Treat the Patient, not the Monitor.....Really?

[jk2185]

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.

[EKUGRAD, BSN, MSN, RN, CNS]

OMG ! I was just using this old warning last week. And I work PSYCH ! At the risk of sounding like Florence's study partner, let me add this to the discussion.

Seriously, I have been a RN for 41+ years, the first 20 in ICU, Trauma ICU, Open Heart, Heart Transplant, Flight Nurse and combat casualty care. It was not unusual for a Trauma ICU patient to have 7 or 8 parameters on the overhead monitor and 2 more portables at the bedside. They also sported up to 10 or more lines, in & out. Throw in an IABP, an ICP screw and it's a party!

Back in 1982 I was honored to be one of the first Instructor-Trainers in the South for American Heart ACLS (started teaching in 1980). It took longer in those days because the manuals were all on slates and the chalk kept rubbing off. Hey, we had LifePaks. They didn't even have a number yet !

When I taught ACLS, especially Mega Code, I almost always needed to use this phrase for a struggling nurse, physician, med student or paramedic student. They wound be stumped as to what to do next and just stare at the monitor, hoping it would reveal the magic words such as, "What are the latest blood gases?" or "When was the last dose of Epi?". Even "How long have we been going?"

I believe the word "intuition" is being used here to refer to a well-experienced and seasoned nurse's ability to put EVERYTHING together and reach an accurate conclusion. If intuition was actually the key, we would be born with it. I have been referred to as "The Magician" myself when I have predicted psych behavior sometimes days before it happens.

The nurse that stands in the door and verbalizes a precise and accurate patient status is relying on unfathomable, immeasurable experiences; cerebral, emotional, spiritual and physical. The sad part is, it can take 20 or 30 years of practice and thousands of patients to develop this ability. I am currently mentoring a group of nurses anywhere from new grad to 10 years experience. They listen, they learn, they practice. When I am done, they will be better than me; the 1000 year-old Japanese concept of Shu Ha Ri (Google it). The old War Horse can still bring it.

But you know what, it's worth it. I was born to 2 nurses and started taking care of patients at age 13, helping Mom ambulate post-partum patients at the County Hospital. It's been a long and at times, rocky road but I wouldn't trade any of it for all the gold in Fort Knox. I would like a few more years to practice but, through mentoring, I can leave a legacy I can be proud of and hope that Nursing's good works will carry on.

[feelix, RN]

All it means is, the monitor has the numbers, but you are the critical thinker. If O2 Sats are low, see if the O2 is even turned on? See if the patient is on Opioids.

You have to have the entire picture before you start treating.

But hell, how do you do that in telemedicine?

[RoxyDi]

Sounds like you might want to brush up on assessment skills, gain more experience and also understand the unintended negative consequences associated with the use of technology. Neither people or machines are perfect. The saying is intended to remind us that the patient should always get first and last attention when a machine gives us data. Nothing more, nothing less. I think you already knew this from your post's comments re: using judgment to decide actions. Healthcare wasn't necessarily "safer" 50 years ago, despite the huge influx of technology since then. Look at the IOM reports.

[medic981, ADN, RN, EMT-P]

Seriously... ? Wow, do you treat the patient or the instruments and tools used to assess a patient? The reason "treat the patient and not the monitor" axiom evolved is that providers were making poor treatment decisions based on what they saw on the cardiac monitor and not the patient on the whole. A healthy athletic patient with bradycardia is treated differently than a symptomatic patient with bradycardia and is the rhythm really V-Fib you are seeing on the monitor or a loose limb lead?

It is kind of like looking for the zebra in a herd of horses. Treat the horse in front of you and don't go chasing after the zebra, that is unless the zebra is staring you in the face.

Axioms are there to remind us to stick to the basics and help us to do our first responsibility which is to "Do No Harm".

[ixchel]

"Look at the patient, not the monitor" doesn't work for me either. I've seen plenty of patients that look fine chatting away with a CI of 1.8 or an SBP around 200. So...as long as my equipment is calibrated correctly and not being assessed by someone who doesn't know how to properly use the devices, more often than not, I believe what my monitor tells me 100%.

What is a CI?

Your story is interesting and it sounds like it made for a terribly stressful day. Seems to me there may have been a failure in protocols. Did anyone check a pulse or responsiveness?

I imagine I am late to this party and probably am beating a dead horse (I've read no other responses yet), but see where your mind has gone FIRST? Can you palpate a pulse? Is the patient responsive? The beeping machines got your attention, but the actual patient's presentation is what you look to respond to.

Even if a monitor shows a shockable rhythm you still follow the BLS survey first. It also seems odd that the monitor in room A (which was presumably hooked directly up to the patient in room A) would show data from a different room. I'm no IT guy for sure, just seems very odd.

You're sort of giving yourself away here. Are you a nurse?

If you are starting the BLS survey on any random person, what's the first thing you do? Surely you remember the, "hey! Hey! Are you okay?!" shouting. You assess the PATIENT!

But, this is a MICU story you're responding to. Chances are, they are vented. How quickly will you, "HEY! HEY! Are you okay?!" these people?

Also, nurses in ICU are looking at ACLS protocols.

Do you know how monitors communicate to the screens at the nurses' station? Do you know how each patient is imported into that monitor? This was more likely to be user error and not an IT thing. I could be wrong, of course. I just know I've seen patients on incorrect rooms twice and it was user error. Those two were on the same day as each other on step-down. The mix up was obvious quickly because we assess the patient, not the monitor. Signs AND SYMPTOMS. The signs tell us to assess symptoms.

