is this really bad nursing judgment?

  1. Hey everyone! This is a half vent, half needing advice post. I promise to get to the point though! Well I'm a new RN working only less than 3 months off of orientation. I come to work one night and assigned a very combative pt in bilateral restraints. This pt was very strong and was agitated all night. Typical nightmare right? When trying to give medicine, the pt was able to swing and hit me in the stomach many times. This pt had a triple lumen central line placed in the groin. When the CNA removed the mittens to get a sugar check, the pt somehow snagged one of the lines. When the pt finally let go after holding it super tight, I saw that the top part was off. Like the port and lock. The CL was still in place and the other lines were flushing and pooling back blood fine. But I immediately thought, this is introducing infection big time and possibly a pulmonary emboli. I called the nocturnist who was baffled and clueless and told me to call the surgeon. The surgeon of course was pissed. He ordered to clamp the line and add a hemostat for extra protection. Not to d/c the CL which is what I thought he would order but hey I'm just a nurse. I even asked our nurse supervisor for her opinion and she didn't oppose to the surgeon just said to do what he ordered. I did what was ordered and told the dayshift nurse what had happened. The dayshift nurse takes it upon herself to d/c the CL. Come back to work to hear that that very nurse (who I have followed after many times, who has event reports on her, and many complaints about the way she practices) told everyone on our unit what happened and criticized my nursing judgment. I believe the nurse said I had bad nursing judgement. Mind you, after she shared with me that if anything happened that that would be on the surgeon and never said anything to my face about her two cents on my nursing judgment. Totally two faced me. Anyway, I'm asking if ya'll think she was justified? Honest but respectful opinions appreciated. I'm new and I want to correct any mistakes I make and be a better nurse.
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  2. 14 Comments

  3. by   Guy in Babyland
    Some people choose to make others look bad in order for them to look better. I hope you documented that you were instructed to clamp the line and add a hemostat, that way there is proof that you followed the surgeon's directions. When the surgeon comes in a finds the CL dc'd, she can't come back blame you for not telling her to keep the line.
  4. by   mlss94
    Quote from Guy in Babyland
    Some people choose to make others look bad in order for them to look better. I hope you documented that you were instructed to clamp the line and add a hemostat, that way there is proof that you followed the surgeon's directions. When the surgeon comes in a finds the CL dc'd, she can't come back blame you for not telling her to keep the line.
    Yeah documented the heck out of the surgeons order.
  5. by   CoffeeYogaNurse
    You can only have "bad nursing judgement" about things that are up to the NURSE to judge. You called 2 MDs and spoke with your nursing supervisor (hopefully you thoroughly documented all this). Once you got the order from the MD not to dc the line it would have been inappropriate to take it upon yourself to dc it. Also, why did the patient have a central? Is he a hard stick? Is something on a continuous infusion that cannot be stopped safely suddenly? If so, then the nurse who criticized you put that patient in a dangerous situation by dcing a line and not having another one. What if that patient codes and you have no access?
    You did the right thing, don't let her make you think you didn't.

    Some people just talk trash to make themselves look better. If she really thought it was bad nursing judgement she should have told you outright during report, not behind your back. You could ask her WHY she thinks it was bad nurse judgement to find out if her reasoning makes sense and show her you know she's been gossiping about you. Something like "hey, I heard that you dc'd so and so's central and thought I should have done that also. Can you explain why so I can understand for next time? Are there times where I should directly disobey a providers order?" Point out to her that it was an MD order and see what she says.

    Don't let the haters get you down!
  6. by   nurse2033
    It definitely sounds like you did the right thing. Gossiping about something that happened is the wrong thing.
  7. by   klone
    One thing stood out at me:

    "Hey, I'm just the nurse"

    You clearly did not agree with the physician's order/judgment, which is why you questioned it with a few people. Always remember that you have your own license to protect. Did you do the prudent thing by following the physician's order when you were concerned about an infection risk? If that patient gets sepsis and dies, and there is a malpractice lawsuit and you're deposed, would not pulling the CL, or following the chain of command, be defensible? Just something to think about.

    With regards to your coworker's behavior - no, gossiping about a coworker and badmouthing him/her to others is never okay.
  8. by   TriciaJ
    What jumps out at me is "bilateral restraints". What on earth are those? If a person is going to be restrained, he really needs to be four-pointed. No point tying some limbs down and leaving other ones to flail. It also allows the patient just enough movement to get himself into trouble but be unable to get himself out. CNAs should not be removing any kind of restraints unless you are right there to secure and re-restrain the limb.

