Hi Allnurses! New grad RN here, and I've been on my own, out of orientation for a few months now.
I work on a busy med-surg floor that does it all, and wow, what a roller-coaster ride this has been. So I just have to share a recent experience with an MD that left me baffled. It actually happened to a fellow nurse, but I think it sums up perfectly the difficult position we nurses are often placed in, when dealing with tired grumpy doctors, and trying to take care of our pts with due diligence.
So another nurse took his pt's BP at around 0200. The pt was on tele, so it's commonplace on our floor to take BP's on such pts around that time, esp. if the nurse has a concern. So the nurse got a bp of 170+ systolic, on a pt who's baselines is about 125 - 135 sbp. He called the night-time hospitalist to let him know, as per hospital policy, and the doctor's response? "What are you doing taking a BP at two in the morning!?!" The nurse began stammering out a response, when the doctor hung up on him.
Wow... so what do you say to that???? The nurse handled it well, I guess as well as can be handled. I asked him what he was going to do, and he said he would chart the conversation, and let the charge nurse know. What else could he do?
I feel that we nurses are often put in impossible situations when dealing with doctors who are tired, overworked, and just don't have time or want to deal with our patients. But the worst part is that this type of behavior by doctors seems to be tolerated. But God forbid if the nurse didn't follow up on that elevated BP, or even fail to take an 0200 bp in the first place. And lets not forget the most important part, the pt's health and well-being, who is at the center of all of this.
Nope. I'm too lazy to look up stuff for someone I don't know who is throwing a fit on the Internet. You can use CINAHL if you want to see it. I have read several studies in journals like AACN showing the criticality of catching changes in vitals early to avoid codes and mortality from later stages of sepsis. They're the reason Rapid Response and similar teams were developed.
Specializes in Cath/EP lab, CCU, Cardiac stepdown.
I don't doubt that you can catch problems, but that can happen any hour of the day. There's nothing magic about 0300. Besides, as I challenged, where's the evidence based research? Anecdotal evidence is just that, anecdotal. The telemetry unit I worked on also had BP designed to go off automatically, we didn't even need to step in the room, unless the cuff had been removed. I would also question what symptoms of a stroke did you see and how did taking a blood pressure lead you to that determination? And again, give me some sources! Even if you catch one stroke in your lifetime, does that justify the damage done to dozens of other patients through disrupting their sleep?
Well vitals are every 4 hour so yeah nothing magical about 0300. As for the symptoms of stroke. When I was taking the patient's blood pressure her arm dropped when I was trying to put the cuff on. That was when I noticed the one sided weakness and prompted me to do a full neuro assessment. But yes to answer your question I do think that it justifies it. You make it sound like some serious damage is being caused.
Nursing care is always a balancing act, as is medicine. We try to do the most good and least amount of harm. If you do a search of research articles you will find a great deal of evidence that interrupting sleep does do harm to patients. Now that isn't to say there aren't times when the scale tips in the other direction, and vitals every 4 hours are beneficial, but those decisions should be based on medical necessity, not a blanket policy. We need to move away from doing things because "that's the way we've always done them". If there isn't real proof that what we do is best practice, we can't just pretend that it is and do it anyway. I'm afraid that is the case for routine Q4 hr vitals. Such nursing is not much different than was done in the 1950's and fails to keep up with what we call the science of nursing.
Specializes in Cath/EP lab, CCU, Cardiac stepdown.
Nursing care is always a balancing act, as is medicine. We try to do the most good and least amount of harm. If you do a search of research articles you will find a great deal of evidence that interrupting sleep does do harm to patients. Now that isn't to say there aren't times when the scale tips in the other direction, and vitals every 4 hours are beneficial, but those decisions should be based on medical necessity, not a blanket policy. We need to move away from doing things because "that's the way we've always done them". If there isn't real proof that what we do is best practice, we can't just pretend that it is and do it anyway. I'm afraid that is the case for routine Q4 hr vitals. Such nursing is not much different than was done in the 1950's and fails to keep up with what we call the science of nursing.
Well patient placement is based on medical necessity. If they're on my floor, a cardiac progressive care floor, you can bet it's a medical necessity.
Currently working on an observation unit. Patients are there specifically for frequent assessments. Not only do we do vitals q4, we hourly round and do assessments q4.
