Sleeping is an observation, not an assessment!

[BUNightingale]

I work in a large urban teaching hospital as a member of the Rapid Response Team. I don't know how many codes I have responded to over the years where the primary nurse tells me "They were fine 15 minutes ago. They were sleeping." Endless chart reviews have shown me that many nurses chart "sleeping" for neurological assessments and pain assessments after narcotics. Narcotics are CNS depressants and a side effect is respiratory depression which can lead to unresponsiveness and death! I am not asking that we wake everyone up for hourly bedchecks but please, wake up your patients when it is time for any assessment. I have seen nurses chart sleeping next to a set of vital signs. You mean to tell me that this patient slept through a BP measurment and did not wake up at all and this seems normal to you? Research has shown that a change in neuro status usually predicts a CPA event within 24 hours. I know it seems rude to wake people up from a deep sleep to ask them questions but to me, the only way to tell the difference between an asleep pt and an unconscious pt is to wake them up. I won't make us any new friends but it could save your license.

[kakamegamama]

If I'm that patient & at risk....I WANT to be awakened!!! Thanks for a good post!

[Flo., BSN, RN]

Interesting. I have a question. I frequently chart pt sleeping after a narcotic during my pain reassessment. We have a computer charting and that is one of the options, we also must chart RR and depending on the route Pulse ox, is this bad practice? I thought it was the standard as that what other RNs on the floor do.

[Anna Flaxis, BSN, RN]

I never chart "sleeping", but rather, something to the effect of "resting quietly with eyes closed, respirations even and unlabored". Since we keep anyone receiving narcotics on continuous pulse ox, and many patients on continuous cardiac monitoring and NIBP Q15, 30, or 60 depending on their condition (more frequent if they're critical), it's not too hard to combine RA O2 sats with eyeballing the patient to determine if they're snowed or simply sleeping. One of the first signs of respiratory depression following opioid anaglesia administration is a decrease in RA O2 sats. You can also look at the rate, depth, and quality of respiration to determine if respiratory depression is occurring. Any snoring and/or periods of apnea, decreased RR, decreased depth of respiration, all of those things would be concerning. And you don't have to wake the patient up to assess any of those things.

Because of all of these things, my reassessment after opioid administration consists of a set of vital signs along with a description of what the patient looks like. Never "sleeping" or "appears to be sleeping". As you mentioned, and unconscious patient can appear to be sleeping!

[Anna Flaxis, BSN, RN]

Interesting. I have a question. I frequently chart pt sleeping after a narcotic during my pain reassessment. We have a computer charting and that is one of the options, we also must chart RR and depending on the route Pulse ox, is this bad practice? I thought it was the standard as that what other RNs on the floor do.

A couple of years ago, my facility added "sleeping" to the choices for pain assessment. What I did to cover my behind was also add a timed nursing note describing what the patient looked like (see my post above) in the "nursing notes" section, even though we charted by exception. In this way, if you just looked at the "pain assessment" screen, you'd see that I did not enter a number because the person was sleeping. If you looked further into the "nursing notes" screen, you'd see that I actually assessed the patient and didn't just make an assumption.

[BUNightingale]

We also have computer charting at my hospital and "sleeping" is an option for pain and level of consciousness. I think it is something we as nurses need to have changed in our standards of practice. I was actually told by our CNO that we cannot wake everyone up all the time to check on their pain status. I disagreed with her infront of a lot of people and got kudos for it. If a patient receives a narcotic in a procedure area or PACU, they never use sleeping because they need to assess neuro status. How can you check neuro status after a narcotic UNLESS you wake them up. If your patient dies and you have to defend your charting and assessment in court, how do you defend the fact that your did not want to disturb them by waking them up? If that was my family member, I would say it is negliegence on the nurse's part because they did not do an actual assessment.

[payang0722]

Thank you for this good thread, reading all the replies is alot of help for me being a new grad/ new nurse.

