Do I do something wrong in this situation?

  1. I posted this in the Renal Nursing Section, but think I should have maybe put it here since more people will see it. I really need some help thinking all this through.


    I have a little situation that happened yesterday and with me being a newbie I am not sure if I handled it right or not.

    As a GVN who has not taken her boards yet, I cover for PCT's while they are at lunch, have patients that are assigned to me and am also being trained with the caths (take off is very easy as far as cath care by the way, but put on I am still nervous about) anyhow. Here is the scenario:

    Lunch time coverage is taking place. I have 6 additional patients to cover plus the 2 that currently I am caring for. 7 of them were doing fine, no problems to mention, one I noticed he was sweating and started yawning, so I do a BP on him, (when he arrived it was 140/86) this was almost 2 hours into his Dialysis, his BP started dropping and was at 88/64, I asked him how he felt he said he felt fine, but new it was dropping, I laid him back and gave him a damp cloth, 5 minutes later it had dropped to 76/56, so I gave him 200cc's NS, the patients eyes started watering, but he really was not complaining, I wasn't for sure if he was being tough or felt like doo doo and couldn't muster up the energy to talk. Amongst all these 5 minute BP's, I am adjusting the cuff and making for sure I am getting a right reading. 5 more minutes later it had dropped to 66/44. I requested a Hypertonic from the Med Nurse, who was on the floor, his response was "he is not my patient, I have another hypertonic to give, plus Immodium to one patient and another Med to give to another patient." I am thinking OK, maybe he will give the Hypertonic and be over here after that. 10 Minutes later the pt's BP was down to 55/35, Charge Nurse was gone to lunch and Med Nurse still had not come over there. The whole time I am documenting my 5 and 10, minute BP's, pt's symptoms, request for Hypertonic yada yada. This is where hell breaks loose, Correct me if I was wrong. I documented with the 55/35 "Hypertonic was pending Med Nurse Arrival".

    I never left the pt's side, I stayed with him and finally a tech came by and I asked her to get either the charge or the Med Nurse now, she got the Med Nurse and he walked up with a pissed off look on his face and I showed him my VS on the Screen, informed him once again of everything I did. I told him, I needed to go and check on my 7 other pt's and I would return. Done, I thought, oh heck no, I got jumped by the PCT who was/is my preceptor (mind you these both are of an International origin and they do stick together, they also speak in their language on the floor while caring for patients who do not speak their language) anyhoo. She told me that I was documenting wrong BP's and why would I Take BP's every minute and document I was taking them every 5 mintues, she felt like I was trying to get the nurse in trouble and we don't document like this, we cover for our Nurses. I told her that as a GVN, I have a legal obligation to document what I do and the time that I do it, she told me know I don't. She told me that I should never, ever of wrote that and that I was wrong for doing it, I then got the rath from the Med Nurse, stating that if I had looked at his previous BP's I would have noticed that he came in with a low BP. He told me that the PCT who was taking care of this patient falsified BP's on Paper but if I had looked at the machine, I would have realized that. NOT because what he was looking at was the BP's that the Monitor was showing, he didn't scroll up and so I told him that if he would scroll up on the screen he would see that the patients original BP was what the PCT had documented. He told me I was trying to make him look like a bad nurse and I promptly replied, "you know what, I am not here for your license, I am here for mine and for these patients and if you don't like that, you know where you can put it."

    So now that I have had time to breath and reflect, did I do something wrong here, should I not have documented what I did?

    Before I give you my Charges response to all of this, I want to here what everyone has to say. I don't want to sway anyone. I want a God's honest truth.
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  2. 28 Comments

  3. by   Justanurse1
    It sounds to me like you did the right thing. I am not sure I would want to work in a place like that,because either they are too short staffed or have some nurses that are not what they should be. Good luck.



    Quote from Nurseinthemaking
    I posted this in the Renal Nursing Section, but think I should have maybe put it here since more people will see it. I really need some help thinking all this through.


    I have a little situation that happened yesterday and with me being a newbie I am not sure if I handled it right or not.

