Nursing

Nine Things Nurses and Patients Should Question


Released January 9, 2017; Last updated January 9, 2017

1

Don’t insert an indwelling urinary catheter or leave it in place without daily assessment.

The use of indwelling urinary catheters among hospital patients is common. Yet it can also lead to preventable harms such as urinary tract infection, sepsis and delirium. Guidelines support routine assessment of appropriate urinary catheter indications—including acute urinary obstruction, critical illness and end-of-life care—and minimizing their duration of use. Strategies consistent with CAUTI (catheter-associated urinary tract infection) guidelines regarding inappropriate urinary catheter use have been shown to reduce health care-associated infections.

2

Don't advise routine self-monitoring of blood glucose between appointments for clients with diabetes who do not require insulin.

Certain groups recommend self-monitoring of blood glucose (SMBG) to help clients with diabetes monitor glycemic control. Yet many studies show that, over time, routine SMBG does little to control blood sugar for most non-insulin-using adults with type 2 diabetes. It should be noted that SMBG would be indicated during illness or medication change, and this should be part of client assessment and education.

3

Don’t add extra layers of bedding (sheets, pads) beneath patients on therapeutic surfaces.

Additional layers of bedding can limit the pressure-dispersing capacities of therapeutic surfaces (such as therapeutic mattresses or cushions). As a result, extra sheets and pads can contribute to skin breakdown and impede the healing of existing pressure wounds.

4

Don’t use oxygen therapy to treat non-hypoxic dyspnea.

Oxygen is frequently used to relieve shortness of breath. However, supplemental oxygen does not benefit patients who are short of breath but not hypoxic. Supplemental flow of air is as effective as oxygen for non-hypoxic dyspnea.

5

Don’t routinely use incontinence containment products (including briefs or pads) for older adults.

Adult incontinence containment products are frequently used for continent patients (especially women) with low mobility. Yet the literature associates their use with multiple adverse outcomes including diminished self-esteem and perceived quality of life, and higher incidence rates of dermatitis, pressure wounds and urinary tract infections. Among older adults, nurses should conduct a thorough assessment to determine the risk of such outcomes before initiating or continuing the use of incontinence containment products. The development of a continence care plan should be a shared decision-making process that includes the known wishes of clients regarding care needs and the perspectives of carers and the health care team.

6

Don’t recommend tube feeding for clients with advanced dementia without ensuring a shared decision-making process that includes the known wishes of clients regarding future care needs and the perspectives of carers and the health care team.

Tube feeding for older adults with advanced dementia offers no benefit over careful feeding assistance related to the outcomes of aspiration pneumonia and the extension of life. While food is the preferred form of obtaining nutrition, oral supplements may be beneficial if this intervention meets the person’s known goals of care. Tube feeding may contribute to client discomfort and result in agitation, the use of physical and/or chemical restraint and worsening pressure wounds.

7

Don't recommend antipsychotic medicines as the first choice to treat symptoms of dementia.

People with dementia frequently exhibit responsive behaviors, which are often misinterpreted as aggression, resistance to care and challenging or disruptive behaviours. In such instances antipsychotic medicines are regularly prescribed. The benefit of these drugs is limited, however, and they can also cause serious harm including premature death. Their use should be limited to cases where non-pharmacologic measures have failed and where patients pose an imminent threat to themselves or others. Identifying and addressing the causes of behaviour change can render drug treatment unnecessary. If a nurse caring for a patient feels that medication is not the appropriate intervention, the nurse has a responsibility to discuss these concerns with the prescriber.

8

Don’t recommend antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.

Signs and symptoms suggestive of urinary tract infection (UTI) are increased frequency, urgency, pain or burning on urination, supra-pubic pain, flank pain and fever. Dark, cloudy and/or foul-smelling urine may not be suggestive of UTI but rather of inadequate fluid intake. Cohort studies have found no adverse outcomes associated with asymptomatic bacteriuria for older adults. Not only does antimicrobial treatment for such bacteriuria in older adults show no benefits, it increases adverse antimicrobial effects. Consensus criteria have been developed for the specific clinical symptoms that (when associated with bacteriuria) define UTI. Exceptions to these criteria include recommended screening for and treatment of asymptomatic bacteriuria before urologic procedures where mucosal bleeding is anticipated. If a nurse caring for a patient feels that medication is not the appropriate intervention, the nurse has a responsibility to discuss these concerns with the prescribers.

9

Don’t routinely recommend antidepressants as a first-line treatment for mild depressive symptoms in adults.

Antidepressant response rates are higher for moderate or severe adult depression. For mild depressive symptoms a complete assessment, ongoing support and monitoring, psychosocial interventions and lifestyle modifications should be the first lines of treatment. This approach can avoid the side-effects of medication and establish etiological factors important to future assessment and management. Antidepressants are appropriate in cases of persistent mild depression where a past history of more severe depression exists or where other interventions have failed. If a nurse caring for a patient feels that medication is not the appropriate intervention, the nurse has a responsibility to discuss these concerns with the prescriber.


How the list was created

The Canadian Nurses Association (CNA) established its Choosing Wisely Canada nursing list by convening a 12-member nursing working group (NWG) of diverse nurse experts from across Canada representing a broad range of geographical regions, practice settings and experience. The NWG began considering its potential list by reviewing existing recommendations, including items from Choosing Wisely Canada’s specialty societies and the American Academy of Nursing (AAN) Choosing Wisely® list, which had already undergone rigorous evidence reviews. In addition, members brought forward recommendations on new evidence-based items. The NWG appraised 195 items for relevance to nursing using a structured process developed for this work. Each of these (171 Choosing Wisely Canada physician-related items, 15 AAN Choosing Wisely items and nine independently submitted items) was appraised by two independent reviewers. Using a modified Delphi process for the next two rounds of revision, the group then refined and adapted 36 items until reaching consensus on a final nine-item list. A literature review was conducted to confirm the evidence for these items, and supporting nursing research was added where appropriate. Subsequently, the final list underwent extensive consultation, in which further input was obtained from nursing experts in patient safety, various members of the Canadian Network of Nursing Specialties, CNA, its jurisdictional members and patient advocates. In November 2016, the Choosing Wisely Canada nursing list was presented to CNA’s board of directors, who gave it their full endorsement and support.


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1

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2

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3

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4

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5

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6

Allen VJ, Methven L, Gosney MA. Use of nutritional complete supplements in older adults with dementia: systematic review and meta-analysis of clinical outcomes. Clin Nutr. 2013 Dec;32(6):950-7. PMID: 23591150.

American Geriatrics Society Ethics Committee and Clinical Practice and Models of Care Committee. American Geriatrics Society feeding tubes in advanced dementia position statement. J Am Geriatr Soc. 2014 Aug;62(8):1590-3. PMID: 25039796.

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7

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8

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9

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