I have two pet peeves about nursing reports. Not peeves, really, that’s too strong, but things I can’t understand.
Number one, respiratory rate. When you ask for the vital signs, the nurses and aides always tell you respiratory rate. Which is good, because that’s what they were told to do. But it doesn’t really matter. First, in the hospital, respiratory rate is always reported as either 18 or 20, depending on what the nurse’s aide’s favorite number was for that shift. No one stands for one minutes and counts the patient’s respirations, and if they did it would be a tremendous waste of time. Secondly, the normal respiratory rate ought to be more like 12 or 14, or maybe 16 (and yes, it has to be an even number, otherwise there’s some serious pathology going on); so if someone actually had a rate of 20, you would want to think about it. Finally, it doesn’t really matter. If the patient is breathing comfortably, you could tell me they had a rate of 40 and I wouldn’t care (ok, maybe just a little); on the other hand, if they seem to be in distress, struggling for air, unable to catch a breath, I’m not going to wait till we count the number of breaths before trying to do something about it. We try to explain this to the medical students; it’s difficult for them to break past the litany of vital signs they were taught only a year or two ago.
(Caveat: respiratory rate can be of value when you’re considering weaning someone off the ventilator. Intensivists vary on this subject. My favorite ICU attending extubates purely on gestalt. He certainly gets it done faster than the guys who calculate NIF (no relation to the Knights) and check multiple abgs on different settings.)
Number two, bowel sounds. After [relatively] minor procedures, we often write orders for “clear diet, advance as tolerated.” To the surgical mind, this implies that if the patient can drink a glass of water, they should try apple juice. If they can drink that, they should have crackers and/or jello. And if that’s ok, for goodness’ sake please give them a regular meal tray at the next mealtime, so we can discharge them to home. This could all happen within the space of a few hours.
To the nurses, however, “diet as tolerated” seems to mean something else entirely. If you’re too busy to pay attention, it could just mean “clear diet for the next several meals until the doctor notices and specifically changes the order.” Or, and this is what really gets me, it could mean “patient is tolerating diet if they’re not throwing up, and if you hear appropriate bowel sounds.” (No one has ever explained to me what counts as appropriate; maybe in all four quadrants.) So the patient could be feeling just fine, ready to eat whatever you’d let them, but if the nurse doesn’t like the bowel sounds, they won’t feed the patient. Sometimes, way over the line, I could specifically order a regular diet, and the nurse could still decide to hold it, because of these nebulous “bowel sounds.”
For the nonmedical reader, bowel sounds are just the noise of fluid moving inside you; sometimes, you can hear it with the unaided ear. This is frowned upon in polite society. Medical people listen with a stethoscope. Now I admit that in some cases bowel sounds are significant: if there are none whatsoever, and the patient has a fever and is complaining of excruciating abdominal pain, that is consistent with peritonitis. But you don’t really need the absence of bowel sounds to make the diagnosis. There is also, according to legend, a particular “high pitched tinkling” that should be heard with bowel obstruction. I thought I heard it once, and said so, which the seniors seemed to regard as one of the most hilarious faux pas I’ve made all year. I still listen, for the same non-reason that I listen to people’s lungs before sewing up their hand injuries, but I don’t talk about what I hear anymore.
Note to nurses: I admire the thoroughness and regularity of your nursing assessment. You often catch important details and bring them to our attention. Bowel sounds, however, are not important. Please feed my patients.
March 19, 2008 at 11:41 pm
5 days I was npo after surgery once. OK, it was a sigmoid resection, but 5 days? All because nobody could hear bowel sounds.
OTOH, they did not listen for the recommended length of time, either. I’m not sure anyone EVER heard bowel sounds before the surgeon was told that the patient was behaving very badly and just ordered a regular diet. Yes, I can be a real PITA at times.
It didn’t kill me. Obviously.
March 20, 2008 at 5:35 am
Judy – If it was just because of bowel sounds, that is too bad. Good for your surgeon for stepping in eventually.
On the other hand, I have seen patients have a true ileus up to four or five days after colorectal surgery. At first I felt really bad about not feeding such patients, but after a few episodes of having to put in NG tubes and having a couple miserable days all around, I feel much more authoritative in telling patients that they’ll be happier if they wait another day or two for, um, bowel function to resume.
March 26, 2008 at 12:47 am
They kept saying it was due to lack of bowel sounds. I woke up from surgery with an NG in place which drained copious amounts of green nasty stuff the first couple of days, but which had been removed at least 2 days, possibly 3 (been a while) before they finally fed me. OTOH, I was exceptionally compliant, for me, and hadn’t been sneaking sips of anything until it was actually ordered by the doc, either.
July 25, 2008 at 10:03 pm
The problem with “diet as tolerated” is that it is not a clear order. Diet as tolerated is the same as oxycodone dosage as tolerated. I know that may seem absurd, yet you have written a order that is in fact equally open to interpretation. Try ordering clear liquids for one day then regular diet as tolerated. This will allow nursing and FANS to present a regular tray and if they still need to be on giner ale, nursing will do so. This may appear to be semantics, howver after a converstation with surgeons vs, primary care folk, “diet as tolerated” has significantly varied approaches.