Am I asking too much from a nurse? - page 3

by monkey2008

4,233 Views | 29 Comments

My dad had surgery Tuesday to remove pituitary adenoma. This is his second surgery in 5 years for this issue. Both last time and this time, he developed diabetes insipidus, which I understand is a common complication from the... Read More


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    This is when knowing the difference between nursing diagnosis and medical diagnosis comes into play. You can say, We are looking at his electrolytes to make sure they are okay. You can't say you are looking for a specific diagnosis. This is really important to know if you ever go to court, you can NOT tell a lawyer a medical diagnosis. We also are not supposed to tell patients or visitors or interpretation of results.
    NurseKatie08, Meriwhen, and loriangel14 like this.
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    Quote from MECO28
    You'll find your own ways of dealing with those questions when you start getting confronted with them. There are ways to deflect giving out information that the MD should be going over while giving a somewhat satisfactory answer:

    For instance- "It is standard to check calcium levels after a thyroid surgery. Your doctor will let you know the results after she interprets them."
    ........
    Short answer, your dad's nurse probably #1. didn't know your dad's sodium level off the top of her head and #2. felt uncomfortable discussing lab values when that is really the job of the MD. and #3.probably hadn't eaten/peed/sat down in 10 hours and was too physically exhausted to think of a good reply. Med-surg is fun!

    I vote for door numbah three-- she didn't have the damnedest idea what it was for or about so she gave that ridiculous answer. "Oh, we just check it" tells me this is a nurse who does tasks but not a lot of thinking. If, OTOH, she does know but is under some foolish facility constraint because they think it's OK to let their patients believe their nurses are uneducated ninnies, that's something else, and not an improvement either way. I'd take a long hard look at that and se what I could do to fix it.

    There is absolutely nothing wrong with saying something like, "Mr. Jones, is it OK if we discuss this now? Yes? OK, then. The surgery you had, as you know, affects the organ that has a lot to do with water balance, and the way we look at how that's going is by checking serum sodium. Dr. Smith will let us all know what he thinks about the result. Please be sure to ask him about this when he comes in if I can't be here when he comes to see you, or your daughter can." (because if I am there I will say, "Mr. Jones wanted to know what his labs showed." )

    There is also nothing wrong with saying, "The radiology report says your x-ray shows you're not doing enough good deep breathing (you know this because there is bibasilar atelectasis postop), so we're going to be working on that today. I'm going to help you to ..."

    "Your blood glucose is much better than when you came in last night. Do you want to talk about how you can keep a better eye on that when you go home?"

    "The radiology reading of your new hardware says it's in perfect position. I'm sure that's a relief after you went for that first tough walk with the physical terrorist, uh, therapist yesterday. You did really well."

    Seriously? Do nurses actually consent to being muzzled like that? Why do you think that is? If it's because the physicians don't think we know what a serum sodium or blood glucose or atelectasis means and how it applies to patient teaching, then we need to make sure they get disabused of that old-fashioned notion. I mean...you DO know what it's all about, right?
    KelRN215, JillyRN, acerbia, and 3 others like this.
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    I'm.thinking.HIPAA....
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    I have never heard of nurses not being allowed to interpret/share lab values with patients/family members. This is something I've done every day of my career since day #1. Working in peds oncology, labs are drawn on the night shift so results are ready for rounds. Often things would happen like transfusions would be ordered, electrolyte boluses would be ordered, etc. long before the medical team would ever set foot on the floor. People generally want to know why their child needs RBCs or Magnesium and Oncology parents are obsessed with the numbers. EVERYONE wants to know their kid's ANC the minute they wake up as it needs to be a certain number before discharge is even discussed. The only results that I'd be able to see but wouldn't share with parents would be Radiology reports. That was always awful... the MRI comes back showing the cancer is rapidly progressing and the parent calls you into the room for a beeping IV... "any word on the MRI?" "I haven't heard" you lie as you wait for the Attending Oncologist to arrive with the Social Worker and to be called into a team meeting where you will listen to them tell devastated parents that their child whose been fighting for so long will soon lose his fight.

