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.

[wooh, BSN, RN]

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

Hourly. Giving a PO medication, the onset of action is going to be variable depending on a variety of factors. Just because you can wake someone an hour after their sleeping pill, and two hours after, and three hours after, and four hours after... Well I've seen people code a full 18 hours after getting their sleeping pill!

[MunoRN, RN]

There are best practice guidelines on this put out by the society of pain management Nursing and there is no rule that works for all situations (as with everything). In terms of a pain re-assessment, you can't assume that a patient isn't in pain just because they are sleeping, which is why it's always a good idea to discuss this when you give the pain med at night, ask them if they want to be woken up to see if their pain is controlled or if they don't. Sometimes a patient may say they always take 1 norco for this same pain and that it works, so don't wake me up. Post-op pain where you don't yet know the effective dose may be different and you may need to wake them up.

In terms of over-sedation, assessing RR and quality of respirations is considered sufficient by best practice guidelines if they have tolerated similar doses before, so no you don't always need to wake them to do a post opiate sedation assessment, best practice is to monitor both RR/quality and ETCO2, although the cost of ETCO2 has been somewhat prohibitive but RR/quality alone is still considered sufficient for many situations.

In the end, it nursing judgment (god forbid). If you just gave a 90 year old lady 4mg of dialudid and they are asleep, you should assess their ability to rouse, regardless of their RR. If you gave a 45 year old who usually takes 80mg methadone daily a Norco, then you probably don't need to wake them if their RR is 18 with deep, full resps.