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.

[BluegrassRN]

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.

You're not there to make friends, no. You're there to use your nursing judgement. I would say our nursing judgements vary wildly if you hOnestly wake every pt every time after narc administration. How often do you check the sugars of your diabetic pts? They can go into a diabetic coma during sleep. I've seen it happen. Do you check your diabetic pts' cbgs at regular intervals throughout the night every night, every diabetic? No? I can just see the conversation now after the code "I thought they were sleeping."

See where I'm going with that? You use your nursing judgement. On a med/surg floor, and probably in many other environments, too, there is no need to wake every pt a hour after narcotic administration. You use your judgement as to who is at risk. And rather than wake them, if you're truly concerned, put on an EtCO2 monitor, or if not available, at least a continuous oximetry, to enable you to monitor their respiratory status post narc administration with disturbing them so frequently.

[CompleteUnknown]

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.

Agree with this, and with those who say a bit of common sense is needed. So much depends on the patient's general condition, whether or not they've just had surgery or a procedure or been commenced on a lot of new medications or whatever, and what they've just been given. Sometimes it would be necessary to wake the patient, and sometimes it'd be a bit like waking someone to check if their sleeping tablet was working. Or.... we could make sure that every patient is attached to every conceivable type of monitor at all times 'just in case'. After all, things can go wrong at any time right?

I think that most of us can tell whether a patient is sleeping or not, or at least whether or not they look 'right'. As Stargazer says, you just have to look at them properly. If there's any doubt, you wake them and find out. You can easily check pulse, respirations, colour, general body position, whether skin is warm or cool, clammy or dry, etc etc without waking a patient.

On a side note, I've never really understood why it's not okay to say a patient is sleeping, but you can say a patient is 'resting quietly with eyes closed'. Saying someone is resting seems to suggest they're awake. Patients can go their whole hospital stay without ever sleeping, they just rest!!

[psu_213, BSN, RN]

If a pt has no indications to be on a cardiac monitor, the doctor agrees that they don't need to be on a monitor, and then the pt. falls into a lethal rhythm (yes, I know that we would not realize it was an arrhythmia that killed them) then the RN would not be at fault if the RN did routine VS and regular checks on the pt, even if they don't wake them up. If the nurse 'covers' an elevated HS blood sugar per order, checks on the pt through the night (again, without waking them up), the pt is without any signs of hypoglycemia, then the pt is found with a CBS of 25 at breakfast, again, not going to be the RN's fault for not taking a random CBS at 4 am.

However, if the nurse gives 1 mg IV dilaudid at midnight, goes back in at 0030 and 0100 and 'eyeballs' the pt. and their RR/sats, that nurse is going to be reponsible (and will be on the chopping block) if their pt had a low BP and was not perfusing his/her brain, kidneys, etc. properly...even if they do chart "sleeping in bed, good resp effort, sat 98%, etc."

[ZippyGBR, BSN, RN]

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.

which is where as Professional you should be able to articulate why you would or wouldn't maintain a certain level of observations on that patient ... rather than hiding behind 'Just following orders'

I have never been fired or punched because I woke up a patient.

it depends how far you wake them , yes i'm going to wake my head injury patient fully every time their Observations are due , but if it's someone we've increased the dose or changsd the route of a Opiate or Benzo - rousing them is probably sufficient - again as a professional you should be able to articulate why or why not ...

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.

you better have a damn good reason for waking patients beyond following orders or just covering my backside when someone makes a complaint about you , especially if the complaint is initiated outside the unit - because once who ever deals with complaints (formal or informal ) is involved they will want a full dog and pony show investigation ...

[llg, PhD, RN]

Gee ... I recently had a bad case of bronchitis that prevented me from sleeping. My doctor gave me some cough medicine containing a narcotic to help me sleep.

So ... I should have set the alarm to wake myself periodically to make sure I was not comatose?

[psu_213, BSN, RN]

you better have a damn good reason for waking patients beyond following orders or just covering my backside when someone makes a complaint about you , especially if the complaint is initiated outside the unit - because once who ever deals with complaints (formal or informal ) is involved they will want a full dog and pony show investigation ...

And I damn well know that I would want to defend myself for waking someone up rather than having to defend myself for not waking up a patient when it turns out the pt. was "narced." Also, I am confident that my superiors will stand by my when I follow policy by waking a pt. up after narc administration. Not so sure they would have my side if a pt. suffered harm because I did not monitor them.

[ZippyGBR, BSN, RN]

And I damn well know that I would want to defend myself for waking someone up rather than having to defend myself for not waking up a patient when it turns out the pt. was "narced." Also, I am confident that my superiors will stand by my when I follow policy by waking a pt. up after narc administration. Not so sure they would have my side if a pt. suffered harm because I did not monitor them.

it's not 'your superiors' you need to worry about it;s the PR conscious lay manager responsible for complaints that you need to worry about ...

It really suprises how many US Nurses are concerns about over sedation given the near homeopathic doses of opiates given what does 2mg of morphine sulphate work out to in mg / kg for the hypothetical average 70 kg adult ( 0.028 mg/kg by the way) , unless the leftpondian populous is some how genetically more susceptible ... Interestingly the BNF suggests 5-10 mg as the routine starting dose of morphine sulphate by any injected route ...

[ZippyGBR, BSN, RN]

Gee ... I recently had a bad case of bronchitis that prevented me from sleeping. My doctor gave me some cough medicine containing a narcotic to help me sleep.

So ... I should have set the alarm to wake myself periodically to make sure I was not comatose?

equally should we wake patients given Benzos as a sleeping tablet ?

once again 'narcotic panic' has struck AN

[psu_213, BSN, RN]

it's not 'your superiors' you need to worry about it;s the PR conscious lay manager responsible for complaints that you need to worry about ...

The person who handles ED complaints from pt relations is a (now non-praciticing) RN. In our ED, when good nursing care (including assessment and pain evaluations) clashes with customer service (letting a sleeping pt. sleep), our non-lay manager will stand on the nurses' side.

(true, this is only one example from this side of the pond...then again, getting really tired of hearing about the "this or that 'side of the pond'" comparisons)

[hannahmaepunk]

Here's how you can assess a patient on narcotics and asleep: enter the patients room, check o2 sat if there's pulse ox hooked. Check the depth of respirations and rate, cause that's what you can do to monitor for respiratory depression related to narcotics, and you can do these things without having to wake them up. Even if it goes to court, you can defend this because you ASSESSED the patient even though the patient is asleep.

[wooh, BSN, RN]

And you don't have to wake the patient up to assess any of those things.

Yep. And if you can't do a set of vital signs without waking a patient up, you'd never get a toddler's blood pressure.

I'm not going to wake up a patient just so I can say I did a "good" assessment. Maybe if there was a real need to do a neuro assessment, but pain med administration IMO doesn't warrant a full neuro assessment. I'm letting them sleep. Not to make friends, but because patients NEED their sleep. And for some of them, that really is their only escape from the pain.

[wooh, BSN, RN]

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.

It's called a "focused assessment." Respirations ok? Heart rate ok? If I (or my family member) am not suffering from a head injury, then let me get some sleep!