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!

[Forever Sunshine, ASN, RN]

So heres what you do... prove to administration that there is no need for their blood pressure to be taken 3x or whatever. Show them the blood pressures .. (given that they are within normal limits for that resident. and the medication hasn't needed to be held in a good period of time. lets say a month). And tell them exactly that.. The resident has a stable B/P and heart rate on this medication.. the doctor has agreed to d/c parameters and so has the resident and/or their family. Present them with facts. There is no need for LTC residents who have stable B/P's to have their blood pressures taken daily. Weekly is enough and I've never seen an issue with it.

[SquishyRN, BSN, RN]

When working in LTC I've always checked blood pressures before giving blood pressure meds and have always checked blood sugars before giving insulin. However, checking has always been indicated because there are parameters for those meds. Diabetics that didn't get insulin usually just had a Q weekly blood sugar check. It's been that way in every facility I've worked. It's weird to hear from this thread that the practice isn't commonplace. The only time I've routinely checked O2 sats, however, is when I worked in a sub-acute unit where all the patients were ventilated. O2 sats were checked every 2 hours alongside the ventilator settings.

[CoffeeRTC, BSN, RN]

Vital signs q shift x 7 days for all new admits, Vitals are also done with showers/ baths so they get done at least twice a week. BPs are not normally done with each bp med unless we have orders/ parameters.

Our facility has Long and short term residents.

Accu checks do vary. Most long term/ stable diabetics are BID, but for the most part they are Qid.

[LittleCandles]

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.

I didn't mean to thank your comment.

So what would happen if you did not hold those 3 times in 4 months? The patient tanked? Died? Then what?

[amoLucia]

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?

Besides just being an inexperienced DON, might I ask if she came to this job from an acute care/hospital setting? It's major culture shock to move from acute to LTC. Many of us who switched know what I'm talking about.

If your new DON is more acute-oriented, she needs documented evidence that all the extra monitoring reflects STABILTY - it's just not needed in stable pts. If you can demonstrate trial periods of stability that's been reflected by the increased monitoring with documentation, she might back off.

You might come up with a more modified monitoring system to offer.

And if all else fails, catch the ear of the attendings or Med Director. They might agree with you that all the extra monitoring is unnecessary for their pts. (I've known physicians who felt if it wasn't causing problems, why look for something.) I've had good allies for some issues after having goon to the MDs.

[JBMmom, MSN, NP]

I think along with many others, I would not object to doing work to keep residents safe. However, the necessity is questionable in a relatively stable population. For a dose change in BP meds I think we monitor for two weeks before administration. If it has not been held within that time, checks would be dc'd. All sliding scale residents get checks TID or QID depending on when it's administered. For those that are stable, we'll get as low at twice weekly if only metformin and a regular Lantus are administered. Our residents get monthly vital signs recorded, and for any change in condition it's vital signs Q shift for 72 hours. It's not only the time and money factor, either, residents get annoyed with constant interventions. We have a few very competent residents that are long-term for chronic, but easily manageable health conditions, and they have told the MD/APRN they object to multiple checks that aren't immediately necessary, so they've been dc'd.

To the OP, I would prepare a summary of the number of times a med was held over the past month or two weeks for the residents and show that the frequency of checks is maybe excessive. (Then again I'm a dork and like numbers, I'm sure you're not sitting around with nothing to do!) Data will always point in the right direction. Good luck.

[DisneyNurseGal, BSN, RN]

In a perfect world, a patient would even check their blood pressure at home prior to taking any blood pressure medications, so yes... I do feel that it is appropriate in any nursing situation. I understand that these are "stable" nursing home patients, but these patients still deserve the care, assessment and critical thinking of trained, professional staff.

[Forever Sunshine, ASN, RN]

In a perfect world, a patient would even check their blood pressure at home prior to taking any blood pressure medications, so yes... I do feel that it is appropriate in any nursing situation. I understand that these are "stable" nursing home patients, but these patients still deserve the care, assessment and critical thinking of trained, professional staff.

They do but .. are you aware how much extra time taking vitals on stable residents takes up from the nurse? A nurse who works in a nursing home may have 20, 30 sometimes 40 patients.

[BrandonLPN, LPN]

It sounds like this DON came directly from the hospital, without any LTC experience. She's probably used to q4hr vitals on all patients and all that jazz.

Students and new nurses are hung up on this "vitals for everyone, every shift" thing, too. This is because nursing schools focus almost exclusively on acute care. I was an aide in a hospital for years before becoming a LTC LPN, so I get it. But as others have pointed out, this is your residents' home. Do people taking routine BP meds at home check their BP every morning before taking their pills? Of course not. It's not necessary.

Now, change in dose? Sure, check before administering for 7 days. And certain meds like digoxin always require a pulse beforehand. And it's always the nurse's prerogative to check vitals whenever his judgement deems necessary. But checking a BP on all residents for all BP meds is an undue invasion of the resident's time in their own home.

And, to be perfectly blunt, all this policy in a LTC setting will achieve is a lot of nurses making up a lot of fake blood pressures.

[BrandonLPN, LPN]

In a perfect world, a patient would even check their blood pressure at home prior to taking any blood pressure medications, so yes... I do feel that it is appropriate in any nursing situation. I understand that these are "stable" nursing home patients, but these patients still deserve the care, assessment and critical thinking of trained, professional staff.

Honestly, if you think a stable nursing home resident always needs a BP check for routine BP meds, that actually shows a lack​ of critical thinking skills.

[amoLucia]

To Brandon - you have said mouthfuls! Keep 'em coming.

[IsmeAmanda, LPN]

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?

I have 20 blood pressure meds to give. And I have to pass meds to 36 residents and 3 g-tubes. I have 2 hours too technically be finished.I would be giving 8am meds until 2pm :/ normally on the MAR it will say check vitals, and normally the vital sign is pulse. I have only 1 daily BP.