    As a GVN who has not taken her boards yet, I cover for PCT's while they are at lunch, have patients that are assigned to me and am also being trained with the caths (take off is very easy as far as cath care by the way, but put on I am still nervous about) anyhow. Here is the scenario:

    Lunch time coverage is taking place. I have 6 additional patients to cover plus the 2 that currently I am caring for. 7 of them were doing fine, no problems to mention, one I noticed he was sweating and started yawning, so I do a BP on him, (when he arrived it was 140/86) this was almost 2 hours into his Dialysis, his BP started dropping and was at 88/64, I asked him how he felt he said he felt fine, but new it was dropping, I laid him back and gave him a damp cloth, 5 minutes later it had dropped to 76/56, so I gave him 200cc's NS, the patients eyes started watering, but he really was not complaining, I wasn't for sure if he was being tough or felt like doo doo and couldn't muster up the energy to talk. Amongst all these 5 minute BP's, I am adjusting the cuff and making for sure I am getting a right reading. 5 more minutes later it had dropped to 66/44. I requested a Hypertonic from the Med Nurse, who was on the floor, his response was "he is not my patient, I have another hypertonic to give, plus Immodium to one patient and another Med to give to another patient." I am thinking OK, maybe he will give the Hypertonic and be over here after that. 10 Minutes later the pt's BP was down to 55/35, Charge Nurse was gone to lunch and Med Nurse still had not come over there. The whole time I am documenting my 5 and 10, minute BP's, pt's symptoms, request for Hypertonic yada yada. This is where hell breaks loose, Correct me if I was wrong. I documented with the 55/35 "Hypertonic was pending Med Nurse Arrival".

    I never left the pt's side, I stayed with him and finally a tech came by and I asked her to get either the charge or the Med Nurse now, she got the Med Nurse and he walked up with a pissed off look on his face and I showed him my VS on the Screen, informed him once again of everything I did. I told him, I needed to go and check on my 7 other pt's and I would return. Done, I thought, oh heck no, I got jumped by the PCT who was/is my preceptor (mind you these both are of an International origin and they do stick together, they also speak in their language on the floor while caring for patients who do not speak their language) anyhoo. She told me that I was documenting wrong BP's and why would I Take BP's every minute and document I was taking them every 5 mintues, she felt like I was trying to get the nurse in trouble and we don't document like this, we cover for our Nurses. I told her that as a GVN, I have a legal obligation to document what I do and the time that I do it, she told me know I don't. She told me that I should never, ever of wrote that and that I was wrong for doing it, I then got the rath from the Med Nurse, stating that if I had looked at his previous BP's I would have noticed that he came in with a low BP. He told me that the PCT who was taking care of this patient falsified BP's on Paper but if I had looked at the machine, I would have realized that. NOT because what he was looking at was the BP's that the Monitor was showing, he didn't scroll up and so I told him that if he would scroll up on the screen he would see that the patients original BP was what the PCT had documented. He told me I was trying to make him look like a bad nurse and I promptly replied, "you know what, I am not here for your license, I am here for mine and for these patients and if you don't like that, you know where you can put it."

    So now that I have had time to breath and reflect, did I do something wrong here, should I not have documented what I did?

    Before I give you my Charges response to all of this, I want to here what everyone has to say. I don't want to sway anyone. I want a God's honest truth.
  4. by   KatieBell
    Yup, you did do the right thing. The nurse is upset because if this patient had say, gotten worse, and then filed some sort of lawsuit, the responsibility of the problem would rest squarely on the shoulders of the nurse- because you clearly noted that you knew there were problems with the BP and the appropriate person was notified.

    Now, ALOT of covering for people goes on in the medical profession. But, it isn't very correct. It's not your job to cover for nurses. It would be one thing if all pandemonium had broken out, but the nurse was giving immodium??? (Big time emergency). Of course they are angry, can you imagine the field day they would have if a lawyer happened to note that the Med nurse was informed of this BP and continued on to give immodium??

    I'd look for somewhere else to work. Firstly, the staff are apparently not very nice, and secondly, it doesn't sound like a safe environment for you to learn.
  5. by   Siouxz2
    You wrote: He told me that the PCT who was taking care of this patient falsified BP's on Paper but if I had looked at the machine, I would have realized that.

    Holy heck! I'm only a student, but this sounds REALLY wrong! This place sounds like a disaster waiting to happen.
  6. by   Nurseinthemaking
    Quote from Siouxz2
    You wrote: He told me that the PCT who was taking care of this patient falsified BP's on Paper but if I had looked at the machine, I would have realized that.

    Holy heck! I'm only a student, but this sounds REALLY wrong! This place sounds like a disaster waiting to happen.