I don't doubt that you can catch problems, but that can happen any hour of the day. There's nothing magic about 0300. Besides, as I challenged, where's the evidence based research? Anecdotal evidence is just that, anecdotal. The telemetry unit I worked on also had BP designed to go off automatically, we didn't even need to step in the room, unless the cuff had been removed. I would also question what symptoms of a stroke did you see and how did taking a blood pressure lead you to that determination? And again, give me some sources! Even if you catch one stroke in your lifetime, does that justify the damage done to dozens of other patients through disrupting their sleep?
There isn't anything magical about 03.00. A higher frequency of vitals for acute or post-op patients means any problem is picked up sooner. I don't need to see EBP to tell me that identifying and treating a bleed or sepsis or stroke or MI 4 hours sooner rather than later is helpful to the patient. If patients are in hospital and requiring Q4 vitals then it is because they are unwell and/or at risk of deterioration. Otherwise they would have been stepped down to less observed care or sent home where sleep is the greater priority.
Ultimately it is the Dr's decision whether an individual is more in need of sleep or a higher level of observation. It is therefore nothing to do with nurses doing things unthinkingly and in desperate need of research to change their sheep-like ways.
I'm surprised you would think a BP cuff attached to someone's arm overnight is a substitute for a proper set of vitals which includes looking/listening to and touching the patient. In addition, the cuff on overnight is a risk for skin damage, a form of restraint, could contribute to a fall and could be uncomfortable, disturbing the sleep of the patient. Perhaps this practice deserves a review of the EBP and a benefit risk/analysis?
At the hospital I currently work in, the CNAs routinely take q6 vitals (not due until 0600) starting at about 0400, and if the pt is being woken up for labs at 0300, they get them then. This is not a true picture of the pt, if I am giving 0600 meds based on 0400 vitals. A CNA asked me one night if I minded her taking the 0000 vitals at 2100 (three hours early). I told her that I prefer they be no sooner than 2300 (the accepted parameter). She stated that she was sure the previous shift had gotten theirs early, anyway so doing them at 2100 should be fine. Not good practice, but admin. doesn't enforce it, so we need to be our patient's watchdogs.
At the hospital I currently work in, the CNAs routinely take q6 vitals (not due until 0600) starting at about 0400, and if the pt is being woken up for labs at 0300, they get them then. This is not a true picture of the pt, if I am giving 0600 meds based on 0400 vitals. A CNA asked me one night if I minded her taking the 0000 vitals at 2100 (three hours early). I told her that I prefer they be no sooner than 2300 (the accepted parameter). She stated that she was sure the previous shift had gotten theirs early, anyway so doing them at 2100 should be fine. Not good practice, but admin. doesn't enforce it, so we need to be our patient's watchdogs.
So true! I did a clinical rotation in a long term care facility where the CNAs were getting AccuChecks at 0600, along with vitals. The CMA would use those levels to dose the insulin, which for some crazy reason I never figured out, wasn't given until after 7:30 breakfast, around 9:00. The nurses would then spend the day treating hypoglycemia and hyperglycemia, depending on the day. They also started getting residents up and dressed at 0500, then parking them in their wheelchairs to sleep in the hallway. Personal convenience was a pervasive thought process throughout the facility.
Systolic of 170 in a non-critical patient is not a reason to call at 0200, sorry. Everywhere I've worked, hydralazine and labetalol were not pushed until the SBP was at least 180, and often the parameter was over 190.
We typically don't don't call on the overnight for a systolic under 180. Let me rephrase... I won't call for a systolic under 180. That said, the parameters are typically systolic 170 / diastolic 100 for hydralazine and labetalol prn's.
I'd notify the charge nurse and work it up the chain of command. However, I would document it professionally as a critical communication or a nurse's note depending on how your EHR works. I'd document "vital signs obtained, see vital signs. Physician paged at time to notify of bp of x. Physician returned call at time. Notified of bp. No new orders received."
canigraduate
2,107 Posts
Nope. I'm too lazy to look up stuff for someone I don't know who is throwing a fit on the Internet. You can use CINAHL if you want to see it. I have read several studies in journals like AACN showing the criticality of catching changes in vitals early to avoid codes and mortality from later stages of sepsis. They're the reason Rapid Response and similar teams were developed.