Tipping (Sacred) Cows and Evidence-Based Practice Part II

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    This is Part I of II-addressing the sacred cows of nursing practice. Read to see if your practice is evidence-based.

    Tipping (Sacred) Cows and Evidence-Based Practice Part II

    Here's Cow Tipping Part II. Read Tipping (Sacred) Cows and Evidence-Based Practice Part I for best practice on stopping continuous enteral feedings for repositioning; the use of Trendelenburg to treat hypotension; inflating foley balloon before insertion; NPO after midnight for elective surgery; wet-to-dry dressings; and verifying enteral tube placement

    Do you ever wonder if you are following the most recent evidence-based care for your patients? Read here and find out. Caution-first and foremost, follow your facility's procedures and policies. If you discover that change is needed to provide your patients the best care, then be an agent for change and help to bring it about.

    "About 30% to 40% of patients do not receive care consistent with current scientific evidence." (Rauen, Chulay, Bridges,Vollman, & Arbour, (2008) p. 123)

    Guess what- we have the power and the responsibility to change our practice!


    Soap and water bathing is no longer best practice. Soap and water is not recommended as soap is alkaline. Bathing wipes are best.

    Many (most?) of us were trained to provide soap and water baths using bath basins for our patients. The best practice in bathing has changed and evidence now shows that basins can be a source of waterborne pathogens and transmit hospital acquired infections.

    Practice Recommendation:
    Use pre-packaged cleansing cloths to wipe one area of the body at a time, then discard. Most wipes can be pre-warmed. Wipes reduce the transfer of bacteria from one part of the body to another, such as infecting a surgical site.

    Instilling Normal Saline for Endotracheal Suctioning

    Insufficient evidence exists to support the practice of instilling normal saline to loosen mucous secretions into the trachea prior to endotracheal suctioning via artificial airway. Suctioning should be limited to less than 15 seconds.

    Practice Recommendation:
    Do not instill normal saline prior to suctioning

    Gastric Residual Volume (GRV) to Assess Gastric Emptying and Aspiration Risk

    Evidence does not support the use of GRV to reliably indicate:
    • Tolerance of feeding
    • Gastric emptying
    • Aspiration risk.

    Aspiration risk increases with altered LOC , mechanical ventilation, and severity of illness. Feeding tubes do not prevent aspiration of contaminated oral secretions or regurgitated gastric contents-both well-documented causes of aspiration pneumonia. Do not use GRV alone to determine aspiration risk or feeding tolerance. All patients fed enterally should be assessed for aspiration risks, such as hemodynamic instability, sepsis, altered level of consciousness, and mechanical ventilation.

    A single high GRV should call for ongoing monitoring, while continuing the feeding.

    Practice Recommendation:
    • Don't hold for a single high GRV <500 mL. Continue to monitor.
    • Consider meds to increase gastric motility if pt has serial high GRVs.
    • Assess GRV every 4 hours during the first 48 hours of feeding, then decrease to every 6 to 8 hours for non-critical patients if goal rate has been achieved and remain at 4 hours for critically ill patients.
    • Keep HOB elevated 30 to 45 degrees during enteral feedings.
    • For GRV greater than 500 mL, hold enteral nutrition and reassess patient tolerance with an established algorithm including physical assessment, GI assessment, evaluation of glycemic control, minimization of sedation, and consideration of a promotility agent.

    Fecal Incontinence and Rectal Tube Management

    The use of tubes to manage fecal incontinence in patients with diarrhea

    Identify underlying cause of diarrhea. Use fecal collection systems starting with an external system such as bags and pouches when securely positioned they reduce adverse skin breakdown to avoid internal tissue injury. Use a tube system Traditional rectal tubes are the least safe

    Practice Recommendation:
    Identify patients at risk for fecal incontinence. Pro actively implement pressure ulcer and dermatitis reducing interventions Critically evaluate when a fecal management systems is needed

    Use of Sandbags to Maintain Hemostasis Following Femoral Sheath Pull

    Sandbags applied to the femoral artery site after a sheath pull (and after hemostasis is obtained ) cannot be relied on to prevent bleeding or hematomas. Sandbags provide diffuse pressure and will not stop a femoral bleed.