[TheMoonisMyLantern, ADN, LPN, RN]

Honestly, I think it depends on the setting and the type of drug administered. Am I going to wake up a patient with chronic pain over a Lortab I gave an hour ago that they also take at home? Of course not, sure I'll count her respirations, observe the color of her skin, etc. Am I going to monitor someone more closely that I just administered Dilaudid IV and it's the first time they've ever received it, absolutely and if they get angry with me "pestering" them then they get angry. As far as not obtaining VS because the patient is sleeping, absolutely not unless the patient is there for end of life care and is comfortable.

I think a lot of this is common sense though, isn't it?

[BluegrassRN]

Wait. So the poster a couple above is saying that, if someone falls asleep after a narc, you should wake them to assess their pain? Really? Am I really understanding that right? That seems excessive to use as a rule.

"Sorry you finally got to sleep, but I wouldn't be a good, safe nurse if I didn't wake you an hour after you took that lortab/2mg of IV morphine/percocet to assess your pain. " Seriously. How many times do pt's fire you, or just punch you in the face? I'm guessing your pt satisfaction scores are in the crapper. Maybe I shouldn't discourage you....finally, someone to consistently ensure that my hospital has higher scores!

On some pts, sure. Ones who are at moderate to high risk for oversedation, sure. However, it's extremely lacking in judgement if you think that the way something is done in one part of the hospital (PACU, where they're coming off of anesthesia and are high risk) means that it is reasonable and prudent to do everywhere. If you're concerned out on the floor, rather than interfere with the sleep process (which is well documented as important to healing and is also in short supply in hospitals, particularly ones where overzealous nurses wake pt's up frequently to assess for pain), why not throw them on a EtCO2 monitor? There are ways of assessing oversedation without waking them constantly.

[psu_213, BSN, RN]

First, obtaining a "full" set of VS (temp. excluded if previously normal) with a pain assessment is a requirement in our ED....not sure what the requirement is on the other floors in the hospital. Also, just because someone has a good RR with a good sat, that does not mean that they are not overy sedated by a narc. Our "pain assessment" form includes 'sleeping' on it, however I don't see how just "eyeballing" a patient is going to allow a nurse to differentiate between sleep and narc induced sedation. I think sleeping is an important part of the pain assessment--most likely, their pain is feeling a bit better if they are sleeping comfortably, but if I chart 'sleeping' I always chart 'easily arousable' (if they, indeed, are...if not, time to get the doc in there).

I can just see the PG comment now..."This is the first time in 3 days the pain didn't keep me from sleeping, then the nurse came in and disturbed me, waking me up after just 30 minutes." Oh well, keeping my pts. alive takes precidence over customer service.

[Anna Flaxis, BSN, RN]

Also, just because someone has a good RR with a good sat, that does not mean that they are not overy sedated by a narc.

Valid point, but that's why I also look at the depth and quality of the respirations, not just the numbers (look at your patient, not the monitor). I think there is room for nursing judgment here. You can tell a person who is snowed just by looking at them, in my experience, just like you can develop a sense for whether someone is sick or not sick just by what they look like.

I can see how in some environments, waking the patient should be part of the assessment (like perhaps a fresh postop on a PCA). But I think I agree with the CNO in a previous post that it is impractical to wake every patient up every single time they've had a narc, and as nurses, we are supposed to have the knowledge and assessment skills to be able to judge when it is appropriate to wake a patient, and when it's okay to let them sleep. Of course we must have defensible rationales for these decisions, and document them appropriately.

[BUNightingale]

For Bluegrass RN

I understand that is seems to be overdoing it to wake a patient up everytime. I have seen pt's who have become unresponsive with just 1mg of morphine or 1 lortab. Yes, these patients usually have comorbidities that probably have contributed to their enhanced response to narcotics. I have never been fired or punched because I woke up a patient. I can just see it now speaking to a family after a code "I'm sorry, I thought he was just sleeping". I would never accept this if I was the family member. I am not here to make friends, I am here to make sure you are kept safe and get better under my care.