    To the OP- I also have Diabetes Insipidus and worked in neurosurgery for the first 5 years of my career. DI was something we dealt with frequently and it was almost always in Neurosurgery patients. (Occasionally we had Neuro-Onc patients who had it, but it was something they developed after surgery and/or because of their tumor's location and their parents were usually well-versed in DI terminology by the time they got admitted for chemo.) Neurosurgery was on the floor for a grand total of about 26 minutes at 6am every day. These patients were on Na checks anywhere from once/day to q 6hrs. I cannot for the life of me imagine not sharing the results with the patient/family because I- as a nurse- am not allowed to interpret the results. A new DI diagnosis requires a LOT of teaching- how do you teach about it without bringing the labs into play? Doesn't the patient want to know why you're holding his ddAVP or giving him an extra dose?
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    Quote from monkey2008
    Thank you all for your responses.

    I did look up why NA levels would be elevated, ad I think I understand. Maybe I'm more confused about my role as a nurse, and how I would handle the question. I start work as a gn next month, so I think I'm also using this as a learning experience on how to handle different situations when they arise.

    Would it have been allowable and reasonable for my dad's nurse to explain why they are drawing it, instead of just saying "oh we just check it"??? Or is that not really an expectation/role of the nurse? I always thought it was, but I also know school is very different from real world, so I'm just trying to connect the dots.

    Your responses brought on something I really hadn't considered (the grey area). It's hard to not think like a nurse when you're playing the daughter role. This is my first experience with it, and I'm trying to learn from it.
    When you are a nursing student, you are taught to interpret things (to assess your knowledge) that you would not have to assess in the "real world" of nursing, including lab values. Additionally, one needs to be mindful that a family member doesn't always have a "need to know" (as nutty as that may sound) therefore, you may find that nurses do not and can not discuss specifics of your family member's care with you. In practice, I would encourage you to defer to the MD to discuss findings. It was obvious that the nurse was drawing labs. As far as asking specifics, I would have answered "Be sure to have your Dad discuss with the MD when he rounds regarding his lab values and what they mean" Nurses are bound by privacy policies. So no matter how well intended a family member is, unless the patient is incompetent (a story for another thread) we are not at liberty to discuss specifics with family.
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    Quote from jadelpn
    Nurses are bound by privacy policies. So no matter how well intended a family member is, unless the patient is incompetent (a story for another thread) we are not at liberty to discuss specifics with family.
    If the patient gives us permission, yes, we can discuss things with family members. Thou shall not fear or misinterpret the HIPPO. The family member who is unable to give permission due to LOC or a/o status is the one that I check and double check who can and cannot be given information. A/O pt with the family member (daughter/wife/son/husband) at bedside? Do we really look at them and say, "I can't give any information to you because of privacy policies." The patient would, 9 times out of 10, look at you like you're crazy.

    There are always exceptions, I know. I've encountered a few of the dysfunctional ones, and I pass it on in report and document in a note. But, we have to think about it, not just proclaim "privacy policies" and leave family members in the dark. "How are you related?" is one of my first questions to visitors. The second cousin twice removed. Nope. No info. The daughter the patient lives with? YES!
    KelRN215 likes this.
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    Quote from jadelpn
    When you are a nursing student, you are taught to interpret things (to assess your knowledge) that you would not have to assess in the "real world" of nursing, including lab values. Additionally, one needs to be mindful that a family member doesn't always have a "need to know" (as nutty as that may sound) therefore, you may find that nurses do not and can not discuss specifics of your family member's care with you. In practice, I would encourage you to defer to the MD to discuss findings. It was obvious that the nurse was drawing labs. As far as asking specifics, I would have answered "Be sure to have your Dad discuss with the MD when he rounds regarding his lab values and what they mean" Nurses are bound by privacy policies. So no matter how well intended a family member is, unless the patient is incompetent (a story for another thread) we are not at liberty to discuss specifics with family.
    Nurses DO have to assess and interpret lab values in practice. I do this every working day of my career and have since day #1. If I notice my patient's ANC is zero, I know that I have to educate the parents about neutropenic precautions and reinforce fever guidelines. I don't need the MD to tell me "your patient's ANC is zero, that means he is neutropenic" because I know how to assess lab values for neutropenia. If I am reviewing lab values and see that my patient's K+ is 2.4 and don't do anything about it because nurses don't "assess and interpret lab values", am I blameless if my patient develops an arrhythmia that could have been prevented if I had notified the MD and sought an appropriate order for a K+ bolus? I have had patients in the hospital who were ordered for PRN Mag boluses for Mag levels less than 1.2. If a patient's Mag level came back at 1.0 and the nurse didn't administer the bolus because she, as a nurse, doesn't "assess or interpret lab values" and the patient's level continues to drop, whose fault is it?

