VERY POOR JUDGEMENT

[HIPPIECHIKRN]

We recently had a pt. that went out for a cystoscopy and needle bx. of his prostate. When he returned to our facility he had a foley cath in. (He's had it since March but the approval for procedures and f/u is really slow)The inmate was able to tell me he expected to have some bloody urine after the procedure and he was going to drink lots of water as the MD. had told him to. Foley draining fine when I left work at 5pm. When I arrived to work the next morning @ 8 AM, a roomate of the pt. came to tell me that he was sick. The post cysto pt. said he had not drained urine all night. Night nurse said the pt. didn't complain of discomfort until late in his shift. He said he'd called the MD on call and was told to let the dayshift MD/PA see the pt. Mind you, we have a fill-in MD who was not coming until afternoon and this RN knew it. He said he was trying to get some "action", but the on call MD would not give an order. He also stated that there was no order to "flush" the catheter. I went to the supply closet and got a new catheter. Sure enough, there was a big,fat clot on the end of the old foley. I wound up having to irrigate the new foley to get it to drain. The drainage was a dark burgundy bloody urine that had been sitting in his bladder all night. During my shift I had to irrigate it a few times to keep it draining. When the MD came in at 1PM, the foley was still draining bloody urine. I got a total of appx 3000 ml drainage on my shift. My question is: Would anyone out there just wait for an MD to show up whenever or would you have taken action yourself? If I could not have corrected the problem, I would send the pt. back to the ER. Is it because he's an inmate he doesn't deserve care? The night nurse even wrote a verbal order in the chart to have the pt. seen by dayshift MD/PA.

[tbrd450]

These people are patients in need of care. They can not admit themselves into an emergency room, they are trapped and totally dependent on others (you). You are absolutely right in recognizing the inherent wrongness of this situation -- this man deserves proper medical care when it was warranted.

I would imagine that if you followed your instincts and treated the patient, you would be able to justifiy it later.

You are a nurse caring for a population of people most vulnerable to neglect and calous disregard. You, as their nurse, should advocate for them, as they can not do so for themselves.

In this situation, did anybody ever say "oops... we made a mistake," later?

[HIPPIECHIKRN]

Nope. The nurse stuck to his guns that he did not/could not get an "order":uhoh3:

[Nurse_Tricia, LPN]

Ok, being that I am a new nurse, this is where I am unsure of what I can do using "nursing judgement".. I am assuming since you did it and got the order later it would fall into the nursing judgement catagory. --- Then now I am thinking why wouldn't the MD's who did the procedure send him back with orders to irrigate prn? Ughh.. HippychikRN, you seem wise and I would love your feedback.

[nursel56]

Not a corrections nurse, hippiechikRN, but no. I would not have let the patient suffer for an easily remedied problem like a blocked catheter. Poor guy.

[Orca, ADN, ASN, RN]

You don't need a physician order to irrigate or change a catheter, unless there are specific orders not to do so. I would have irrigated it first, and if that yielded no results I would have changed it. If there was still no output I would have called the doctor for orders, and I would have insisted on an order to transport to the hospital.

You have to use good nursing judgment. I once received an order to give Lasix to an inmate with a severely swelled member. I decided to wait until I inserted a foley before I gave it. Good thing: His urethra was blocked by the swelling. I had to send him to the hospital to have one inserted with a guide wire. Had I given him the Lasix his bladder might have ruptured before he got to the hospital (the facility was 50 miles away).

[Nurse_Tricia, LPN]

Since I have been in "real world" nursing, I have often come across using nursing judgement which is so contrary to what we learned in school being 1st thing you do is check for the order. Thanks Orca for your guidance. :)

[tranquilgrl]

Are there no standing protocol orders related to foley cathedar's? I can sympathize with your frustration. We are all human beings no matter what the cirrcumstances. The night nurse should have made a repeat phone call to the on-call MD until she received an order.

[katkonk, BSN, RN]

You don't need a physician order to irrigate or change a catheter, unless there are specific orders not to do so. I would have irrigated it first, and if that yielded no results I would have changed it. If there was still no output I would have called the doctor for orders, and I would have insisted on an order to transport to the hospital.

Ditto to this info. Irrigating a foley should be covered under protocol, assuming you have policy and procedure manuals. It should be listed in there. NOT doing anything could make you liable in case of adverse outcome (not to mention a lousy human being for just letting that happen). You were right. I usually try 3 flushes before d/c. If post procedure, you could have great difficulty inserting a new one because of swelling of prostate or urethra, or both.

[shell911rn]

Nurses often forget or feel uncomfortable "telling" on physicians to their supervisor or chain of command when the physician doesn't give an order for something, but we have to remember we are patient advocates. This is a very important part of our job, especially in corrections. If you remind the physician that you will document and/or notify the supervisor and/or make suggestions about what you think should be done, the physicians will change their tune and give you orders. Unfortunately, there are still health care professionals out there in corrections who believe all inmates are faking it and thus, they withhold treatment, sometimes to the detriment of the patient/inmate.

[diane227, LPN, RN]

I would have irrigated his foley right from the start when his urine output dropped and kept irrigating it PRN. These patients actually need to have a three way foley and be on CBI.

[Wanna_BA_Nurse]

While I do think that many of the people in jail are in jail for their respective reasons, I don't agree with the mistreatment he was met with. He is an inmate, but he is also a patient. As his nurse, all he should have been was his/her patient. He has already been judged and is already paying for his crimes. Good for you for noticing him and taking care of that for him. That is what a good nurse does!