This is my least favorite "go-to" that I hear all to often. Why even have monitoring in the first place? I trust the monitors more than my own ability to intuitively know a patient's condition based on my limited assessment skills; and just to ward off evil comments spawning from this notion I want to remind everyone that we all have limited assessment skills, our senses can only do so much. And of course, if your monitor screams asystole or vfib and your patient is smiling at you politely asking for more apple juice, I do hope that we all know to check lead placement or something.
We didn't have numbers 100 years ago and look what kind of healthcare we had...not the greatest.
I just wish we could flush this saying out or maybe change it.
I think this is the classic case of a family that argues over each other before realizing that everyone essentially agrees.
OF COURSE monitors can be good. But if I started bagging every newborn baby whose pulse was 74 via pulse ox I would a) be wasting a lot of equipment and b) hurting a lot of babies. Because the baby's pulse is actually 148 (perfectly fine for a newborn) but because the pulse oximeter is a machine that picks up a certain wave amplitude as a pulse, and newborn radial pulses (where we measure preductal sats) aren't always at an amplitude that the oximeter can read unless your placement is perfect all the time. A newborn who's pink, alert, and has excellent tone is unlikely to actually have a pulse of 74.
If we freaked out and sectioned every patient whose FHR apparently drops to the 70s on the EFM (continuous EFM being another discussion altogther), we'd be wasting a lot of money and cutting a lot of people for no reason. Because a lot of times that pulse in the 70s is mom's pulse, not baby's.
I'd say I treat the patient and not the monitor way more often than the other way around.
I worked with a cardiologist in Central America who could listen to a heart and diagnose the patient exactly. The echo was essentially to confirm what he already knew. He's been a cardiologist for 50+ years and spent 30+ years working in the developing world, so he has seen plenty of stuff. He manages and treats people who should not be walking around alive, and he does it mostly without monitors. He is from that old breed of clinicians who rely on their five senses to do the majority of diagnosing. I would trust him with my life or any of my kids' lives every day of the week.
The saying itself truly varies. If someone is having a potentially life-threatening arrhythmia, like sustained vtach, its not something to ignore, not matter how well the patient feels. However if someone throws a couple of PVCs and is asymptomatic, it really isnt anything to get your panties in a wad over. However some people can have PVCs and get very dizzy and lightheaded. So in that case if it really affects their ability to function, then its an issue.
When my loved one was recently in the hospital, they ignored bigeminy and trigeminy.
of different sources.
I thought the frequency of these PVC's warranted notification of the physician, an EKG, and/or a cardiology consult.
When I worked ICU and Tele many moons ago, trigeminy definitely was never ignored, especially if it occurred more than once.
Specializes in Psych, Addictions, SOL (Student of Life).
Well no duh!!! Of course if your patient looks horrid and the monitor doesn't reflect that you should most definitely perk up and do some investigating.
Im regretting this post!
Your assessment skills can fail you just as badly as a monitor can, we have to use ALL THE DATA at our disposal.
I just took an advanced patient assessment class and we had to accurately tell what was going on with a patient using only data we could see and feel without monitors. It was very enlightening. I work a lot of psych and we don't usually have a lot of monitors. We have to think on our feet and use ours hands and eyes. I am one of those "Witches" who can "SEE" a patient getting ready to go South. I honestly don't know how I do it, but nurses on other units will call me to come look at someone.
ps
I can also fix most machines by simply laying hands on them.
I had always been taught to look at patient first, then monitor..brought home sharply one evening in ICU when a patient's core temp was reading 103 on the monitor from the rectal probe and they'd been on cooling blanket for some times...but when I assessed the patient, their skin felt like ice. I did an ear, oral and rectal temp which all said 95 degrees. apparently probe had quit working a few hours before when the patient temp was still high. And of course we've all had tales of crazy lethal monitor rhythms and low sat readings with patients who are obviously not in distress.
The monitor is a tool, do not depend on the tool to assess the patient for you. Nothing beats hands on assessment, thus treat the patient and not the monitor...
And of course we've all had tales of crazy lethal monitor rhythms and low sat readings with patients who are obviously not in distress.
I will never forget this incident during clinical. My patient's pulse ox read 76%. Me being a nursing student, ran to my to instructor, who ran into the room with me to find the patient sitting comfortably watching tv. I thought I failed clinical that day. But my instructor was cool about it. it was a good lesson.
I feel like the OP is saying the same thing as the objectors, but in a different way. OP is saying "don't ignore the monitors," because a patient might feel ok without actually being ok. If I have a patient with lung Ca with says in the 70's, don't ignore the low saturation just because she doesn't feel short of breath. When my numbers look bad but my patient looks fine, it helps to draw a definable line. "If she takes longer than 5minutes for her sat to come up, I will call the doctor." (Treat the monitor, not the patient). Alternately, I treat a BP of 85/40 differently when it is a little old COPD/CHF lady with an EF of 20%, vs a 32yo with sepsis (treat the patient, not the monitor).
We're all saying the same thing. In the words of my favorite nursing professor: THINK!
I'm an experienced Critical Care Nurse. I took a gig working in a GI Lab where the nurses administered Versed and Fentanyl for procedures. None of the other nurses had Critical Care experience. We loaded the Meds up front. All patients started out on 2 L nasal cannula. Some would initially start to drop their Sats. The non CC nurses all panicked, grabbed a non rebreather mask or asked the Doc if they should reverse the patient. They actually got mad at me when I would dismiss the high flow O2 masks. One actually said "what,...don't you like oxygen?" I would calmly tilt the patients chin up to unobstruct the airway and the O2 Sats would instantly return to normal. No emergency, no reversal and abandoned procedure, no incident report to be filed for reversing the patient. Use monitors to HELP decide how to treat the patient. Use all information available to actually treat the patient.
Here's a less dramatic reason for treating the patient rather than the monitor. I have PVCs----lots of them, on a regular basis. Sometimes I feel them; sometimes I don't. Nurses often get concerned when they see me on a monitor, because they don't know if the PVCs are longstanding, or if they indicate an ominous new problem. But, when they see that I'm asymptomatic and vitals are stable, and I tell them that it's a chronic thing with me, that changes the picture considerably.
Years ago, they did treat PVCs, regardless of how the patient looked or felt. Couplets or triplets, or even a brief run of bigeminy, or >6 PVCs per minute, would send the CCU nurse running for the lidocaine. Since then, we've learned that automatic treatment of PVCs (i.e., treating the monitor rather than the patient) is pointless, and can in fact be harmful.
When it says "Treat the patient, not the monitor," it isn't saying, "Disregard the monitor." It's saying that the monitor is an important tool to determine what's going on, but that you should also take the patient's general appearance and vitals (and history, if possible) into consideration, before reacting to what the monitor says.
Another example of this is asystole. If you've taken ACLS, you know that you don't treat asystole, per se. You consider possible causes (the "Hs and Ts"---hypovolemia, toxins &c.) and treat them.
If you trust the monitor, I hope a lead never falls off. If you get a flat line and the patient is talking to you, are you going to call a code? I hope no. You may think is an exaggeration but that's when it is said look at the patient. Also unless you have a 12 lead on at all times, how do you know that one or two leads you are monitoring are picking up the right part of the heart? Most patients know themselves better than we ever will. Listen to them then look at the monitor.
Kooky Korky, BSN, RN
5,216 Posts
There is way too little physical exam these days.