Stubborn CNA in ICU

Nurses General Nursing

Published

So we have this CNA in our ICU. We love her. She loves the patients. She's a very hard worker. But she's also spread very thin. 18 bed ICU with one CNA. She's seriously phenomenal until you do something that isn't her way.

We we don't use diapers in our ICU due to the skin breakdown they can cause so instead what she does is get soakers and basically makes diapers out of them. I've asked her several times why I don't like to use them on my patients and she refuses to comply. I've spoke with a couple nurses about it and they say, "well if you want her help, then you have to do it her way." She even went on a tirade recently yelling out loud, "this is the ICU. This is how it's done." Quite disrespectful and not taking into account that I've been an ICU nurse my entire career and also an ICU tech before then.

But my question is, shouldn't we do what is best for our patients? How can I manage this and make sure my patients skin is taken care of! I need her help but I also am a big proponent of best practice. I haven't really been able to find any articles supporting my cause to present to her so any and all advice would be greatly appreciated!

brownbook

3,413 Posts

You will have to tell me how incontinent patients are kept clean and dry in an ICU?

I don't know what a soaker is? I know foleys are discouraged. I know leaving a patient in a wet or dirty diaper will cause skin breakdown. But I don't know what a CNA with 18 patients, hopefully not all of them incontinent, is supposed to do to keep them clean and dry? Along with I assume her other CNA duties? What is the protocol?

AnnoyedNurse

63 Posts

Hey Brownbook! Thanks for replying. Let me clarify. So in the past, protocol would have been to keep patients in diapers and change them when you notice they were incontinent. However, diapers actually promotes skin breakdown because there is no "wicking." Best practice is to place a non-fabric absorbant understand and let the patient be open to air under their hospital gown. The pad absorbs the moisture and takes it away from the skin of the patient, keeping the patient dry in between changes. Obviously she's not the only one doing the work. We work as a team, but when she's in the room it has to be her way. And I get because having multiple layers makes cleaning easier because according to her, when they make a mess, "you can just pull out the wet layer." Too many layers plus a soaker (which is basically a diaper pad) is really bad for the skin. Technically, you are only supposed to use 1 underpaid OR 1 soaker. Not one underpaid and 3 soakers. Does that clarify a bit? I don't know. Maybe I should just do it her way and get the help I need...

cleback

1,381 Posts

Hey Brownbook! Thanks for replying. Let me clarify. So in the past, protocol would have been to keep patients in diapers and change them when you notice they were incontinent. However, diapers actually promotes skin breakdown because there is no "wicking." Best practice is to place a non-fabric absorbant understand and let the patient be open to air under their hospital gown. The pad absorbs the moisture and takes it away from the skin of the patient, keeping the patient dry in between changes. Obviously she's not the only one doing the work. We work as a team, but when she's in the room it has to be her way. And I get because having multiple layers makes cleaning easier because according to her, when they make a mess, "you can just pull out the wet layer." Too many layers plus a soaker (which is basically a diaper pad) is really bad for the skin. Technically, you are only supposed to use 1 underpaid OR 1 soaker. Not one underpaid and 3 soakers. Does that clarify a bit? I don't know. Maybe I should just do it her way and get the help I need...

You keep saying it's best practice but you also say you actually can't find any information on this. Maybe bring your nurse educator in to see what the evidence says? And then she or you may be able to do an in service on this topic?

You won't be able to change her personality but I think the above would be the best way to address the practice.

brownbook

3,413 Posts

Yes, thanks, that makes sense. Unfortunately I am long past dealing with bed bound incontinent patients.

Hopefully other nurses and CNA's will respond with brilliant ideas or suggestions.

AnnoyedNurse

63 Posts

Clebak , I know! Lol you would think something best practice would be able to be found on a database. When I was a nursing assistant in a trauma icu, the educators there provided a presentation. I'll see if I can reach out to them and see where they got their evidence! Hopefully I'll get some suggestions here as well. I just want to make sure I'm doing right by my patients. If I get a general consensus on here that why my CNA is doing isn't causing harm, then I'll just go with how she does it :) thanks in advance everyone!!!