    Hopefull you read on further and realized that the Tech did not falsify BP's the nurse was acting like a jerk and assumed they were falsified without scrolling up and reading the earlier BP's.

    Just wanted to clarify that.
  7. by   Demonsthenes
    You did the right thing. However, they gave you way to many patients to cover. The techs are neither trained to monitor patients during dialysis nor to assess them prior to dialysis. The reason that techs are hired is that they are cheaper than licensed nurses. They are trained to do the dialysis process as quickly as possible. Notice how many foreign nationals are dialysis techs? The many foreign dialysis techs are indicative of the desire of employers for employees who care more about their jobs and their income than the welfare of the patient. The emphasis in dialysis is to initiate and complete dialysis as quickly as possible. True assessment and intervention before, during, and after dialysis is time consuming and expensive. This results in decreased profit margins. As a result, nurses in dialysis who insist on following the moral and legal dictates with regard to prudent nursing care are, as a rule, discharged. My personal experience with a dialysis company confirms this. Your personal experience corroborates my personal experiences in dialysis. :stone
    Last edit by Demonsthenes on Oct 1, '05
  8. by   talaxandra
    Quote from Nurseinthemaking
    you know what, I am not here for your license, I am here for mine and for these patients
    Nice
    In my hospital we call a code for a SBP <90, and that includes haemo, unless the patient has a different SBP reportable recorded.
    Sounds to me like you did well in a trying situation.
  9. by   talaxandra
    PS Standing up for yourself is important, and not easy to do, especially when you haven't much experience. Just be careful about diminishing the impact of what you say by making things personal - "I am not here for your license, I am here for mine and for these patients" is good, but adding "and if you don't like that, you know where you can put it" reduces the impact of your message and give the person you're speaking to ammunition.
    Similarly,
    mind you these both are of an International origin and they do stick together, they also speak in their language on the floor while caring for patients who do not speak their language
    can come off as being racist or biased, and doesn't add to your case.
    Just my
  10. by   Nurseinthemaking
    Quote from talaxandra
    PS Standing up for yourself is important, and not easy to do, especially when you haven't much experience. Just be careful about diminishing the impact of what you say by making things personal - "I am not here for your license, I am here for mine and for these patients" is good, but adding "and if you don't like that, you know where you can put it" reduces the impact of your message and give the person you're speaking to ammunition.
    Similarly, can come off as being racist or biased, and doesn't add to your case.
    Just my
    I am not trying to prove a case, I am stating the facts. I asked for help in determing if my documentation was wrong or the patient care I gave was wrong. I am not racist and the only thing I am biased about is my kids. What they do is what they do. They stick together like glue and I promise you, if you would have seen it with your own eyes you would know exactly what I am talking about. It is hard to relay the message via internet.
  11. by   DusktilDawn
    Nurseinthemaking,

