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  1. ok... heres the situation.... Lets all pretend that its a busy night on a rehab floor, and we're hideously understaffed (4 nurses with groups of 12 patients on a 3-11 e shift, 1 nurse doing admissions from 3p-7p, and an LPN on light duty. Her(the LPN) duties include fingersticks for glucose, and assisting with admissions, some meds, vitals et al... no lifting/pulling... anyway.... there are 4 UAP's and an assistant manager from 3p-8pm, followed by one of the staff RN's being charge.)

    now, the situation is this... its 5:30PM, although you have 12 patients, its not that crazy yet... you have one one with a 1:1 sitter that the asst manager just dug up, and another who tends to climb out of bed, but has a bed alarm that will go off when he gets too close to the sides, and all 4 rails up. So Far, the alarm hasnt gone off. The LPN Does your fingersticks, and all are relatively within normal limits. Your Admission shows up at about 6ish, dayshift recieved report, and, the patient arrives.
    68 WM, Dx of Rehab of S/P Right BKA r/t PVD. HX of TB, has been on the coctail for a few months, Smoker(last cig, 10 days ago).
    The LPN goes into the room, notes that the patient looks blue, no difficulty breathing, and rhonchi over all the lung fields. She orders a stat pulse ox, and tells the admission nurse that the patient is blue. VSS, NAD. 2 minutes later, we get the PO2, and it is 68. Subintern is on the floor, respiratory tech is on the floor. O2 3l by nasal cannula started, Since the pt is in no distress, still A&Ox3 no difficulty breathing, we do not want to do an abg yet. The nurse who has this patient in her group is notified that her patient has a pulse ox of 68. D/T the Staff RN being notified, the Admissions nurse figures tha the Staff RN will address the situation. The LPN writes the first note on this patient addressing the situation. 20 mins later, po2 goes up to 82. The Respiratory tech changes the O2 to 40% via venti mask, and does the ABG stat, a CXR, EKG were also ordered stat and done within 10 minutes of ordering. ABG resulted with co2 moderately high, o2 moderately low ( I dont remember the numbers, but they were bad, but not horrible) and the O2 sat was 87. The lpn writes another note as to whats going on, as the staff RN has been nowhere to be found for about the last hour or so...
    The LPN consults the Charge RN with the Question "Should'nt the RN have written a note somewhere between the resident on call's note, and the second note?"
    The charge RN affirms the Staff RN should have written a note, as it was her patient, and not the LPN's patient. The Charge RN (CRN) directs the Staff RN (SRN)to assess the patient.
    SRN: I did that, the patient looked ok
    CRN: How were his lungs
    SRN: I dont know, the LPN checked that when the patient came in. (its now about 9 or so...)
    CRN: So you Didnt assess the patient, even though he has been there for 3 hours.
    SRN: I looked at him, he looked ok, and the LPN didnt tell me that anything was going on with him...

    Mind you all... this room is right ajacent from the nurses station... figure, you must look into the room if you pass the desk, which you must do if you want to get water for your pitcher and the medcart.
    A constant stream of people were in and out of that room for 3 hours in an attempt to bring up his sat without a vent, as he was still NAD... dont get me wrong, but a stream of 2nd Year Residents, and attendings up on the Rehabilitation floor after 4pm is a rarity, and saved for something big.
    The SRN never entered the room until the charge nurse directly told her to.
    Last edit by Yeti1313LPN on Nov 24, '01
    •  
  2. Poll: The Floor LPN tells you-"Your new admission has a po2 of 68." What do you do?

    • Walk with my flowsheets to the lounge, delay my med rounds and sit and do them, and if anyone asks me later, I'll swear that 'nobody told me nuttin', while I leave the Charge nurse and Light Duty LPN to deal with the problems at hand

      0% 0
    • Freak out completely, and race the patient to the ICU without clearance, and demand a bed.

      0% 0
    • Acknoulage the person telling me this, and go into the room and glance at the patient, as 'the LPN has already assessed the patient', then leave the Light Duty LPN to deal with the problem, but, I'll be around if she needs anything

      0% 0
    • Carefully listen to the report, then RE-assess the patient, starting the assessment on the LPN's concerns, then the whole patient, and then work with the LPN to stabalize the patient.

      100.00% 48
    48 Votes
  3. 13 Comments

  4. by   debbyed
    Immediate disciplinary action needs to be taken against that nurse for failure to follow standards (I'm assuming you have standards of care which cover this situation). Along with the disciplinary action this nurse needs to be put on a learning action plan and her perfromance needs to be routinely checked for the next several weeks. If no sustained improvement is obtained she needs to be terminated.

    Too strong? I think not. Suppose that patient was your mother or father, husband or wife?
  5. by   hoolahan
    Did they pt have congenital heart disease, or clubbed fingers, which may indicate that cyanosis is not an acute condition for him. If his pH on the ABG's were fine, and he was in NAD, then all the actions taken were appropriate....except by the nurses.

