How Often Do You Check...?

[flashpoint]

We have recently started checking blood pressures on almost every resident almost every time before we give blood pressure medication. This was something started by a newish DON. Our computer program allows us to check how often medications and we have only held medication three times since the new orders to check were received (about four months ago).

We are also checking blood glucose more often. We have several residents who we check four times a day. We have had levels low enough to hold insulin only twice.

The same goes for pulse oximetry. We check everyone who uses oxygen at least twice a day. Several residents get checked four times a day. I can see it for the one or two who sometimes need their oxygen bumped up to three or four liters, but most of our residents run between 93% and 99% consistently. We have no orders to increase the flow rate for anything below 90%.

None of if takes a long time, but 10 blood pressures, 8 blood sugars, and 22 pulse ox readings certainly can add up to more than a few minutes!

[TheCommuter, BSN, RN]

As a former LTC nurse, here are my thoughts. I'll emphasize that the practice setting is a nursing home. It is home to the residents who live there.

Low-acuity residents do not require full head-to-toe assessments more than once per week. Low-acuity residents do not need their vital signs checked multiple times daily. Your DON needs to see the big picture and be mindful that LTC typically doesn't deal with an acutely ill patient population.

Many people in the community live with chronic health issues such as essential HTN. Would the neighbor across the street with HTN who takes Lisinopril daily and Coreg every 12 hours check her blood pressure and pulse around the clock? Nope. She just swallows the pills. And she doesn't drop dead because she's not acutely ill. It's the same concept with nursing home residents who have chronic stable disease processes that are managed in their homes.

Constantly checking vital signs before all medications are administered is not necessary and sucks up valuable time. Other than checking blood glucose prior to giving insulin, or listening to apical pulses prior to administering Digoxin, or checking BPs for medications that have physician-ordered parameters for systolic and diastolic BPs, it is a poor use of time to constantly vitalize stable nursing home residents.

We are not working in the acute care hospital setting. Remember that.

[flashpoint]

I am very curious about how much time and money we are spending doing such frequent checks. If we were holding blood pressure medication frequently, I would not question the need for checks. If we were finding high or low blood sugars on a regular basis, I wouldn't object to checking. If we were finding that residents were able to maintain without oxygen or needed more oxygen, it would make sense to check four times a day.

When I started working there six months ago, there was a focus on trying to help residents sleep at night by minimizing the number of medications and assessments that we do after 10:00 PM. Now, we seem to be monitoring everything far more frequently than we did before.

[heron, ASN, RN]

I can only assume that the new DON is inexperienced. There are other possible explanations for her mandate, none of them complimentary, so let's leave it at that.

OP, are you looking for suggestions on how to address this with the DON?

[flashpoint]

I would like to address this with the DON. We are spending a ton of time poking holes in fingers and squeezing arms. Not fair to the residents to be poked and picked on so much. This is NOT how LTC is supposed to be.

[heron, ASN, RN]

Let me think on it. Meanwhile some other posters are likely to have good ideas.

[CTnewgrad826]

Like you've mentioned it's all circumstantial on the patient. Fingersticks don't need to be checked for metformin as it works differently from insulin as we all know. If they're on a sliding call however yes.

BP meds I'd still be hesitant not checking...I don't necessarily check after giving the med though I agree that would be overboard.

Finally sats I just stated we check ours only during vital rounds...if your orders are to check once a week then your covered.

I had seen you posted in LTC, but now that you've specified the patient population/acuity a bit more I can too specify my answer. And I didn't mean offensive by asking if you were a nurse, hope none was taken! Seems you'll be working with management to come to a better arrangement for every one. Good luck!

[MN newbie]

I work in long term care and we do try to keep in mind this is their home. Most people do not check their blood pressure daily, especially if they are stable.

When one of our residents are ill we do start monitoring their vitals every shift and more often PRN.

We have minimized our blood glucose checks for most of our residents to once daily, though that increases PRN for illness or if they become symptomatic.

Our residents don't wear name tags and are very involved in their care.

i agree that seems overboard for LTC. Perhaps your staff can start asking how often they were checking vitals at home.

in assisted living we only checked vitals once monthly and PRN. That is still more frequently than a lot of ppl who only get them checked at the MD office every few months.

[bluegeegoo2, LPN]

In the past, if my efforts to address an issue with management is fruitless in regards to resident care, I go to plan "B". Plan "B" is I address the issue directly with A/O residents, and with families of demented residents. I have had plenty of A/O residents c/o "I"m tired of getting my fingers stuck every time I turn around" or whatever over-monitoring issue it is and address it with the MD, usually get orders to d/c or reduce monitoring and chart accordingly. Same with dementia residents. "You know, your (family member) is getting finger sticks 4x/day and her levels are always in range. She is not on a sliding-scale insulin so it's really not necessary. Would you like for me to see if Dr. Smith would like to reduce how many times we do them so we don't have to poke her so much?" I can't recall a single time that I've had a family member refuse to reduce how often we "fiddle" with their loved one. I know that you're perfectly aware that we are the patient's advocate, and there's more than one way to advocate for them. Best of luck.

[crj96]

I can't imagine giving sliding scale, fast-acting insulin without knowing a current blood sugar, or giving many heart/BP medicines without knowing a current HR/BP. Yes, it takes longer but it's time well spent if you can bypass a major medical issue.

[brownbook]

YIKES....there have been to many common sense replies on this post, I'm feeling giddy...I think I'd better check my blood pressure....I do take lisinopril once a day....get my blood pressure checked about once a year.

[brownbook]

PS...in all seriousness....I know nothing about LTC's, but shouldn't a lot of routine vitals and glucose checks be covered/ordered, by the MD?

[flashpoint]

PS...in all seriousness....I know nothing about LTC's, but shouldn't a lot of routine vitals and glucose checks be covered/ordered, by the MD?

They are ordered by the MD. Most of the time when they order things like blood pressure medication, they don't order routine B/P unless we ask for it. Sometimes they will order checks for a few days until a new med or dose is therapeutic, but most often, they don't. All of the new and frequent monitoring is because someone at the facility asked for it.