Treat the patient, not the monitor

emtb2rn, BSN, RN, EMT-B · Apr 20, 2016

Not sure I get your point. Ignore the patient & how they present clinically, just treat based on what the machines tell you? How do you handle pea?

offlabel · Apr 20, 2016

Not sure I get your point. Ignore the patient & how they present clinically, just treat based on what the machines tell you? How do you handle pea?

Sigh....

akulahawkRN, ADN, RN, EMT-P · Apr 20, 2016

I use the phrase "Treat the patient, not just the monitor." The monitors, lab tests, and the like all tell you about one part of the patient's clinical picture. Just looking at the patient can sometimes tell you the monitor is lying and doesn't know it.

The other night I had a patient that supposedly had a pulse rate of 33 and a HR around 78 and the person monitoring the tele screens told me about this. Oh, and supposedly there was a good pleth on the SpO2 side of the monitor. One look at the patient told me all that I needed to know. The patient was OK. Then I looked at the monitor and saw that the patient was in an NSR with occasional sinus pause that correlated with breathing. The EKG rate and SpO2 rates were obviously calculating rates based on different intervals. So, about 2 seconds into a pause, the SpO2 indeed showed a pulse rate in the 30's and the HR was still showing a rate near 80. After the pause was done, the patient's HR and pulse rate would "recover" to something more "normal" and the displayed rates would match.

I can't even begin to count how many times the monitor alarmed for an SpO2 of 85% with a barely acceptable pleth only for me to find out that the sensor wasn't properly positioned and was apparently getting its readings from the overhead lighting...

The point is, when the monitor alarms, look first at the patient to see if there's some correlation there. Asystole and a conscious & happy patient don't usually match. When they do, you already know the patient isn't your garden variety case.

heinz57 · Apr 20, 2016

I use the phrase "Treat the patient, not just the monitor." The monitors, lab tests, and the like all tell you about one part of the patient's clinical picture. Just looking at the patient can sometimes tell you the monitor is lying and doesn't know it.
The other night I had a patient that supposedly had a pulse rate of 33 and a HR around 78 and the person monitoring the tele screens told me about this. Oh, and supposedly there was a good pleth on the SpO2 side of the monitor. One look at the patient told me all that I needed to know. The patient was OK. Then I looked at the monitor and saw that the patient was in an NSR with occasional sinus pause that correlated with breathing. The EKG rate and SpO2 rates were obviously calculating rates based on different intervals. So, about 2 seconds into a pause, the SpO2 indeed showed a pulse rate in the 30's and the HR was still showing a rate near 80. After the pause was done, the patient's HR and pulse rate would "recover" to something more "normal" and the displayed rates would match.
I can't even begin to count how many times the monitor alarmed for an SpO2 of 85% with a barely acceptable pleth only for me to find out that the sensor wasn't properly positioned and was apparently getting its readings from the overhead lighting...
The point is, when the monitor alarms, look first at the patient to see if there's some correlation there. Asystole and a conscious & happy patient don't usually match. When they do, you already know the patient isn't your garden variety case.

What you described was more operator errors.

I would rather respond AND CORRECT an alarm then do the charting on a dead patient. Surely you can troubleshoot a pleth or an ECG well enough to know how to correct it.

Are we wasting our time by doing vitals and having monitoring? That seems to be the message here. Just because you can point out one or two incidences where the monitor was "wrong" doesn't mean it is not a valuable tool. Do doctors just look at a patient and send them home or do they collect all the data from the monitors, vitals and labs?

If you want to discard the value of the pulse ox because you don't know how to place it correctly or know that trouble shooting equipment is part of the job then maybe it is time to retrain and gain more knowledge about that equipment. Radiology, US and many other professions know how to get the best picture or data and know when something is not quite right or poor data.

With experience you will also learn to verify blood pressures. The patient might look great but if the BP is taken manually or on another arm, you get a different value which can as to a more definitive diagnosis.

A patient can appear to be great but if you disregard the equipment's data you have and don't at least try to get a correct number, you aren't doing a good service to your patient.

Don't just take a patient's appearance as an end all to any exam.

Helori · Apr 20, 2016

I like the phrase, I've used the phrase and will probably continue to. To me it doesn't mean you ignore either the pt or the monitor simply that all the monitors and technology in the world is not a substitute for a good and thorough assessment. That being said I've worked CCU long enough that if I was on a regular floor I could have the most stable looking pt in bed in front of me and I'd still feel twitchy not being able to see their telemetry rhythm on the bedside monitor or an arterial pressure even a cvp. Just the thought makes me nervous lol.