What's scary to me is you might be calling the doctor with vitals that LOOK bad but aren't (when you see my 55 BPM and almost 90 systolic, I really don't want a liter bolus at 0200), or you might be giving a brand new, second dose ever, beta blocker after the first dose dropped someone from 120 BPM to a beautiful 65 BPM.

Wait - are you trusting a tech with that crappy machine to get this right? Is this the tech who always does a recheck on both arms because she remembers it wasn't like that earlier? Or is this the one who huffs and puffs at you because they don't feel like "doing your job for you" all the time?

I'd say my point of view only works if you know what you are doing. It doesn't work if you put the wrong size BP cuff on a patient, or if you have bubbles in your pressure lines, or if you don't check your patient's pulse and responsiveness when you have some strange artifact that often does look fib-ish.

But do you? You decry this phrase, but your wording in your posts indicates you DO look at the patient to ensure the patient is responsive and you double check vitals, lead placement. Do you ask how they feel? Or is it all about machines?

I just find this old expression to be only mildly useful. Of course you use your intuition and assessment skills, but the notion that you should treat based on what you see over data drawn from high-tech equipment seems a little over the top.

I think the nurses on my floor would hear one line of the above, take you gently by the hand, walk you to the elevator, then drop you off on a floor that shall remain nameless. I think our hospitalists celebrated the day that floor became a closed specialty unit because those nurses would code a sneeze.

You are stressing yourself into an early retirement. Relax. The high tech equipment you are championing dings all the time. High tech equipment is no match for boob sweat.

[raybrownrn]

Too. Three letters. Jeez...

[angelmomjr]

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.

"I'm 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'm not understanding what you expected from your post. Nurses have shared with you their experiences from their own assessments and use of monitors. Any of these nurses, use both of the methods to diagnosis and treat. There is no "fail safe" method for diagnosis and treatment. It is a combination of the nurses assessment skills, to treat a patient.

I don't get your post!

[silasozzie]

I had a family member come to me yelling " He's flatlining!!" I knew straight away that he was looking at the spO2 trace. I asked the grown up son... "what is he actually doing?" "Oh, he's talking to me" Cue massive eye roll and a verbal warning that this is not the movies!!

Also had a monitor go off whilst physios treating the patient. They jumped on his chest for....... ARTIFACT! Physio kept lookig at monitor and continuing CPR. I ran in and said "Get off him for christs sake! He's looking at you wondering what the hell u are doing!" ...... poor little bloke.....

[KatieMI, BSN, MSN, RN]

What is a CI?

CI - Cardiac Index. Left ventricle output (HR x stroke volume)/ body surface area, L/min/M2. Norm 2.6 - 4.2. Roughly, below that = cardiogenic shock, guy is cold and mottled; above that = high output heart failure like in sepsis, guy is warm and pink (for a while).

[KatieMI, BSN, MSN, RN]

I had a family member come to me yelling " He's flatlining!!" I knew straight away that he was looking at the spO2 trace. I asked the grown up son... "what is he actually doing?" "Oh, he's talking to me" Cue massive eye roll and a verbal warning that this is not the movies!!

Also had a monitor go off whilst physios treating the patient. They jumped on his chest for....... ARTIFACT! Physio kept lookig at monitor and continuing CPR. I ran in and said "Get off him for christs sake! He's looking at you wondering what the hell u are doing!" ...... poor little bloke.....

This is why I am adamantly against "family-initiated" rapid responses, codes, etc. Families need to be listened to, and what they say sometimes has great value, but they should not be allowed to direct care unless there are some very special circumstances. I saw many times someone too enthusiastic jumping onto patient's chest while yelling for help and "code" while patient just had seizures, or was sleeping a little too deep from PCA, or his ECG pad fell out, or otherwise made family members thinking that "his heart might have been stopped" and going accordingly frantic. Quite a few times the result was unexpectedly prolonged stay because of, at the best case scenario, a few broken ribs.

[paige1075]

I agree with you! And I understand what you mean when you say use ALL of your data. As a novice nurse, I still sometimes need that monitor to help me recognize a potential complication.

And as a fresh nurse I'm going to remind everyone of something probably all of my very experienced instructors have taught me, "no nurse is perfect". It is still possible to make mistakes or misjudgements with 30 years of experience.

So I think it is important to remember that every patient is in fact very different and all assessments must be taken into consideration when using critical thinking and taking action.

Would you disregard any other piece of information on your patient Just because your assessment showed otherwise? Or would you dig deeper?

I don't care for phrases like this in general though, just because I don't think that patient care should be made so narrowed and concrete, it's definitely not textbook, it is actually very different for each patient and each nurse. Which is why you use all the info you can get!!

it should instead just say "treat the patient." And leave the treatment plan up to the nurse and her resources.

[nursemcsleepy, BSN, RN]

I experienced this when I was in the hospital myself a few years ago. I had a bad sinus infection that led to orbital cellulitis - not the worst thing in the world, but it did earn me a week long stay in the hospital for IV antibiotics.

Anyway, when I came into the hospital my blood pressure and heart rate were very high for me due to pain and infection, but within the normal rage for most people. I've always been very athletic, and I have a very low resting heart rate. Well, after a few days of antibiotics, my heart rate came down to my normal 35-40 bpm. I was asleep and the nurse called a code when my heart rate dropped into the 30s, and the team of doctors and nurses racing into the room and checking my pulses woke me up in a panic. I was totally fine, and if the nurse just checked my pulse, or tried to wake me, she would have seen I was completely okay.

Monitors are amazing to alert you to POSSIBLE problems, but you should still look at the patient before jumping to drastic measures.