Withholding prns??!!

  1. I have never in my nursing career been so angry!!

    That said I need advice. I work on an acute Ventilator unit where pain and anxiety reign supreme. After dealing with 2 pts who were in such a state that one was ripping her skin to shreds and the other was pulling at her trach/trach tubing so badly that the tubing and HME were filled with frank blood.

    After trying relaxation, diversional and communiction techniques to no avail (done by myself, resp therapy, 2 other nurses & the CNAs) I asked the med nurse (A float, unfamiliar with the floor) if they were due for their prn meds.

    Ready? She told me that the off going med nurse had told her under NO circumstances were these pts to be given their prns!!

    I showed her the MD order, I showed her the VS I had taken other than the normal elevations you would expect to see with pain/anxiety they were stable & then I told her that she needed to use her own nursing judgement at which point she started to cry. ( I still feel like a turd) She did give them at my request with a positive effect inside half an hour.

    I then went to the Nursing Supv. explained the situation & she asked me to write it up. I explained that this would be a fruitless gesture as the offgoing nurse is favored by my UM. This nurse gets away with yelling, swearing ( daily ) and has even thrown the med keys at other nurses. Withholding prns is not new for her, she has been seen telling pts no she will NOT give then pain meds as they are NOT in pain.
    In the end I did write it up & gave a copy to the nursing supv & the DON, bypassing my UM. However I know that I have effectively put my head on the chopping block. I know there will be hell to pay from my UM no questions asked.Her response to our various complaints r/t this nurse is always "oh thats just her way", "Oh, thats our girl". How much more frustrating can you get??!!

    I know in my heart I did the right thing. On further investigation it was discovered she had given the same directives to another float nurse.

    Other than letting me vent, TY. I would like to know if anyone has any idea if this is a state reportable offense? besides the fact I don't think that there will be any repurcussions for her, only me.....This whole thing has really gotten to me & I want to make sure that I do everything I should but I don't want anger to cloud my judgement!
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  2. 28 Comments

  3. by   Marie_LPN, RN
    Yes it IS a state reportable offense. People suffered when their meds were withheld for no reason. That's abuse.
  4. by   Squeeta2
    I realize this which is why it makes me so angry. Being angry & making decisions have never gone together well.

    My ideal would be that the facility will take care of this and not make me suffer for it. So do I take a wait & see attitude or will it then be to late? Will I then be in trouble STILL for not reporting it to the state ASAP.? To be clear I am referring to the Nurse who instructed her NOT to give them.
    Last edit by Squeeta2 on Aug 2, '03
  5. by   Tweety
    You did the right thing. It is not up to the off going nurse whether the patients will need prn medicines through the next shift.

    Not treating pain and anxiety appropriately is wrong. You did the right thing by first reporting it to the supervisor and writing it up. See what happens then. I wouldn't be running to the State just yet. I know here in Florida they would be obligated to do an investigation, and probably will investigate the entire facility in person. Not the board of nursing the medical board, I can't remember what they are called, I'm on my first cup of coffee. They've been to our hospital several times after the newspaper put their phone number in the paper as to who to complain to about improper care.

    But definately followup. Patients are not getting proper care and that's wrong.

    Hold your ground if your head gets on the chopping block get ready to pick it back up and hold your head high knowing you care about your patients.
  6. by   Marie_LPN, RN
    If you wait and nothing happens, then you'll be asked WHY you waited whenever you'd go to the state.

    Why did the off going nurse tell her not to give the meds I'm wondering. Only times I have been told that you are to withhold a med is if the pt. is experiencing bad side effects, swallowing difficulties (assuming it's a pill), or by MD order. And whenever a med is to be withheld, to call the MD to get an oder to hold it. If a med is being withheld by a nurse, and the pt. is asking for it, and there is no order to hold this med, then why was it being held. Even though sometimes the instincts may say that someone might be saying they are in pain, and are acting in pain, yet you step out of the room and they are mysteriously calm, yet you have to believe when they say they are in pain, that they are. When it's THAT obvious they were in need of their medicine as you described, that's flat-out wrong.

    Look back on the facility, and any other problems they might have had before this one, did they take care of the problems when they were alerted to them? If not always, then it's a toss up on whether they will this time, bad as that is to say.

    If it were me, i think i would wind up being liable for not reporting it. What our facility's guidelines state is that even by just seeing or witnessing an incident, you're just as liable for not doing something about it.

    It puts you between a rock and a hard place, I know.
    Last edit by Marie_LPN, RN on Aug 2, '03
  7. by   maureeno
    what a horror!
    hard place to work if you can't give the patients you care for what they need...
  8. by   PJMommy
    I'm sorry...I "just" a student nurse but have to comment on this one. In class and clinical, we are drilled about how pain is always to be treated, pain is whatever the patient says it is, and we are to NEVER try to objectively determine whether or not a pt is in pain (unless the patient is a non-verbal child or a dementia patient). PRNs are there for a reason and, in my humble opinion, if a pt says they are anxious or in pain, then the nurse needs to give that med. Furthermore, our instructors have repeatedly told us that pain is the "fifth vital sign" and JCAHO is VERY closely monitoring pain management.

