Sacred cows that need to be laid to rest

[stevierae]

Here are a few of mine--they are things that no one who does them can explain the rationale for, other than justifying it with these 6 words, their mantra:

"We've always done it this way."

1. Putting down a "foot sheet" (usually a drape sheet; half or 3/4 sheet) before putting down the main drape (lap sheet, transverse lap sheet, split sheet or whatever--)

My question: WTF for? Do people not trust that the surgical drape companies have put time and money into researching just how thick the surgical drapes need to be to make them impervious to strikethrough or instrument penetration?

2. "Testing" the balloon on a Foley catheter before inserting it--

Again, what is the rationale? Do they somehow think that the balloon on a Foley is prone to failure to inflate--have they ever actually SEEN one not inflate?

When I put a Foley in, I insert it all the way to the hub, inflate the balloon with the full 10cc of H2O, then pull the catheter back--it stops on its own, proving the balloon is inflated.

Never once have I seen a Foley slip out because the balloon failed to inflate--and if it did, so what? Has any harm come to the patient? Of course not! Just get a new catheter and reinsert it.

I don't think that sterile items should be handled more than necessary--putting on gloves to "test" a Foley balloon, taking them off, doing another task, and then regloving to actually perform the catheterization--often announcing to whomever they think cares: "I tested the balloon earlier" is, to me, an unnecessary practice and one that can potentially contaminate the catheter and lead to a nosocomial UTI.

3. Double gloving for every single task--even patient transport

First off, I think it is a waste of gloves, but second--everybody keeps quoting "research" that says double gloving is "safer--" I even saw a recent AORN article that quoted someone as saying something to the effect that double gloving will reduce the likelihood of needlestick or other sharp object penetration by 50%--

Now, that sounds reasonable in theory, but is it actually true in PRACTICE? Has anyone actually SEEN this research, or is it anecdotal? Does this mean that if we triple glove, we wiil reduce the chance of sharp object penetration by 70%? Should we put on 4 pairs of gloves, thus reducing the chance of needlestick by 75%? Why not just wear 5 pairs, reducing the chance to... well, you get my point.

And, while we're at it, why not just put on 2 gowns and 2 masks--hey, if one is good, shouldn't 2 be better? Where do we stop and say, "Enough, already--this is just silly."

Again, I think that, just as with the example of the surgical drapes, the glove companies have a vested interest in making gloves that are strong and durable--why should they make a product that necessitates wearing two of for safety?

I have never double gloved, and I have only been stuck once in my career--by a sharp needle that would have penetrated 2, 3, or 4 pairs of gloves; double gloving would have served no purpose whatsoever--

If people feel the need for thicker gloves to make them feel "safe," ortho gloves serve that need just fine.

OK, I know I will get flamed especially for my double glove views, but I just think we need to use a little more common sense and not rely so much on outdated "policies" and practices that MAYBE made sense in the '50s--MAYBE--but maybe, even then, they were sacred cows--

Let's hear YOUR sacred cows!!! Bring 'em on!! Remember, there are student nurses out there reading this board who can learn from us; it will be nice to provoke critical thinking in the generation that will be providing our perioperative care, possibly sooner than we think---

[JaneRNBSN]

As a PACU nurse in a small rural hospital, this sacred cow really does need to be euthenized. Hypotensive patients are routinely put into Trendelenberg; research has suggested that this can "trick" the sensors in the Aortic arch which can result in an even lower blood pressure. The new standard is to keep pt. flat but raise the legs instead. Makes sense to me.

[EmilyCCRN]

Great thread.

A few months ago in the AJN, an infection control expert debunked the myth that gloves are necessary for SQ injections. Makes sense. Whoever bled from an insulin injection?

Patients receiving anticoagulant therapy, for example, can bleed quite a bit from SQ injections, so I wear gloves when I perform this task. If a patient starts bleeding, I don't want to have to take the time to put on gloves and THEN apply pressure to the site.

[cocothemonkey]

Well--I have worked in various ORs for nearly 30 years--and, no, I have never done a cystoscopy for a balloon that didn't deflate, and I have never seen a defective balloon. In the OR, we don't usually use a syringe to deflate our Foley balloons in order to d'c the Foley--we cut the limb that goes to the balloon with a scissors, and the H2O in the balloon leaks out.

