharge home later that morning.

After a while I began to ask "why?" Was this really necessary? Is it even an order?

I sat down and examined my order sets- there was no order for every four hour vital signs due to weight. I checked my facility's policies and procedures- it did not exist there either. Eventually, another nurse new to the unit began to question it and help me hunt for evidence of this order; there was none. On the night we were doing this, a charge nurse verified for us that there was no such order, as did the nurse educator early the next morning.

Apparently, in the past it had been a standing order- but several years had passed since this was the case. The unit educator agreed with that it was often unnecessary, and that it is up to us as nurses to use our judgment and decide when more assessments than are ordered are needed.

In my opinion, this is the crux of the matter. It is up to nurses to use our critical thinking skills and determine when more monitoring and assessments are needed, and when they are not needed. Additionally, we are supposed to be individualizing are patient's care plans- many of the order sets put in by the physicians state "at the nurses discretion".

Nurses who blindly follow "we have always done it that way" without carefully examining their patients are not using the full scope of their nursing role and are missing a crucial piece of nursing practice.

There seems to be a fear on my unit that without these unwritten rules, nurses will carelessly allow patients to go unmonitored and decline; perhaps this has been a problem on this unit in years past. My co-workers are not giving enough credit to themselves and each other when they do this- I do not know of one nurse who would not re-check a temperature on a baby with low temps, simply because it is only ordered every eight hours.

Furthermore, they are forgetting that as nurses we can always re check vital signs (and on our unit blood sugars on baby) if we feel it is warranted. We do not need an order for this- it is within our scope of practice. The physicians and other care providers we work with rely on us to use our thinking skills, monitor the patients, know when something is not WDL, and act accordingly.

Conversely, we should not forget that less is often more. How many times have nurses witnessed a 90 year old patient with a full code, despite actively dying, or the patient who demands every diagnostic test available despite there being no indication (except fear) for those tests?

Less is more; we do not need to endlessly assess and put our patients on edge or disturb a new mother and baby who are healthy and stable. We need to stop, think, use our nursing judgement and ask ourselves what a particular patient may or may not need.

Finally, we must always ask "why?" Why are we doing these assessments and interventions? Does this patient need something additional not ordered, or do they need less interruptions?

We owe it our patients , and we owe it to ourselves; trust your judgement, use your brain and trust yourself. Our patients will thank us for it.

RN- Experience in TCU, LTC, ambulatory and a busy Tele Unit. Currently working in OB (finally!) The area I have wanted to be in since before nursing school. I am passionate about evidence-based practices MPH degree, 2020

530 Posts

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BSNbeauty, BSN, RN

1,939 Posts

As a postpartum nurse I agree with you one hundred percent. It still irks me that I have to wake Mom and baby up for one am vital signs. Why ?

Julius Seizure

1 Article; 2,282 Posts

Specializes in Pediatric Critical Care.

I see this issue in the pediatric ICU and step-down units as well. While a child may initially need hourly VS including blood pressures, once their condition has improved and their vitals are ordered q3 or q4, many of the nurses will continue to leave the blood pressure cuff on them all shift long, cycling automatically every hour. How annoying and uncomfortable must that be after several days?

In general, I think that we as heathcare providers often interrupt our patients rest too much. Even if the bedside nurse tries to cluster their care activities, it inevitable follows that the respiratory therapist, physical therapist, social worker, attending, fellow, resident, consulting doctors will all appear at different times, just as the patient was starting to relax and dose off. If they are stable enough, sometimes some undisturbed rest is the most therapeutic thing that we can give our patients!

dinah77, ADN

530 Posts

Specializes in Tele, OB, public health.
I see this issue in the pediatric ICU and step-down units as well. While a child may initially need hourly VS including blood pressures, once their condition has improved and their vitals are ordered q3 or q4, many of the nurses will continue to leave the blood pressure cuff on them all shift long, cycling automatically every hour. How annoying and uncomfortable must that be after several days?

In general, I think that we as heathcare providers often interrupt our patients rest too much. Even if the bedside nurse tries to cluster their care activities, it inevitable follows that the respiratory therapist, physical therapist, social worker, attending, fellow, resident, consulting doctors will all appear at different times, just as the patient was starting to relax and dose off. If they are stable enough, sometimes some undisturbed rest is the most therapeutic thing that we can give our patients!

Yes, all of this! I know my pt's are not getting rest during the day either, as there is lab, docs for both mom and baby, hearing test personnel rounding, in addition to the day nurses......

Rest is sooooooo crucial. It really irks me that there is not more emphasis placed on rest, ESPECIALLY on OB, as these pts are not going to get any rest once they are home for a looooong time

ixchel

4,547 Posts

Specializes in critical care.