An example is a pt I had with a horribly low hgb. Her sat was 100%. Despite the fact that she was practically gasping for breath and getting more lethargic and confused in front of me the resident thought she was fine cause her sats 100%. I finally had to explain to him that all that meant was that the 4 hgb molecules she had left in her body were 100% saturated! Not that she was getting enough oxygen! I went over his head to the fellow and surprise surprise the pt ended up tubed.

Trying to be a cowboy or not asking for backup when you need it has nothing to do with the phrase. It's just a good reminder that pts don't always follow the rules. They can look a lot sicker than the numbers indicate they can also be a lot more stable than the numbers show. Monitors and assessment go hand in had for good care.

akulahawkRN, ADN, RN, EMT-P · Apr 20, 2016

What you described was more operator errors.
I would rather respond AND CORRECT an alarm then do the charting on a dead patient. Surely you can troubleshoot a pleth or an ECG well enough to know how to correct it.
Are we wasting our time by doing vitals and having monitoring? That seems to be the message here. Just because you can point out one or two incidences where the monitor was "wrong" doesn't mean it is not a valuable tool. Do doctors just look at a patient and send them home or do they collect all the data from the monitors, vitals and labs?
If you want to discard the value of the pulse ox because you don't know how to place it correctly or know that trouble shooting equipment is part of the job then maybe it is time to retrain and gain more knowledge about that equipment. Radiology, US and many other professions know how to get the best picture or data and know when something is not quite right or poor data.
With experience you will also learn to verify blood pressures. The patient might look great but if the BP is taken manually or on another arm, you get a different value which can as to a more definitive diagnosis.
A patient can appear to be great but if you disregard the equipment's data you have and don't at least try to get a correct number, you aren't doing a good service to your patient.
Don't just take a patient's appearance as an end all to any exam.

I did not say to ignore the monitor. I did not say "Treat the patient, not the monitor." I did say that the monitor, labs, etc are all part of the clinical picture. The above story by Helori is also an excellent reason you take into account the monitor when treating the patient. You always do an assessment and correlate it to the rest of the clinical picture. In Helori's case, she had a patient whose Hgb level was 4, SpO2 100%. Yes, the monitor thinks everything's fine but the patient in this situation is short of breath/gasping, likely very hypoxic at the tissue level, and I would imagine has a generally high serum lactate because the body is probably largely doing anaerobic metabolism to stay alive.

There's a reason why the phrase "Treat the monitor, not the patient" isn't in circulation... and the phrase that I use is a quick reminder why. In the case I used as an example, it wasn't operator error or anything else, but a nurse that was looking ONLY at the monitor and not at the patient and fell into the "Treat the monitor" trap.

Pheebz777, BSN, RN · May 3, 2016

What about "Treat the patient, THEN the monitor?" (if this catches on, then you know where it started!) LOL!

I don't know how many times I've seen a patient with O2 sats in the 90's while the pulse Ox was on the floor. Or a monitor saying the patient's HR is 180's but the actual HR was in the 80's with a tall T wave that the monitor was reading as a QRS complex.

RescueNinjaKy · May 3, 2016

How about just "Look at the whole clinical picture and do some critical thinking". Patient assessment is important and so are the data we get from machines but what we do with it is the most important.

You're busy so an aide grabs vitals for you. They're wdl but the patient looks like crap. The aide only reports the vitals or hands you the piece of paper. You glance at it, it all looks good and the last time you rounded the patient was fine so you go see your other patients. This is an example of looking at monitor only being bad.

Now different patient. Looks perfect, assessment is good, walkie talkie, watching tv and smiles at you when you enter the room. Looks great right, on to the next patient. But you didn't review their labs, their potassium was low and you didn't check it. Even though they look fine we should still replace potassium levels so that they don't go into some dangerous arrhythmia. This is where just your physical assessment of the patient is not enough. Got to have that data.

Basically look at the patient as a whole. Do some critical thinking. What do these labs vitals assessment all say about the patient. Do they look stable? How likely are they to become unstable? Critical thinking and seeing the patient as a whole is the key emphasis.

heinz57 · May 3, 2016

How about just "Look at the whole clinical picture and do some critical thinking". Patient assessment is important and so are the data we get from machines but what we do with it is the most important.