    It seems there is some confusion as to who has ultimate responsibility for the pt. The admit nurse? The staff nurse? or the charge nurse? Seems to me it should be the staff nurse, but there are just too many cooks in the pot here. The admit nurse is an RN, so why couldn't she have followed up for the busy staff nurse? Sounds like the LPN did everything right, but maybe she needed to follow thru with the staff nurse?? I am confused by your system! I can't believe the staff RN didn't listen to the lungs of a cyanotic pt when she said she "assessed" him! That is a little scary!

    Sounds like she needs to take a physical assessment course. The manager needs to sit down with this nurse and explain the chain of command, in fact, it sounds like everyone could use a review of this, maybe a new system is in order.

    Frankly, to me, it would be better to have less pt's per nurse, and do my own admissions. And yes, I am aware of all the paperwork involved in a new rehab admission, it is only slightly less than that for a home health admit. I mean if I am ultimately responsible for this pt anyway, I want to follow through on what I started. Just the way I like to work. I never did like team nursing, I prefer primary nursing much more.
  6. by   P_RN
    This whole scenario looks like the script for a nasty lawsuit. Did the other RN usually get away with not assessing her patients?

    In our state ONLY an RN may perform Assessment.
    The LPN may gather information such as allergies, living will etc., but the RN must do the assessment and do the documentation for that assessment.

    I was an Admissions Nurse for a year and a half and no one understands better than I do how much there is to do, and how little the other Nurses realize what we do.

    It being a rehab floor, I take it that this person came from an Acute Facility? Was he transported by EMS there? Was he a floor to floor transfer? Someone surely took report on him? What was his baseline? I'm not sure I'd even receive a patient with no explanation for the hypoxia. (As an aside, we had a night shift RN "receive" an EXPIRED patient from the ER once. An aide rolled the bed to the floor, the RN didn't receive or assess the patient until the aide left......get the picture?)

    You say each RN had 12 patients right? Why not make each team consist of the LPN RN......the RN (Chg) and the other nurse? Was all she was doing was admissions on your floor and not over the whole facility?....(when I did it there were 80 beds involved.)
  7. by   CashewLPN
    its gonna sound odd, but this story was the basis of my night last friday..
    I work in an inpatient rehabilitation floor in a rather busy hospital in an outer boro of NYC. It is the only inpatient rehab unit on this boro.

    In our rehabiliatation floor, we have 2 units, the A wing, and the C wing. The A wing holds 49 pts, the C wing holds 22 patients.
    Typically, we are staffed with either 5 or 6 nurses for the evening shift for the A wing. 2 RN's for the C wing. Admits usually begin arriving at 2PM, from other medical units in the hospital, outside hospitals in all 5 boros and Northern NJ, we do not typically admit from home, the ER, or SNF's.

    The rule is that LPN's assist the RN's with assessment. All LPN assessment is co-signed by the RN. It is the RN's responsibility to verify what is what with the patient.

    The admissions nurse was assisting with the admissions on the A wing. There were 6 that night, as it is usually a rush at the end of the week to fill the beds.

    The patient had no Prior medical history other than +TB w/ lung lesions(on the ABx Coctail for a month or so.), +Smoker. No COPD, Cardiac Hx. Social Hx- Pt has no family, no friends. Lives in a Group home off the beach.

    The staff nurse in question is not a new nurse. She worked in another facility out of the country, and often remarks about IV pumps, ventilators, PO2 machines and, well, any other equiptment discovered after 1960 that'Gee, they dont have that in my country'. This nurse has a poor understanding of english, and has been sent to classes in assessment, IV skills, time management, and English writing and reading for the medical professional.

    We do not use team nursing, as we are WAY too short nurse wise... our total E staff consists of 2 LPN's, one of which is on light duty, the other a new grad, and 9 RN's, most of which have P/T positions of 3-4 days every 2 weeks. 3 RN's have F/t Posts.... So, if I'm not mistaken, unless there are gonna be 2 teams of 23 patients... Well... if anyone has ideas on teams... lemmie know.

    When the patient arrived, he was pink. Turns out that the admitting attending 'forgot' to order the o2. Transporter did not transport this patient with o2(basically, a screwup... the patient removed his nasal canula, and tossed it to the floor just prior to transport.), from the 3rd floor A wing to the 4th floor A wing... we think that after the 2 minute trip up into the room, he desatted within a few minutes, which is when we checked him.
    The yellow 'write up' slips were flying today...
    I recieved one for 'not reporting patients status to staff RN'
    I fought it, and had it struck from my record with the assistance of the admitting nurse, and the PGY2 who was caring for the patient.
    The staff nurse got one for not properly assessing her patients, not doing dressings, or required notes for the evening.