We recently changed our 0200 vitals requirement to nurse discretion, except patients who were admitted within 24 hours or are admitted with CVA. At first I didn't like it. I mean, how can these people survive without me knowing their vitals at 0200?! (I kid!) Plus we had a tech who would constantly give nurses a hard time if we needed vitals done. (She's no longer employed there, thankfully.) It makes the patients happier to not have to get up at 0200. And really, can you blame them? I hate waking people up. If I have IV meds due at 0000 or 0200, I'll tell them at 2200, ask if they have questions at that time, and then I'll let them know I'll try to work as quietly as possible when I come in if they are sleeping. Tired patients make for cranky and/or crazy patients. I don't like cranky or crazy patients who direct the cranky crazies at me, so I do my best to keep them well rested. :)

I think it's great you thought that one through, OP. As I was reading, I was thinking that being on tele before OB is helping you in that on tele units, we're sort of trained in orientation to ask, "why?" for every order. Sick patients require different thinking than healthy ones do, and I'm sure that while you're still orienting to OB, you still have that habit of thinking like you would on tele. Your patients are very grateful for the end result (sleep!), I'm sure!

Elvish, BSN, DNP, RN, NP

4 Articles; 5,259 Posts

Specializes in Community, OB, Nursery.

This used to drive me batty when I worked on mother/baby. (What I do now tends to have a much quicker patient turnover so this is much less of an issue.)

What I used to do was have them call me. Whether she's a newly delivered mama or an antepartum she is more than likely going to be up in the middle of the night. Rather than wake her, I'd either strike a deal with her that whenever she's up to pee (or up with the baby) sometime betweeen 0300-0500 to just call me. That way she's only waking up once, I get what I need, and I'm not going back in there once she's just gotten settled back down. And if I didn't hear from her by around 0500 I'd go in if I had to, but that was rare. Babies like to be awake sometime between 03-05. But I was also usually the one asking to please be able to leave our long-term antes alone between 2300-0600 as long as they were afebrile (or asymptomatic for whatever other issue they'd been with us for).

gypsyd8

1 Article; 276 Posts

Specializes in TELE, CVU, ICU.

I am so glad I am not the only nurse who thinks sometimes less is more. I work ICU, and sometimes we have DNR patients being poked, prodded, and pestered when all they need is rest. I let them rest, and some horrified old timer says "DNR does not mean do not treat!" I am treating, by leaving them alone.

Common sense prevails!! Thank you for this article!! I can remember being in nursing school and my instructor asking me a question and I responded with, "common sense tells me..." and she bit back, saying, "there is NO SUCH THING as common sense in nursing!" In there lies the problem. We can call it critical thinking or whatever make us feel good....but please lets apply it. I am a rehab nurse in a brain injury unit and this type of thinking is much needed. I'll take it one step further....I find sometimes some nurses find validation in finding something that can be "reportable" to the physician which ultimately makes no difference to the patient's outcome. In order to find something reportable, they are poking and proding at their convenience, not taking into account the needs or discretions of the patient. So many times I find myself thinking...we need to put ourselves in their shoes.

dinah77, ADN

530 Posts

Specializes in Tele, OB, public health.

I am soooo annoyed right now!!!

Just came back on to NOC, and I noticed one of my babies that I have been with for the past three days had a serum billirubin drawn on him today

His TCB was low, he does NOT look jaundiced in any way, so I was immediatly thinking what the heck?

Turns out the nurse working today "acidentally released" the order- so this baby was poked for NO reason, and guess what, the serum??? LOW

I should add that this is the SAME BABY who 2 days ago had to have his metabolic screen drawn TWICE simply because the HUC mislabeled the slip and the Lab tech did not notice

Like we don't do enough unecessary stuff already!!:banghead:

Thessaly36

16 Posts

Thank you for this. I feel validated in my practice now as I often question the "culture" of my floor in this regard and do some things in my own way if I find the common assumption of how to do it to be ineffective or an inconvenience to my patient. I'm glad I'm not the only one to do this as it often seems I am in the small insular county in which I currently work.

banterings

278 Posts

I am going to touch on one of the biggest complaints of patients: undressing completely for ALL surgery. I can't tell you how many providers (doctors, nurses, techs, etc.) have defended this practice. When called out on this the two most common responses are infection control or incase something goes wrong (cardiac arrest).

Usually the "infection control" is just written to the procedure guidelines, no studies or research cited. As for the something goes wrong, a team in the ED can remove all clothing from a fully dressed patient (coat, boots, etc.) in less than 30 seconds.

It comes down to "this is how we have always done it."

