Pt autonomy vs competetent nursing care

[chef2rn]

I'll try to make a long story short.

Our med-surg unit is the 2nd home to a chronically, congenitally ill woman in her early twenties. She has a complicated medical history and multiple problems including renal failure, gastroparesis (she has a g-tube for self compression & drainage), neurogenic bladder, and chronic pain. Emotionally she is about 13 although she is quite intelligent and sophisticated regarding her medical care.

Recently she was admitted to the ICU for sepsis secondary to a UTI. She got out on the floor after a day. One of her meds is an antibiotic to be instilled into her bladder, held for an hour, and then drained. Because she self-caths, and because the staff knows her, and because she can be a very "intense" patient, she is allowed to keep the medication at the bedside and administer it herself. She just tells the RN when she did it.

Then I come along. I have a pretty good rapport with her, although I had not yet cared for her during this hospitalization. When I questioned her, she said she'd done it, but the volume of medication was unchanged & the irrigation kit untouched. I called around to the other units where she'd been & NOT ONE RN had ever seen her do it or even seen the drainage in the 3 WEEKS she been hospitalized FOR A UTI!!!:smackingf

I told her I'd need to either watch her, see the output, or administer it myself. Otherwise, I'd have to chart it as refused. Needless to say she freaked out.

She's also been allowed to have a box of saline flushes by the bedside because she likes to flush the ports of her port-a-cath herself.

I suggested to staff that JCAHO or the state might have something to say about that. The flushes disappeared from her room for a day & then were right back.

Then I got into an argument with a nurse who thought we were giving her the idea that we didn't trust her. Um, I don't.

Does anyone else have experiences like this?

[mandykal, ADN, RN]

I did have this problem but it's not as severe as this. My problem is at LTC with creams.

As you stated "she is allowed to keep the medication at the bedside and administer it herself." Does the hospital require a doctor's order for pt to be allow to administer self?

If she is allowed to do this there should be a nurse's note documenting that she was educated, observed and is fully competent to self administer medication.

Sepsis,oh my! what is she really doing? you did good by asking...

[TachyBrady]

In this situation, building trust is secondary to medical treatment, in my opinion. In situations like these, I imagine the worst case scenario.... the pt has a bad outcome and I am sued. How will it look in court to admit that yes, I am responsible for this patient and yes, I read the doctor's order for administration of antibiotics, but no, I did not follow that order. Flushes at the bedside do not sound safe either. I value my liscence and my career too much to take chances. If the patient chooses to give herself this kind of care at home, that's fine but he/she is not going to do it in the hospital and on my watch.