    I requested a Hypertonic from the Med Nurse, who was on the floor, his response was "he is not my patient, I have another hypertonic to give, plus Immodium to one patient and another Med to give to another patient." I am thinking OK, maybe he will give the Hypertonic and be over here after that.
    This is where I have a question. Was the Med Nurse fully appaised of the situation concerning the declining BP? It sounds like you assumed that when he was done what he was doing he would give the Hypertonic. Sorry, but if you didn't explain to the Med Nurse exactly what was going on with this patient and if the Med Nurse didn't tell you he would give the Hypertonic, this would be where you're at fault here.
    10 Minutes later the pt's BP was down to 55/35, Charge Nurse was gone to lunch and Med Nurse still had not come over there. The whole time I am documenting my 5 and 10, minute BP's, pt's symptoms, request for Hypertonic yada yada. This is where hell breaks loose, Correct me if I was wrong. I documented with the 55/35 "Hypertonic was pending Med Nurse Arrival".
    This is where I have the same question. When did the Med Nurse say he was coming to give the hypertonic or did you assume he was coming. I have a rule to never assume anything. If the Med Nurse did say he was coming to give the patient a Hypertonic, then your documentation here would be correct, if not then I would say your documentation was based on an assumption and therefore incorrect.
    I never left the pt's side, I stayed with him and finally a tech came by and I asked her to get either the charge or the Med Nurse now, she got the Med Nurse and he walked up with a pissed off look on his face and I showed him my VS on the Screen, informed him once again of everything I did. I told him, I needed to go and check on my 7 other pt's and I would return. Done, I thought, oh heck no, I got jumped by the PCT who was/is my preceptor (mind you these both are of an International origin and they do stick together, they also speak in their language on the floor while caring for patients who do not speak their language) anyhoo. She told me that I was documenting wrong BP's and why would I Take BP's every minute and document I was taking them every 5 mintues, she felt like I was trying to get the nurse in trouble and we don't document like this, we cover for our Nurses. I told her that as a GVN, I have a legal obligation to document what I do and the time that I do it, she told me know I don't. She told me that I should never, ever of wrote that and that I was wrong for doing it, I then got the rath from the Med Nurse, stating that if I had looked at his previous BP's I would have noticed that he came in with a low BP. He told me that the PCT who was taking care of this patient falsified BP's on Paper but if I had looked at the machine, I would have realized that. NOT because what he was looking at was the BP's that the Monitor was showing, he didn't scroll up and so I told him that if he would scroll up on the screen he would see that the patients original BP was what the PCT had documented.
    Now I have some real problems with the PCT and Med Nurse here. I don't think this is a race issue but a CYA issue. Unless the PCT and Med Nurse can prove tampering with the monitor I don't understand how they can argue false documentation, unless your monitors don't have the time or an incorrect time on their display. The PCT was out of line telling you that you did not have an obligation to document what you do and the time you do it, PCT is for Patient Care Tech, unlicensed also, probably not educated the way an LPN or RN would be in the area of documentation. As nurses we do not omit or falsify pertinent documentation to cover another person, that is called fraud/malpractice and is subject to disciplinary action both legally and professionally. Why was PCT assigned as your preceptor to start with?
    He told me I was trying to make him look like a bad nurse and I promptly replied, "you know what, I am not here for your license, I am here for mine and for these patients and if you don't like that, you know where you can put it."
    Sounds like the Med Nurse made this personal first, I would have left off the part about where he could put it.

    Now as for the Charge in this situation, how may people were at lunch at this time? Was it appropriate to have this many people at lunch at this time, etc?
    It sounds like there were only just you and the Med Nurse for ??? how many patients, I know you had 8, how many did he have? How far along are you in orientation and was it appropriate to leave you and one other nurse alone?

    No slamming intended here, Nurseinthemaking, but I do have some questions concerning the situation as you can see.
  12. by   Nurseinthemaking
    Quote from DusktilDawn
    Nurseinthemaking,


    This is where I have a question. Was the Med Nurse fully appaised of the situation concerning the declining BP? It sounds like you assumed that when he was done what he was doing he would give the Hypertonic. Sorry, but if you didn't explain to the Med Nurse exactly what was going on with this patient and if the Med Nurse didn't tell you he would give the Hypertonic, this would be where you're at fault here.

    This is where I have the same question. When did the Med Nurse say he was coming to give the hypertonic or did you assume he was coming. I have a rule to never assume anything. If the Med Nurse did say he was coming to give the patient a Hypertonic, then your documentation here would be correct, if not then I would say your documentation was based on an assumption and therefore incorrect.

    Now I have some real problems with the PCT and Med Nurse here. I don't think this is a race issue but a CYA issue. Unless the PCT and Med Nurse can prove tampering with the monitor I don't understand how they can argue false documentation, unless your monitors don't have the time or an incorrect time on their display. The PCT was out of line telling you that you did not have an obligation to document what you do and the time you do it, PCT is for Patient Care Tech, unlicensed also, probably not educated the way an LPN or RN would be in the area of documentation. As nurses we do not omit or falsify pertinent documentation to cover another person, that is called fraud/malpractice and is subject to disciplinary action both legally and professionally. Why was PCT assigned as your preceptor to start with?

    Sounds like the Med Nurse made this personal first, I would have left off the part about where he could put it.

    Now as for the Charge in this situation, how may people were at lunch at this time? Was it appropriate to have this many people at lunch at this time, etc?
    It sounds like there were only just you and the Med Nurse for ??? how many patients, I know you had 8, how many did he have? How far along are you in orientation and was it appropriate to leave you and one other nurse alone?

    No slamming intended here, Nurseinthemaking, but I do have some questions concerning the situation as you can see.