Consider the the standard procedure for prepping a patient for all surgery, including outpatient: naked wearing only a gown, wheeled into the OR on a gurney. Consider what LDS Hospital in Salt Lake City, Utah did as part of their overhaul of healthcare delivery in 1998:

SOME PATIENTS were especially bothered to spend half the day without underwear -- for shoulder surgery, say. Ms. Lelis was convinced this longstanding practice was meaningless as a guard against infection, persisting only as the legacy of a culture that deprived patients of control. "If you're practically naked on a stretcher on your back," she says, "you're pretty subservient." The nurses persuaded an infection-control committee to scrap the no-underwear policy unless the data exposed a problem; they have not. Source: The Wall Street Journal

NOTE this was implemented in 1998!

Even the annual pelvic exam has been described as ritual:

The annual pelvic exam has long been a routine part of women's health care, but new guidelines say there's no good reason for it.

The recommendations, laid out by the American College of Physicians (ACP), advise against pelvic exams for women who aren't pregnant and have no symptoms of a potential problem.

The reason? There's no good evidence the screening exams benefit women, the ACP said.

"I think a lot of women will be relieved by this [recommendation], especially since it's based on scientific evidence," said Dr. Linda Humphrey, a member of the ACP's Clinical Practice Guidelines Committee, which devised the new advice after reviewing 32 studies on the benefits and harms of routine pelvic exams.

So how did pelvic exams become so routine in the absence of evidence? "In medicine, a lot of things have been done because we think they might help," Humphrey said.

"The reasoning behind why clinicians are doing it has never been very clear," said Dr. George Sawaya, a professor of obstetrics, gynecology and reproductive sciences at the University of California, San Francisco.

Instead, the pelvic exam is more like a "ritual" than an evidence-based practice, said Sawaya, who cowrote an editorial published with the new guidelines in the July 1 issue of the Annals of Internal Medicine. Source:

It is time to take the Voodoo out of healthcare. The Internet has taken the sacred knowledge away, now everybody has access to it. If a provider says something, they better be able to back it up with something other than "this is how we have always done it."

This is exactly why healthcare is in it's current state, and it is NOT getting any better. Healthcare has lost just about all it's credibility.

Credibility is like virginity; once you lose it, you can never get it back.

Providers have been relegated to the role of advisor. People no longer have stockbrokers, they have financial advisors. They no longer have lawyers, but a team of legal advisors. This has happened when a profession has lost the trust of the people it serves. Healthcare is down there with congress, BUT ratings for individual providers are high.

That is because of people like the OP and others who speak up for the patient.

Finally, here is a doctor speaking about this very issue of credibility, protecting patients, and speaking up: Where Is The Physician Outrage?

This was an excellent topic. Thank you for starting the discussion.

dinah77, ADN

530 Posts

Specializes in Tele, OB, public health.
I am going to touch on one of the biggest complaints of patients: undressing completely for ALL surgery. I can't tell you how many providers (doctors, nurses, techs, etc.) have defended this practice. When called out on this the two most common responses are infection control or incase something goes wrong (cardiac arrest).

Usually the "infection control" is just written to the procedure guidelines, no studies or research cited. As for the something goes wrong, a team in the ED can remove all clothing from a fully dressed patient (coat, boots, etc.) in less than 30 seconds.

It comes down to "this is how we have always done it."

Consider the the standard procedure for prepping a patient for all surgery, including outpatient: naked wearing only a gown, wheeled into the OR on a gurney. Consider what LDS Hospital in Salt Lake City, Utah did as part of their overhaul of healthcare delivery in 1998:

NOTE this was implemented in 1998!

Even the annual pelvic exam has been described as ritual:

It is time to take the Voodoo out of healthcare. The Internet has taken the sacred knowledge away, now everybody has access to it. If a provider says something, they better be able to back it up with something other than "this is how we have always done it."

This is exactly why healthcare is in it's current state, and it is NOT getting any better. Healthcare has lost just about all it's credibility.

Credibility is like virginity; once you lose it, you can never get it back.

Providers have been relegated to the role of advisor. People no longer have stockbrokers, they have financial advisors. They no longer have lawyers, but a team of legal advisors. This has happened when a profession has lost the trust of the people it serves. Healthcare is down there with congress, BUT ratings for individual providers are high.

That is because of people like the OP and others who speak up for the patient.

Finally, here is a doctor speaking about this very issue of credibility, protecting patients, and speaking up: Where Is The Physician Outrage?

This was an excellent topic. Thank you for starting the discussion.

Excellent Points!!

I have never worked OR/PACU or anything related so I was not aware of the clothing issue with surgical patients

With all due respect to nurses with a lot of years under their belts, they are often the ones holding things back.

NOT ALWAYS; often it is a nervous newbie over vitaling and assessing our patients to death.

Seriously, and then people wonder why more and more people are looking at home birth or birth centers

Heck I tried to use a birth center- didn't work out for me, but with my next pregnancy I fully intend to try again- why? Because if my baby and I are stable I do not want to be bugged every few hours!!