Now, if you re-read my post, you will see that I was referring to ANOTHER person in the room--that is, a PA or OR tech or other nurse or whatever--unasked, trying to be "helpful" by opening up your Foley tray (say, while you--the circulator-- were out getting the patient.)

Then, you enter the room, and this "helpful" person (who has also opened your prep tray) says, "I tested your Foley balloon for you." Great--just great. Now I have had ANOTHER pair of hands on my Foley--I HOPE they have used good sterile technique manipulating it (and, if you don't trust this person, you will have to throw out the entire tray, rather than compromise sterility and ASSUME he or she used scrupulous sterile technique) --the more hands on a sterile item, the more chance for contamination---and I have to open up ANOTHER pair of sterile gloves to INSERT the Foley when it's time, as that "helpful" person has used the pair in the set that were meant for the person (me) doing the catheterization.

Or, another scenario that I presented--circulators who subscribe to the "I must test the ballon" theory--but don the sterile gloves in the Foley tray to do it (often before the patient is even in the room) and then move on to another task. THEN, when their patient comes to the room, they must open ANOTHER pair of sterile gloves to do the catheterization, because they have already used the pair in the tray that was MEANT for that task.

Get it?

I suspect that any balloon that does NOT deflate easily is for this reason: in the OR, we usually put the entire 10 cc. of H2O in the balloon. On the floors, many nurses only put 5cc. When they attempt to deflate the ballon with a 5 cc syringe, it does not deflate fully. If they used THEIR critical thinking skills, it might occur to them that there is more than 5 cc in the balloon--and attempt to aspirate the residual, or cut the limb to the balloon, as we do. The remaining water will leak out, and the Foley will slip right out.

I still believe it's a sacred cow--I think it goes back to the '50s, when Foleys were made of lower grade latex (these days, due to potential latex allergies, most ORs in which I work have switched to all silicone Foleys.)

Here's another Foley sacred cow---believing that if one does not hang a Foley bag below bed level, it can reflux into the bladder--which can present reflex arc problems with quadriplegic patients.

Now, it's true that it might not DRAIN as well (forces of gravity and all that--) however, Foleys have, for MANY years, had anti-reflux valves built into them--so this is no longer an issue.

I've also had a foley balloon that wouldn't deflate, something defective with the valve maybe. Luckily I tested it before inserting it in the patient. Also why would someone else test your balloon for you. I've never had that happen to me. It only takes a few seconds to test the balloon. :dunno:

[HelenofOz]

2. "Testing" the balloon on a Foley catheter before inserting it--

I'll add my name to this list-I've also been in the situation of being unable to empty the baloon & having to cut the valve off-that seems to be a more common occurrence than being unable to inflate the balloon or finding leaks.

Also if I'm inserting the catheter I would be less than impressed with someone else interfering with "my toys".

As to wearing gloves-in the PACU you never know what you'll find where, and it is so much more dignified to look like you're ready before you find it, rather than the last minute scramble when...... "errr yukk"! So I wear gloves almost everytime I go near a patient, regardless of what I'm doing for them.

[Marijke]

About checking the foley balloon. Checking the balloon could actually harm the patient (according to one of the urologists I work with). When you inflate and deflate the balloon, the surface of the catheter becomes less smooth, this could be irritating, especially when you are talking catheters with large balloons. Makes sense to me.

Marijke

[Ferret]

Some people in the 5 Australian operating suites I've been in test the ballons, others do not. The manufacturer recommends not testing the baloons.

The wire inside a size four embolectomy catheter is fine enough to fit down the fluid channel of a foley catheter and is longer than a foley catheter, so could be used to pop the balloon without further trauma to the patient, if necessary.

Use your clinical judgement.

Ferret

[sweet31eve]

We always were told to check the balloon before insertion, but only until recently we have stopped. We recently switched over to all non-latex items and the sales rep that supplies our latex free catheter kits told us NOT to check the balloon. It is not necessary and may even lead to the it malfunctioning because it is made to inflate and deflate once.

[grimmy, RN]

in nursing school, i was taught to always check the foley balloon, but when i arrived at this facility, the policy is never to test the balloon since it weakens the balloon, and can cause irritation for the pt. so, i don't ever test it.