    As far as your gobby coworker, just blow her off. If she has had numerous write-ups and incident reports herself, she is just trying to mitigate her reputation by making someone else look bad. It never works so she really is the least of your problems.

    You documented that you called 2 MDs and got an order from the surgeon to not d/c the line. You followed through and documented everything. If leaving the line was the wrong thing to do, then you and the surgeon will both have a learning experience. I wouldn't second-guess the doctor unless I was more sure of my own expertise in that area. You checked with the charge nurse; she didn't have a better idea so you followed orders. That's as good as it gets.

    Your coworker then d/c'd the line without an order. She's now either the hero who saved the patient's life, or she gets another write-up. Not your problem.
    Last edit by TriciaJ on Aug 28 : Reason: Missed a sentence.
  9. by   JKL33
    Pay no mind to this coworker of yours. People who act that way are ridiculously immature.

    If you have concerns that you should have done something differently, first check your CL policies and see if they happen to address the situation of a line being compromised in this way. If not, seek feedback from your manager, educator, supervisor, or a trusted peer.

    To some extent, your success in nursing depends on knowing when to care and when not to care. Don't lose sleep over people who try to feel better about themselves by undermining others.
  10. by   Union-Jack
    You contacted 2 MDs and got orders from one. DOCUMENT the entire thing, including being passed from the 1st MD to the 2nd. Then document your nursing assessment, and the fact that you ran it by the nurse supervisor who approved the MD's orders. Then document what you did. Basically, CYA!!

    Regarding the other nurse, if it was me, I would go directly to the source and I would have at least one other person present. Stay calm, summarize exactly what you did and why (as above), read from your documentation if need be. Then ask directly whey she considers that you made a bad nursing judgment. Then be silent. Then conclude with, "in the future, I would appreciate you coming directly to me with your concerns, rather than spreading bad feeing about. I am open to constructive criticism, and I am happy to learn, but undermining my decisions is both detrimental and rude." Then leave.

    I know others won't agree with me on this, but I can't stand this type of behavior and I'd absolutely have to address it.
  11. by   YumCookies
    I would've done the same. You covered you behind by notifying the surgeon, and you did what you were instructed to do. The day nurse was in the wrong here by d/c'ing that central line without an order. Your coworker sounds like a moron - don't even worry about it.
  12. by   Irish_Mist
    Assuming you described this situation in great detail to the surgeon, he came to his own professional conclusion and gave you an order to keep the line. As long as you documented that appropriately, this other nurse that is bad mouthing you can sit on a fire ant pile. You had an order and followed through with it. That's not to say that all orders are good ones. As you gain more experience, you'll know when to question an order. This order doesn't sound unreasonable to me at all given your explanation of the situation. Let's say you did discontinue that line despite the surgeon telling you not to and then something came up later where you desperately needed IV access. THEN what? Not a good situation to be in especially at night!

    There will always be people who want to look like a hero and tear others down to make themselves look good. Do your job, DOCUMENT DOCUMENT DOCUMENT, and learn to stop doubting yourself. What one nurse says about you in a lame attempt to feel good about herself has no bearing on you or your practice.
  13. by   SICUmurseCCRN
    i think what you did was the correct thing to do. one thing that i thought of was you could have pulled a small amount of blood from the TLC to do your sugar check and you wouldn't have had to remove the restraints. also 4 point restraints are rarely used unless you're working in psych or you are really having a raging patient. i think i have seen that maybe 1 time and only for a short period of time. idk the specifics of the pt but bilateral wrist plus mittens should do the trick plus maybe an order for ativan/haldol etc.; a pt should not be that agitated the entire night. the documentation alone on 4 point restraints is too time consuming.
  14. by   Kooky Korky
    Quote from klone
    One thing stood out at me:

    "Hey, I'm just the nurse"

    You clearly did not agree with the physician's order/judgment, which is why you questioned it with a few people. Always remember that you have your own license to protect. Did you do the prudent thing by following the physician's order when you were concerned about an infection risk? If that patient gets sepsis and dies, and there is a malpractice lawsuit and you're deposed, would not pulling the CL, or following the chain of command, be defensible? Just something to think about.

    With regards to your coworker's behavior - no, gossiping about a coworker and badmouthing him/her to others is never okay.
    Going against the surgeon's order would not, IMO, be defensible unless a new order to do so had been obtained.

    OP, what's this about the pt hitting you in the stomach? Too bad you didn't get an order to sedate him. Or some help to hold his arms and hands while you were giving meds. Don't allow patients to do this to you any more. Being beaten is not part of your job.

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