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.
One reason I quit ICU work and went to floor nursing with a passion is I got sick of watching machines. For me they seemed to interfere with my communication with the patient. That was MY own feeling. Of course then the floors got all the things that bing and bong and we wound up running after the alarms. You really get alarm fatigue quicker than you realize. I took care of full code vent patients on the floor, those who were medically stable enough to come out of the ICU. Take a vent, a few IV lines, etc and there you are right back taking care of alarms. The alarms are also distressing to the patients and families. May be there is a way to have the alarms go to a pager that the RN carries? I don't know the answer but I know what drove me crazy. Alarms on new machines that continued to beep regardless of what you did, so we went back to what we knew, manually timing drips until we could get a different machine. Sometimes we went through 3-4 machines until we got one that worked. They were so over used that pieces of them broke off after a few months. Who knows, maybe in a fit of pique some nurse tore the machine up so they would not have to listen to it. Fluid and electrolytes, drips, antibiotics, all need close monitoring but if you can't rely on the machine they give you then what do you do? I learned timing drug and drips by drops/min. I calculated the H---l out of those things and watched the patient like a hawk. Anyone remember the chambered IV lines used in pediatrics?
You had a measuring chamber that you put fluid in, then added your meds and stood there and watched it while it dripped. Not a perfect system but so many times I hung out in the baby's room and played, changed, bathed while the meds went in so I knew the rate and was sure that they got the right dose at the right rate, over the right amount of time and made sure there was not infiltration. Seeing as how we gave stuff like micro doses of Gentamycin which is oto-toxic it was important. Plus we were giving minute doses of the stuff. I much preferred staying with the patient over answering a machine. Maybe I am too old and need to shut up. I don't know. I just know alarm fatigue is a real problem and it does not help patients. Their anxiety goes through the roof and then you have more problems to deal with.
There is nothing so good as the "gut" feeling of an RN. Regardless of what a monitor says, trust your gut. If you know the patient then your gut tells you how to go. I know that many docs do not understand that "nurse gut " thing but some do and if you can back up that feeling with any clinical sign at all you can usually get an order for labs, x-rays or something to help diagnose. I have had many "gut" discussions with residents and after you are correct once and they don't see you as a threat(presentation is everything) well, BAM, you have a believer. I have had more than one resident thank me for the heads up. Let the resident know you are on their side and just advocating for your patient and I have found it usually wins them over. It has certainly improved my subsequent conversations with them. After all we are a team. OK now I shut up.
I understand what you mean...but I also understand the phrase as well. I work ED so many of my pts are on continuous monitoring. A few weeks ago I was in a patient's room when one of the techs came in and told me there was an emergency next door and the physician wanted me in there right away. The patient was a middle aged person with abdominal pain who had spent 4 hours in the ED with stable vitals. I walk in to see the monitor showing a BP of 72/49. HR is normal, and the patient is pink, sitting up in bed, asymptomatic. One of the techs is putting in a second iv and they've started a fluid bolus on the other. The doctor starts barking at me about why he wasn't informed that the patient was unstable. He continued to bark regarding fluid orders and pressors if she wasn't fluid responsive. The patient told me she felt fine. I walked up to her and noted her BP cuff was extremely loose, and had fallen down below her elbow. I responsitioned the cuff and the resulting pressure was completely normal, in the range she had been in since arrival. I asked if anyone had checked the cuff before we just started blasting this asymptomatic patient with fluids an an unecessary second iv. Everyone just stared and the doctor huffed out.
another time a nurse came out screaming her pt was in vtach, put the pads on and everyone rushed in to help. We walked in to see a rhythm that looked nothing like vtach.It was artifact and incorrect lead placement which caused the monitor to alarm vtach...and the nurse decided to completely abandon her own common sense I suppose.
Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
I agree with the need to treat the patient and think she needs to learn much, but I disagree that she should not ask question because it is too soon. She has every right to question everything, after she does her research, hopefully. That mentality is what keeps nursing from making leaps and bounds into the future as opposed to little steps. That was an awful thing to say.
Please use the "Quote" function so we know to whom you are replying.
