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.

[cayenne06, MSN, CNM]

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.

Absolutely. we are blessed to have access to diagnostic tools beyond just our hands-on assessment. And you are 100% correct that solid clinical assessment skills are the foundation of good practice, in part because of the fact you mentioned above- you might not always have access to modern diagnostic tools.

However, it does not then follow that clinical assessment alone is "just as good" as assessments that are coupled with appropriate diagnostics. There are many cases when clinical assessment alone is enough, but just as many cases where appropriate diagnostics can greatly influence your differential and/or plan of action for that patient. I don't imagine there is any disagreement on that.

[SmilingBluEyes]

Well hate to rain on your rant parade, but I LOVE that saying. Too often we rely on technology that trumps our common nurse sense. I DO treat the patient, not the monitor in my practice. And as human beings, I am sure our patients would appreciate our treating their symptoms and needs before some machinery.

[Garden,RN, ASN, RN]

None whatsoever, I just do not think we should ever forget that our skills are the most important because we may never know what situation may come our way, such as hurricane Katrina. The other thing is as patient, I hate the testing, when you don't feel well it is very traumatic and anytime a provider saves me from that, I prefer that route.

[ixchel]

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 love this post.

I had a Lung Ca admitted for pneumonia. Family stayed with him 24 hrs. They loved me because I listened. They felt blown off frequently, so we got along well. One night, he just wasn't right. No sure reason why. Hemodynamics were WNL, assessment WNL, lung sounds still dim, but improving. My gut said strongly - but there is SOMETHING.

I grabbed the NOC MD, who said she could see a change in him as well. (She admitted him and he'd been A&O, speaking appropriately.) He was just OFF. You know what I mean. Grabbed ABGs and labs. On the ABGs, O2 resulted higher than I've ever seen. I'd never had a patient run O2 like that before, so it went against everything in me to let his sats drop. It just didn't feel right! We explained to the family what was going on so they wouldn't worry a lot. I made sure he was married to the unit tele screen so we could keep a close eye with the alarm in the room off.

We got him better for a short while. The cancer did get him a short time later, though.

That's one story of trusting my gut. I was born into the world of beeps, though, so they are intertwined a bit into my practice. It would be strange (at times, unnerving, probably) to go without them. I'd love to learn to get my assessment skills strong enough to feel 100% without them. I may believe STRONGLY in the "treat the patient, not the monitor" saying, but there are many shifts when I rely on those monitors to tell me when I need to check on something. (Even if it is boob sweat. )

[ixchel]

I am having the hardest time tapping "quote" and getting a response to post. This is really glitchy today.

OP, I do not regret asking if you are a nurse. It is not childish, damaging, or whatever the other word is. Your OP and first comment read to me like an early-ish nursing student with enough med/surg experience/knowledge (or perhaps you are an inpatient CNA in school) to start gaining strong opinions on something you haven't put into practice.

I stand by my question and every part of my comment.

Katie, thank you for your comment on CI. The only CI coming to my brain was Clinical Instructor. Or Clinical Investigator.

[LadyFree28, BSN, LPN, RN]

Well hate to rain on your rant parade, but I LOVE that saying. Too often we rely on technology that trumps our common nurse sense. I DO treat the patient, not the monitor in my practice. And as human beings, I am sure our patients would appreciate our treating their symptoms and needs before some machinery.

I love the saying too-there are other variants, but the common theme I think we can all agree on patient physical assessment...we must home and be confident in those clinical skills that give us the tools to ensure we are not missing anything.

There are even settings that set many nurses up to not utilize their nursing skills because of their technological aspect; when one decides to change specialities, especially ones who don't emphasize technology; then that can be a clinical conundrum.

The physical assessment on the patient is what dictates and drives the plan of care; not the monitor; I think we all have stories on patients having great vitals but their physical assessment allowed us to intervene soon rather than later; a patient can compensate for hours and days until the monitor clues in (or never does).

[WKShadowNP, DNP, APRN]

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.

To your latter statement, yes. That irks me. I was hired as a charge nurse of a unit years ago and someone asked me a question regarding why a patient was receiving a certain medication or having it withheld (I can't remember which) in relation to the diagnosis. If I recall correctly, the patient was experiencing cholecystitis and the medication had nothing to do with that, per se. I knew the answer was "because of its anticholinergic properties." So thinking critically about it I suspect the patient was on a muscarinic for other reasons and it had to be held to avoid excitation of the irritable gall bladder and biliary tract.

Guh, I wish I could remember more because I think this tale is losing its punch. At any rate, they didn't believe me and they asked another nurse who happened to be young, new, but well known and very very smart. But she didn't know. After they all looked it up they were amazed that I was correct.