Purple_roses

1,763 Posts

That is a predicament. On the one hand, I understand wanting to help the CNA out as much as possible and to make her job a bit easier. But skin breakdown occurs so easily, especjally in bed-bound, incontinent ICU patients. Whether it's your facility's personal policy or not, the research is out there that fewer layers is the way to go. I agree with others who have said that you need to get in touch with your nurse educator and dig around until you can find a policy. If you don't have a policy, maybe it's time to create one. When you've gathered all your info, you can talk to the CNA again come at it from an educational standpoint.

I think your concerns are warranted and I do think you should be a stickler about it (in a nice way) because ultimately the paper trail on skin issues leads back to you.

KatieMI, BSN, MSN, RN

1 Article; 2,675 Posts

Specializes in ICU, LTACH, Internal Medicine.

You can educate all you want and present all the evidence you want, but here is the fact: one CNA for 18 mostly incontinent, critical care patients can do very little indeed. What she does may not be the best, but she tries to do as much as she can, with meager resources she has on hands. Plus, she quite possibly might feel like "the one in charge" because, well, the one she is - her replica about "how things done in ICU" is telling one. I pretty much foresee that the CNA in question will grungingly sit thrtough all mandatory meetings and then continue to do what she did before, with argument of "it was ALWAYS THIS WAY" and "they do it there somewhere, but me never do it here". If soakers disappear, she will wortk around other supplies to use them the same way.

For you (and other nurses in your unit) it should be a hot time to get onto your management's neck and stay there till the unit staffed appropriately, or get CNA's responsibilitiesrearranged so that she actually can do her job. Meanwhile, you can cooperate with other nurses so that your patients received care according to your standards. I do not like the way most of our CNAs do and report vitals - so I do them myself, keeping me calm and on top of things, and them happy and able to do their job better.

lorias

52 Posts

Please do not call them diapers. I'm assuming that you don't have all infants in the ICU. Call them briefs or something else that would not be demeaning to an adult who has to use them.

LovingLife123

1,592 Posts

We use chux. Depending on the amount of incontinence, sometimes I use two to three of them and make a flap on top. It still wicks away the moisture and helps keep the rest of the bed clean. If you have somebody who is peeing every hour and you have to clean, it's impossible to get everything else you need to do done when you are constantly changing the bed.

I'm guessing you are going to not have to rely on the cna to help every time. We usually only have one tech for 18 patients on our unit and I can't possibly expect them to come every time a patient needs cleaned up.

There are certain times I ask for things to be done a certain way. Turning and tucking pillows is one. I've never had a tech tell me no in my requests. I justexplain why I do things the way I do. And I can't always expect them to remember each time either so I just remind them the next turn the way I do it.

allnurses Guide

hppygr8ful, ASN, RN, EMT-I

4 Articles; 5,044 Posts

Specializes in Psych, Addictions, SOL (Student of Life).

I don't like to call them diapers either but when I was working LTC I had this observation. We would send our acutely ill patients to a local Hospital that had just gone "Diaperless". Patients would with intact skin and return with skin breakdown. I did some checking and found out that the hospital was putting bath towels under patients as well as towels between the legs. The combination of dampness and the rough terry cloth texture was a disaster. After we found this out and brought it to the attention of the DON at said hospital a new policy was put in place where Pt's were photographed prior to transfer from or to said facility. The practice seem to stop right away.

Hppy

amoLucia

7,736 Posts

Specializes in retired LTC.

Multiple paddings are usually PROHIBITED in most facilities I've been - worthy of a writeup for the offending staff. That may be the way to go except IT WOULDN'T BE ME doing the writeup.

Get management or Staff Dev to set the stage and then follow whatever protocol. Your CNA can't balk then.

+ Add a Comment