    I appreciate your response. Yes, he was fully informedm given BP's, status, Complaints and continued dropping. He told me it was not his patient, (let's think about this, when you walk on the floor, as a nurse, you assume responsibility for every patient on that floor. We have 2 Med Nurse, obviously they cannot take lunch at the same time, so when one goes, one stays, he assumed care of ALL patients Meds while she was out. He still told me that was not his patient, he would take care of him once he passed his meds to his patient, knowing the status of the patient. There was no assumption, he said, this is not my patient, but I do have 3 meds I have here, one being another hypertonic and one being Immodium, another was k+ I think, but at this point I can't remember it wasn't something of Dire Importance. Rapidly decreasing BP's have precedence over patients who need Immodium and K+, not that I am saying those patients are important, but there seems to be an issue with the fac that the RN who knowwhich comes first RIGHT. Especially one with 10 years under his belt and is a CNN too.

    Yes our machines have times of BP's they will even tell you if they were Manual pushed or Machine done. They were all there in black and white, but he was so mad, he couldn't see past the end of his nose at that point. Apparantly he has a history of this sort of behavior I found this out after all the smoke had settled.

    At the time this occured, there were 30 patients on the floor, the Med Nurse, Myself and 3 other Techs. THEY were all in the back corner congregating, just as they do each day. This is a very frustrating situation because the Dialysis Center I did Clinicals at in School, the Nurse actually sat between her patients and talked to them or if they didn't feel like talking she just monitored them. It is very hard to see patients sitting in their chairs spread out in a room with no one watching over them. I catch patients even before they say they are cramping, just by watching their facial expressions. I graduated August 19th and started there August 21st. They put me with a PCT to learn the machines, but in all honesty, she has only been with me 3 times. I requested last week to not be with her anymore, a) because there is a language barrier, B) because she has some handwashing issues c) she falls asleep while sitting in a chair d) she speeks in another language while I am working with a patient for all I know she may saying what a big butt I have , I have no clue, but imagine how it makes the patients feel.

    I was told by a Staffing Agency that after I had 6 months under my belt at a Dialysis Center they would consider that to be a years worth of ICU. So I don't want to leave Dialysis by any meens but am wondering if this is the place for me. I really do feel like Dialysis is my calling for any reasons, just not sure what to think about this situation.
  13. by   Hellllllo Nurse
    This has got to be a Fresenius unit. Is it in Lubbock?
    Giving hypertonic for hypotension while on dialysis is an old, outdated intervention, and consisered dangerous by DQI. But, many Fresenius units still do this.

    Anyway, you might have also turned off the UF on the machine.

    Sounds like a unit where I used to work, notice I say used to.


    Also, chronic dialysis is totally different from ICU. Any agency that tells you they consider 6 mos of chronic dialysis as a year of ICU experience has no idea what they are talking about. In chronic dialysis, cardiac meds, vasopressors, heart moniters, vents, etc are not used. We're talking apples and oranges.

    I am a dialysis nurse, and I live in TX. but the dialysis situation is so bad here (staffing, insubordinate techs, poor standards of care) that I am now a traveler, and work in other states. I won't do dialysis in TX.
    Last edit by Hellllllo Nurse on Sep 30, '05
  14. by   DusktilDawn
    Thanks for responding Nurseinthemaking,

    Since the Med Nurse was apprised of the situation, yes he should have prioritized here, what was he thinking :smackingf If there was nothing else of equal importance going on, this should have been his first priority, most definately. He also had the option of sending one of the PCTs congregating in the back to get a nurse to come back from lunch, if necessary.
    (let's think about this, when you walk on the floor, as a nurse, you assume responsibility for every patient on that floor
    Absolutely agree with you on this one. You may be assigned patients you will be primarily caring for, but each LPN, RN, CNA/PCT owes a duty of care to ALL patients on the unit that they work on. It makes me balistic when I hear the phrase "That's not my patient," :angryfire :angryfire :angryfire

    Like I stated, the CNA and Med Nurse carrying on about VS being documented incorrect, despite the fact the dynamap has a display, is probably an attempt to CTA (T as in Their butt). For whatever reason the Med Nurse choose not to prioritize this patient and both were making excuses after the fact.

    Now I can see why you were paired with a CNA, to become familiar with the equipment. I hope you specified the reasons why you requested not to be paired with her. Sleeping on the job Speaking another language in front of patients/other staff, could be considered rude.

    I hope this situation was handled appropriately after.

    Dialysis may be your niche, Nurseinthemaking, but have you tried to get into the Dialysis Center you spent clinical time at? I don't like the sounds of this place, it doesn't sound like too much team work goes on here.

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