I wish people on this site wouldn't ask damaging things such as,"are you a nurse?" or "how many years have you been a nurse?" just bc you disagree. I find this very childish and cutthroat. I wish we were all more supportive of each other. This is supposed to be a forum for discussion and learning, not bullying and chastising.
As for the BLS survey. You most definitely perform the BLS survey first during a code, albeit you may do it in 3 seconds, you still do it. Even on the vented patient. Not all vented patients are sedated either...we may be trying to extubate or performing a sedation holiday. Also, not every patient in the ICU is vented; in my experience half are and half are not. ACLS is the heaviest protocol used in a code, but step one is always BLS.
Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
I wish people on this site wouldn't ask damaging things such as,"are you a nurse?" or "how many years have you been a nurse?" just bc you disagree. I find this very childish and cutthroat. I wish we were all more supportive of each other. This is supposed to be a forum for discussion and learning, not bullying and chastising.
As for the BLS survey. You most definitely perform the BLS survey first during a code, albeit you may do it in 3 seconds, you still do it. Even on the vented patient. Not all vented patients are sedated either...we may be trying to extubate or performing a sedation holiday. Also, not every patient in the ICU is vented; in my experience half are and half are not. ACLS is the heaviest protocol used in a code, but step one is always BLS.
Pardon my ignorance, but I fail to see how asking "are you a nurse?" Or "How long have you been a nurse?" Is damaging, childish or cutthroat. So far, the least colleaguial and most chastising posts on this thread have been your own. Or is disagreeing with you childish and cutthroat?
If you've been paying attention, you will have learned from this thread and this discussion. Perhaps that isn't what you wanted; perhaps you just wanted to see posts agreeing with you. Fortunately, unthinking agreement won't be found much on this forum.
One of the problems with this whole discussion is that the saying isn't "Look at the patient, not the monitor." It's "TREAT the patient, not the monitor."
This distinction is important, because the first version implies that it's an either/or situation----that you must disregard one of the two, and therefore you should disregard the monitor. Obviously, that's not true. You should take both monitor and patient assessment into consideration, but, if the patient's appearance and behavior are widely at variance with what you see on the monitor, believe the patient, not the monitor.
A good clinician uses every assessment tool available to get the best total picture possible. But in the end there's no piece of equipment, however elaborate, that can reliably replace good assessment skills.
I wish people on this site wouldn't ask damaging things such as,"are you a nurse?" or "how many years have you been a nurse?" just bc you disagree. I find this very childish and cutthroat. I wish we were all more supportive of each other. This is supposed to be a forum for discussion and learning, not bullying and chastising.
As for the BLS survey. You most definitely perform the BLS survey first during a code, albeit you may do it in 3 seconds, you still do it. Even on the vented patient. Not all vented patients are sedated either...we may be trying to extubate or performing a sedation holiday. Also, not every patient in the ICU is vented; in my experience half are and half are not. ACLS is the heaviest protocol used in a code, but step one is always BLS.
You might consider that the reason for the question is that the answer given will be different, or at least explained differently if the OP is a layman, a student or a new grad as opposed to an experienced nurse.
The one time I would trust my monitor implicitly is in ct cause if they're going to arrest they'll probably do it just after they've gone into the scanner......
Obviously this is a false dichotomy. No one is treating the patient without looking at the monitors, and no one is making assessments based on the monitors without evaluating the patient directly. I don't even understand the controversy.
In most cases, I cannot diagnose a UTI based on a urine dip alone; I interpret it within the context of my patient's symptoms. And conversely, I am not going to diagnose a case of hypothyroid based on clinical presentation, no matter how convinced I may be.
I agree with everything except in the last line. I just want you to consider that there are clinicians in parts of the world that have nothing but their clinical assessments. As a patient, I like my providers to be that skilled and save me all the distress of testing and traveling from place to place. I was raised by one of those clinicians.
I like the expression "Treat the patient, not the machine" and use it all the time when I teach Basic Arrhythmia, along with the story of a patient whose night nursing assistant documented a HR of 72 at 0600 by standing at the monitor banks and reading the screen.
Day shift arrived, the new day nursing assistant went in the room to take vitals, and found the clearly dead patient in rigor mortis. Meanwhile, the pacemaker kept firing beautifully.
Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
I like the expression "Treat the patient, not the machine" and use it all the time when I teach Basic Arrhythmia, along with the story of a patient whose night nursing assistant documented a HR of 72 at 0600 by standing at the monitor banks and reading the screen.
Day shift arrived, the new day nursing assistant went in the room to take vitals, and found the clearly dead patient in rigor mortis. Meanwhile, the pacemaker kept firing beautifully.
Yes, I've seen that, too. Or the patient with normal vital signs charted at 0200 and 0600 whose Holter monitor showed ventricular tachycardia advancing to asystole at midnight.
I've spent most of my career in ICUs of various teaching hospitals. Every year there's that one new intern (or R1, as they're called now) who cannot see past the colored lines and little bleeps to the patient in the bed. Every time I teach my intra-aortic balloon pump class, I caution the nursing staff to be certain that the R1 LOOKS at the patient. More than once, I've seen a resident refuse to pronounce someone who has an arterial blood pressure of 42/24 -- a BP that can be generated by the balloon pump alone -- because the art line has a pulsitile pressure created by the inflation and deflation of the intra-aortic balloon triggering off the pacemaker. Usually, they're even "breathing" with that ventilator. Sometimes brand new residents have to be convinced that the patient is dead. Once I even had a resident "code" a dead patient for three hours until his fellow came in, even though the patient had nothing going on except pacer spikes, balloon artifact and a ventilator that was requiring increasing pressures . . . . I was new at that job, the charge nurse had less than two years of experience and absolutely did not understand what was going on and since I was new, didn't trust my explanations.
On another note, it sucks to change jobs as an old bedside nurse . . . you see all these teaching opportunities, but have to swallow it until your new colleagues have accepted and trust you.
moldyoldyrn
98 Posts
One reason I quit ICU work and went to floor nursing with a passion is I got sick of watching machines. For me they seemed to interfere with my communication with the patient. That was MY own feeling. Of course then the floors got all the things that bing and bong and we wound up running after the alarms. You really get alarm fatigue quicker than you realize. I took care of full code vent patients on the floor, those who were medically stable enough to come out of the ICU. Take a vent, a few IV lines, etc and there you are right back taking care of alarms. The alarms are also distressing to the patients and families. May be there is a way to have the alarms go to a pager that the RN carries? I don't know the answer but I know what drove me crazy. Alarms on new machines that continued to beep regardless of what you did, so we went back to what we knew, manually timing drips until we could get a different machine. Sometimes we went through 3-4 machines until we got one that worked. They were so over used that pieces of them broke off after a few months. Who knows, maybe in a fit of pique some nurse tore the machine up so they would not have to listen to it. Fluid and electrolytes, drips, antibiotics, all need close monitoring but if you can't rely on the machine they give you then what do you do? I learned timing drug and drips by drops/min. I calculated the H---l out of those things and watched the patient like a hawk. Anyone remember the chambered IV lines used in pediatrics?
You had a measuring chamber that you put fluid in, then added your meds and stood there and watched it while it dripped. Not a perfect system but so many times I hung out in the baby's room and played, changed, bathed while the meds went in so I knew the rate and was sure that they got the right dose at the right rate, over the right amount of time and made sure there was not infiltration. Seeing as how we gave stuff like micro doses of Gentamycin which is oto-toxic it was important. Plus we were giving minute doses of the stuff. I much preferred staying with the patient over answering a machine. Maybe I am too old and need to shut up. I don't know. I just know alarm fatigue is a real problem and it does not help patients. Their anxiety goes through the roof and then you have more problems to deal with.
There is nothing so good as the "gut" feeling of an RN. Regardless of what a monitor says, trust your gut. If you know the patient then your gut tells you how to go. I know that many docs do not understand that "nurse gut " thing but some do and if you can back up that feeling with any clinical sign at all you can usually get an order for labs, x-rays or something to help diagnose. I have had many "gut" discussions with residents and after you are correct once and they don't see you as a threat(presentation is everything) well, BAM, you have a believer. I have had more than one resident thank me for the heads up. Let the resident know you are on their side and just advocating for your patient and I have found it usually wins them over. It has certainly improved my subsequent conversations with them. After all we are a team. OK now I shut up.