    Sandbags can provide the nurse a false sense of security, and prevent visualization of the arterial puncture site. They may be beneficial in reminding the patient to not flex at the hip.

    Practice Recommendation:
    The use of sandbags to control bleeding in the angioplasty patient is not supported by evidence. Inspect the site regularly for signs of bleeding and hematoma formation. In cases of retroperitoneal bleed, patients complain of back pain. Be on alert if patient's HR increases.


    AACN 2016. AACN Practice Alert. Initial and Ongoing Verification of Feeding Tube Placement in Adults. Accessed January 2017 Initial and Ongoing Verification of Feeding Tube Placement in Adults - AACN

    American Society of Anesthesiologists Committee on Standards and Practice Parameters. Anesthesiology. 2011;114(3):495-511

    APIC Implementation Guide: guide to preventing catheter associated urinary tract infections. 2014. http://apic.org/Resource_/Eliminatio...I_web_0603.pdf.

    Johnson, D., Lineweaver, L., & Maze, L. M. (2009). Patients' bath basins as potential sources of infection: a multicenter sampling study. American Journal of Critical Care, 18(1), 31-40.

    Makic, M. B. F., VonRueden, K. T., Rauen, C. A., & Chadwick, J. (2011). Evidence-based practice habits: putting more sacred cows out to pasture.Critical Care Nurse, 31(2), 38-62.

    Hanrahan, K., Wagner, M., Matthews, G., Stewart, S., Dawson, C., Greiner, J., ... & Cullen, L. (2015). Sacred Cow Gone to Pasture: A Systematic Evaluation and Integration of Evidence‐Based Practice. Worldviews on Evidence‐Based Nursing, 12(1), 3-11.

    Metheny N. Turning tube feeding off while repositioning patients in bed. Crit Care Nurse. 2011;31(2):96-97.
    Stewart ML. Interruptions in enteral nutrition delivery in critically ill patients and recommendations for clinical practice. Crit Care Nurse. 2014;34(4):14-22.

    Miller, J., Hayes, D. D., & Carey, K. W. (2015). 20 questions: Evidence-based practice or sacred cow?. Nursing2015, 45(8), 46-55.

    Rauen, C. A., Chulay, M., Bridges, E., Vollman, K. M., & Arbour, R. (2008). Seven evidence-based practice habits: putting some sacred cows out to pasture. Critical Care Nurse, 28(2), 98-123.
    Last edit by tnbutterfly on Jun 14, '18
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  3. by   Spidey's mom
    I'm enjoying reading these.

    I've never thought bathing a patient using two basins of water is a good idea. Regardless of going from "clean to dirty" . . . that water is dirty pretty much after the first area washed.

    But, some CNA's and nurses where I work still do it. I much prefer the warmed wipes.
  4. by   NotReady4PrimeTime
    Some (sacred) cows are much more resistant to tipping than others. We still have respiratory therapists who insist saline instillation is essential but are unable to offer rationale that makes any sense. "It helps them cough up their secretions," is the most common reason given. Hand-ventilating with a larger tidal volume for a couple of breaths does that too, but generally has fewer negative effects.

    Bath wipes are not high on my list of favourites. They don't remove dried blood or other body fluids as well as a wet washcloth does - with or without soap. I've cleaned up trauma patients using a new, empty suction canister filled with warm water and a dozen washcloths, discarding in same manner as I would with the bath wipes and gotten the patient far cleaner. Once that nitty-gritty aspect is handled, then bath wipes are fine. Except if you're having trouble keeping dressings and electrodes on your patient... the film they leave behind sometimes interferes with adherence.

    As someone who has delayed gastric emptying when I'm otherwise well, I know if I was being tube-fed my feeds would be off more than on.

    Another cow that needs tipping is the routine clamping of EVDs when repositioning patients. Studies have shown that prolonged raised ICP occurs after such practices. Risks of Routinely Clamping External Ventricular Drains for Intrahospital Transport in Neurocritically Ill Cerebrovascular Patients - Journals -

    Keep these coming please, Beth!