    Sick thing is that we did the same amount of patients with 3RN's, 1LPN, full duty, 1LPN light duty, with 2 admits tonight, and tomorrow, although no admissions, there are only 3 nurses on the schedual for the floor, and 1 light duty.
    Again... Bedlam....
    sigh... I'm tired...
    --Barbara
  8. by   Jenny P
    Barbara, those nurse/patient ratios are ridiculous and appear to be setting your institution (and/or the nurses!) up for a lawsuit. Even if all of these patients are alert, oriented, and totally self care (which your first post proves is not the case!); how can you do all of your assessments, treatments, and teaching with those kind of ratios?
  9. by   Furball
    I agree, those ratios are insane. Were any slips written for management? How about the CEO? It sounds like you guys are set up for disaster on a daily basis geesh....
  10. by   hoolahan
    {{{{Barb}}}} that is nuts! First of all, isn't a nurse on "light duty" on a rehab floor an oxymoron in the first place?? Light duty should mean reassingment to medical records, or being the unit clerk and NOT counted as staff! I am sorry to offend anyone, but a nurse working on a physically demanding unit like a rehab, on "light duty" is only a burden to the rest of the staff!

    And, you did the best you could under horrible conditions. If anyone stuck a yellow slip under my nose after a night like that, I'd rip it up in their face, and tell them to shove the peices where the sun don't shine!!

    YES!! Write up management for unsafe ratios next time! And every time.
  11. by   shunda
    Hello,
    I am only a nursing student, but I have a question. What would have happened if that patient would have died? Also, I hope and pray that you all do not have too many more situations like that or you all are going to be in a lawsuit. Just try to keep your back covered.
    Shunda
  12. by   kewlnurse
    Thats is crappy staffing, but thats how it is in NY State, at least for the most part, That is the staffing on every ACUTE floor in the hospital system I work for whethere it's neuro, ortho, tele, ..., the rehab floor would consider that great staffing! In the CCU's the staffing is 2-3 patients at one time, on the ilcu floor it's 4 pt.s not to start a new thread but what is staffign like elsewhere, i know it's got to be better than it is here in hell, aka Buffalo, armpit of the nation.
  13. by   amy
    I find pretty much the same types of staffig patterns. ER, a charge nurse, three aides, a triage nurse, one nurse who always shows up 5-10 min. late, short 2 floor nurses, and me. So, nurse-wise; a triage nurse, a charge nurse (like pt flow and does not do direct pt care in that position as being on the desk really is a full time job in itself) and on the floor just me. You guessed it, full house, in halls, holds full, rooms full, etc. we got it done though!!


    I LOVE NEW YORK
    Last edit by amy on Jul 3, '02
  14. by   CashewLPN
    ok.... well... now, after a talk with my boss....
    I told her that me being on light duty and working on the floor at the same time was a little crazy... (I worded it nicer) I end up doing about 30 sec of work for each nurse... little dressings that can be done without having to hold up the affected extremity, and fingersticks. Total these past 3 days, I've done 7 admits.

    My boss told me that technically, my presence on the floor reduces pt to nurse ratios. I told her that doing that was a bad practice... and god forbid anything happen, it'd essentially be her fault for not staffing properly, as every nurse is protesting the assignment.

    Typically, our staffing is terrible.... but not unbearably horrible as its been for the past few days... We've just lost 3 more evening nurses...

    And....Shunda--- if the patient would have died, there would be a lawsuit, and everybody who had taken care of the would have been sued. SO-- I'd say, you need good malpractice insurance just for issues like that...

    NY does not have safe staffing laws... if it was up to me, I'd say no more that 6 patients per nurse... and, that would mean 8 nurses every day for the evening shift. sad thing is, we only have 11 nurses now total for the shift. Turnover is high d/t the high stress (both mental and physical), and the fact that we need to be crosstrained in everything, and that the higher ups are hireing the nastiest, laziest nurses that Nobody wants to deal with.... but, thats another story...

    lucky me has 2 days off now... I think I'm gonna sleep every minute...
    --Barbara
  15. by   mcl4
    Originally posted by kewlnurse
    Thats is crappy staffing, but thats how it is in NY State, at least for the most part, That is the staffing on every ACUTE floor in the hospital system I work for whethere it's neuro, ortho, tele, ..., the rehab floor would consider that great staffing! In the CCU's the staffing is 2-3 patients at one time, on the ilcu floor it's 4 pt.s not to start a new thread but what is staffign like elsewhere, i know it's got to be better than it is here in hell, aka Buffalo, armpit of the nation.

    Generally on a med/surg or surg. floor staffing is four patients on day/eve and six on nights. CICU patient ration is one or two patients and tele is the same as the med/surg and surg floors.


    Recently, we've had great staffing since they hired several new nurses. Four to five patients on a surg. floor on nights has been the usual. I told the new nurses they can not leave
    It has been really helpful to orientating these new nurses since staffing is so good and frankly, we noticed how much less stress we are all under at work. In addition, it has been nice to be able to talk to each other during the shift during down time.

    When I started on this floor, six to eight busy patients was the normal patient load with as many five being fresh surgicals.
    We ran all night.

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