    As far as privacy goes- there's nothing in the OP's post that suggests that her father didn't want her to know his lab values. If I am sitting at my mother's bedside and ask the nurse a question, he/she can ask my mother if it is ok to discuss this with me. My mom would most definitely want me to know because I have medical knowledge that she does not have and I have more time to explain it to her than a nurse with 5 patients would. When my grandfather was dying, I was only a junior in nursing school but I was still the one who had to interpret all the info for my mother and uncle. Dad very well could have told the nurse that he wanted his daughter to have this information because she is a nurse and can help him understand it.
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    Quote from dudette10
    If the patient gives us permission, yes, we can discuss things with family members. Thou shall not fear or misinterpret the HIPPO. The family member who is unable to give permission due to LOC or a/o status is the one that I check and double check who can and cannot be given information. A/O pt with the family member (daughter/wife/son/husband) at bedside? Do we really look at them and say, "I can't give any information to you because of privacy policies." The patient would, 9 times out of 10, look at you like you're crazy.

    There are always exceptions, I know. I've encountered a few of the dysfunctional ones, and I pass it on in report and document in a note. But, we have to think about it, not just proclaim "privacy policies" and leave family members in the dark. "How are you related?" is one of my first questions to visitors. The second cousin twice removed. Nope. No info. The daughter the patient lives with? YES!
    Yes, even with family members at bedside, the rights of the patient come first. Period. And the patient is free to discuss what they want to with family. You can not assume anything other than that. We can lose our jobs for that stuff. One nurse had a patient who was on Viagra. That the wife had not a clue about. Stated to patient something regarding the medication, and lo and behold, opened a huge can of worms. You can not and should not get into the practice of discussing anything regarding the patient because family members are present. They do not have a need to know, unless the patient wants them to know.
    Meriwhen likes this.
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    Quote from KelRN215
    Nurses DO have to assess and interpret lab values in practice. I do this every working day of my career and have since day #1. If I notice my patient's ANC is zero, I know that I have to educate the parents about neutropenic precautions and reinforce fever guidelines. I don't need the MD to tell me "your patient's ANC is zero, that means he is neutropenic" because I know how to assess lab values for neutropenia. If I am reviewing lab values and see that my patient's K+ is 2.4 and don't do anything about it because nurses don't "assess and interpret lab values", am I blameless if my patient develops an arrhythmia that could have been prevented if I had notified the MD and sought an appropriate order for a K+ bolus? I have had patients in the hospital who were ordered for PRN Mag boluses for Mag levels less than 1.2. If a patient's Mag level came back at 1.0 and the nurse didn't administer the bolus because she, as a nurse, doesn't "assess or interpret lab values" and the patient's level continues to drop, whose fault is it?

    As far as privacy goes- there's nothing in the OP's post that suggests that her father didn't want her to know his lab values. If I am sitting at my mother's bedside and ask the nurse a question, he/she can ask my mother if it is ok to discuss this with me. My mom would most definitely want me to know because I have medical knowledge that she does not have and I have more time to explain it to her than a nurse with 5 patients would. When my grandfather was dying, I was only a junior in nursing school but I was still the one who had to interpret all the info for my mother and uncle. Dad very well could have told the nurse that he wanted his daughter to have this information because she is a nurse and can help him understand it.
    I said nothing about not notifying the MD. I am saying that as nurse, we do not (at least in my neck of the woods) take it upon ourselves to discuss lab values with a patient. We certainly should bring it to the attention of the MD, but as far as getting into values with a family,or with a patient until the MD has reviewed and decided what to do to treat-- this is different.
    And one should not get into the habit of asking the patient in front of the family member if it is "ok" to discuss anything with said family member. And in fact, maybe Dad did say "tell my daughter and not me" or something of that nature, but we all have to be mindful that no matter how well intended, some patients just don't want family members in their business. Period. And if they are alert and oriented, THEY can share what they want to.

    Another scenario is a triage situation when a family member wants to come in and be part of the medical decisions....no can do, sorry, but until we have the opportunity to ask what is needed, and ask the PATIENT in private who should know what, then I can only say "I will have the MD speak with your Dad about this"......

    The patient has a right to privacy. The nurse gets into hot water when discussing medical diagnosis with family.
    Meriwhen, TheCommuter, and loriangel14 like this.
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    Besides, unless you're the designated POA, he can't discuss labs or much of anything else with you without Dad's permission.
    jadelpn and loriangel14 like this.


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