This ^^^

When examples like akulahawk's which seem to dismiss a sinus pause to make a point that the "monitor is wrong" when the monitor has alerted you to a situation to which you should be able to use some critical thinking skills. Sinus pauses are not always benign. Even an SpO2 monitor can pick up missed beats and will alert you to a different number. Dismissing this as just another "Treat the patient and not the monitor" issue may cause you to miss a valuable piece of information.

The other part is to learn to use the equipment correctly. Don't put finger probes on earlobes and cover the pulse ox probes when an infant is under lights. Properly prepare electrode sites and use a configuration which is most ideal for the patient's situation such as pacemakers or ectopy. Like any piece of technology, the data given is often a direct reflection of the knowledge of the operator.

I too can give examples but where people ignored the monitor and failed the patient.

Pheebz777, BSN, RN · May 5, 2016

How about just "Look at the whole clinical picture and do some critical thinking". Patient assessment is important and so are the data we get from machines but what we do with it is the most important.
You're busy so an aide grabs vitals for you. They're wdl but the patient looks like crap. The aide only reports the vitals or hands you the piece of paper. You glance at it, it all looks good and the last time you rounded the patient was fine so you go see your other patients. This is an example of looking at monitor only being bad.
Now different patient. Looks perfect, assessment is good, walkie talkie, watching tv and smiles at you when you enter the room. Looks great right, on to the next patient. But you didn't review their labs, their potassium was low and you didn't check it. Even though they look fine we should still replace potassium levels so that they don't go into some dangerous arrhythmia. This is where just your physical assessment of the patient is not enough. Got to have that data.
Basically look at the patient as a whole. Do some critical thinking. What do these labs vitals assessment all say about the patient. Do they look stable? How likely are they to become unstable? Critical thinking and seeing the patient as a whole is the key emphasis.

I agree with this to some degree, but I believe the OP was referring to nurses reaction to false and true alarms when they are warranted. Besides if a patient suddenly goes asystole for no reason that you know of, I don't think digging up a patients labs, looking at his meds, reading about his history is the first thing that will come to mind.

Especially if the patient IS NOT under your care and you know nothing of the patient.

The first thing any prudent nurse would do would be to "Treat the patient" first. When you find out the patient is alive, talking, repositioning herself after sipping a cup of coffee and doing just fine, THEN you "treat the monitor" and find out why it is giving you an asystole reading. Leads off?? Was there a long sinus pause?

Thus:

Treat the Patient... then the monitor! lol

We have to keep in mind that we're not only taking care of the patients assigned to us, but we also have a responsibility to all patients on the unit.

RescueNinjaKy · May 5, 2016

I agree with this to some degree, but I believe the OP was referring to nurses reaction to false and true alarms when they are warranted. Besides if a patient suddenly goes asystole for no reason that you know of, I don't think digging up a patients labs, looking at his meds, reading about his history is the first thing that will come to mind.
Especially if the patient IS NOT under your care and you know nothing of the patient.
The first thing any prudent nurse would do would be to "Treat the patient" first. When you find out the patient is alive, talking, repositioning herself after sipping a cup of coffee and doing just fine, THEN you "treat the monitor" and find out why it is giving you an asystole reading. Leads off?? Was there a long sinus pause?
Thus:
Treat the Patient... then the monitor! lol
We have to keep in mind that we're not only taking care of the patients assigned to us, but we also have a responsibility to all patients on the unit.

That's why I said critical thinking and looking at the whole picture. If it says asystole assess your patient. Does the patient have a pulse? Breathing? Yes? Then looking at the whole picture where the monitor says asystole and the patient clearly isn't you can fix the leads. As nurses we gotta multitask, don't just treat the patient because some things aren't readily apparent, don't just treat the monitor cuz it could be a false positive, you take in all that data while simultaneously assessing your patient. That is why the whole clinical picture is important and using your critical thinking skills to find out what to do with that data.

when a patient actually goes asystole i start cpr and initiate a code and look at the h and t's which include labs and history. These can be going on all at the same time.

I think nursing school needs to emphasize on critical thinking. There's too much focus on data. Assessment data, symptoms, medications, vital parameters, but what the heck are we doing with those. Where is the why? What should we anticipate? What should we look out for?