    Sorry if I am a little peeved about this. Once you are on the other side, you understand a heck of a lot better. I had the good ol' gall bladder out last year (emergent) and had a med/surg nurse who avoided helping me with the excruciating pain - despite my rating it at a 8 or 9. I kept hearing "it was only gall bladder surgery, you should be in that much pain". After spending a long, long night -- crying, alone and in pain - the surgeon told me he'd left orders for PRN morphine PCA and had no idea why the RN hadn't implemented the PCA. I told him she didn't think I should have been in that much pain. I found out then that the gall bladder was gangrenous and my liver was massively inflammed -- no run-of-the-mill elective cholecystectomy.

    The behavior this nurse is displaying is unexcusable. Orders to not give pain meds...without any explanation as to why...is absolutely ridiculous.
  9. by   Squeeta2
    3rdShiftGuy, That is exactly what i said in the write up & to the nurse who was issued that directive, there is no way she could discern what prn was going to be needed over the next 12 hours.

    BTW, this did happen on the ON & she also told the nurse that we on the ON give out prns just to keep the pts quiet so we don't have to do anything. Gotta love that old day shift/ night shift conflict huh?

    PJMommy, no nurse, in training or otherwise is "just" anything!! we have the same opinion about pain meds & its the same hot topic in my state about it being the pts say so. I'm just wondering if they will feel the same way about anxiety meds....

    I am heartened to see i am not the only one upset by this incident. I try to always maintain my professionalism but this one has put me on edge.

    Also i want to say that the nurse who withheld the prns was a float nurse & following the directives of a "regular". She is a great nurse always willing to do what no one else wants to. She just got caught in a foul position & I don't want to see her reprimanded for what she percieved as an order from someone more knowledgeable. Should she have used her own judgement? Questioned the charge nurse,me, about its appropriateness? Absolutely. But overall she is an excellent nurse caught in the crossfire.
  10. by   goingCOASTAL
    Originally posted by PJMommy
    I'm sorry...I "just" a student nurse but have to comment on this one. In class and clinical, we are drilled about how pain is always to be treated, pain is whatever the patient says it is, and we are to NEVER try to objectively determine whether or not a pt is in pain (unless the patient is a non-verbal child or a dementia patient). PRNs are there for a reason and, in my humble opinion, if a pt says they are anxious or in pain, then the nurse needs to give that med
    Absolutely! Occasionally, we do get patients that could be classified as "seekers" (prescription drug abusers), and their "pain calls" that fall exactly on the minute as the prn order allows can be annoying (Curses to the nurse that tell 'em, "Oh, you can have it every three hours as needed!" LOL!) . There are a lot of debates as to whether we should be "enabling", or trying to really help them. Personally, if the order is there, and they ask for it -- unless it is medically contraindicated, it is my duty to give it to them. For those that are using Demerol and Morphine to mask their personal coping skill problems, we can always suggest psych consults and such, but deciding whether or not they NEED any sort of medication is a "medical" judgement, and withholding ordered medication intentionally is the equivalent of "practicing medicine," which no state allows a licenced nurse to do.

    I agree with the rest: follow your chain of command, if nothing is done then call the boards.
  11. by   Squeeta2
    I'm bound to catch hell for skipping my immediate supv. but like i said she would just sweep it under the rug. So my butt is on the proverbial line.

    Thanks to everyone who has offered advice & support. Now I'm off for another night of fun & games!!! I'll be sure to check back for more insight, it is greatly appreciated!!!
  12. by   jnette
    Originally posted by Squeeta2
    I'm bound to catch hell for skipping my immediate supv. but like i said she would just sweep it under the rug. So my butt is on the proverbial line.
    Just a thought... I think I would have sent a report/complaint to ALL (which would have INCLUDED your immediate supervisor).. and this would also have alerted your UM to the fact that yes, indeedy, a copy went to HER superiors as well.. get my drift? That way, she would not have felt "left out" or "uninformed" and couldn't hold that against you... also she would be aware that the OTHERS have been informed as well, and she would have to have some darn good reasoning for upholding this controlfreak "nurse".

    Yes, this angers me as well. Very much so.
  13. by   sjoe
    SQU, Assuming that your account above is accurate:

    1) The offgoing nurse countermanded an MD order, which is practicing medicine without a license which is, of course, against your state's laws. and

    2) The oncoming nurse accepted this countermand order and ignored the original MD order, which is ALSO against your state's laws. Crying or not, the MD order is the one she was obligated to follow. (Did she really think a verbal order from an RN--whether the offgoing RN or you) superseded a written order from an MD? If so, she obviously needs some further training.)

    IMHO.
    Last edit by sjoe on Aug 2, '03
  14. by   felix
    as stated & regardless of what country u live in, incidents like that need reporting through the full chain of command
    the float nurse isn't just caught in the middle, she needs her butt kicked as well, don't feel sorry for her, tears included

    Felix

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