Case study: Need inputs!!!

[mg1303]

Hi Everyone , here is another case study I have to discuss

Maxine Overland is an RN, working on a medical-surgical unit in a partnership model of primary nursing. She has been on vacation for 2 weeks, and when she returns, she finds that the unlicensed assistive personnel she typically worked with is not expected to be back at work for several months because of a family emergency. A new nursing assistant, John Maxwell, who had worked in the hospital for only 2 weeks, is assigned as her partner.

Maxine was pleased to learn that John had previous experience in another hospital and is a certified nurse aide. However, as she began to work with him, she realized that he does not understand the delegation rules established by the state Board of Nursing. For example, she entered a patient's room to find that John was removing an IV from the patient's arm because it had infiltrated. Maxine took over the task, noting that the IV was in fact infiltrated. After leaving the room, she asked John why he had begun to remove the IV instead of calling her. He indicated that he had been taught how to do this at his last place of employment. She indicated to him that this was not a delegated task in this hospital. He responded, "Why? I know how to do it."

Later in the morning, Maxine was reviewing the vital signs of the patients to whom they were assigned. The values for all blood pressures, pulses, and respiration's were numerically very close, despite the fact that the patients had previously had widely different vital signs results.

If you were Maxine, what would you do?

MY ANSWERS:

According to what is happening here and if I were Maxine, I would speak with John and explain to him that this is a different place from where he was working before and it has different rules and regulations. Nursing Assistants do not do certain task that pertains to the Registered Nurses and he may read the rules and regulations books because every facility is different, the vital signs values and procedures are different. I will also encourage him to go to the nursing supervisor in case he has any questions and if he needs help I will be there. If something like this happens to me, I will talk to John and I will clarify to him that he is only allow to perform within the limits of his license as a CNA he is not allowed to perform as an RN, that I am the RN and I am liable for the care of the patient. I will point to him that the IV was infiltrated and the vital signs are not correct. I would tell him not to do my job. If he does not understand and replies the same way he did to Maxine then I will report the incident to the supervisor or nurse in charge so he can be corrected. If I were in a situation like she was I definitely talk to John clearly, letting him know that I am the RN and I am responsible for the health and wellbeing of the patient while under my care and that he is not qualified to do my job and it is not acceptable in any place a CNA to perform as an RN and then I will talk to my supervisor or nurse in charge. I would retake patient's vital sign again and I will record the results in the patient chart.

[Episteme]

Wow. A challenging case study, indeed. You hit almost all the things that occurred to me as I read it. But I'd like to raise one other concern.

John's over-stepping his scope of practice is a problem. But the issue of the vital signs is very much more concerning to me. First, because I can't trust his numbers, a patient may be changing and I would not know it as soon as I should. That puts patients at risk.

Second, John has a major character issue. You're highly suspicious that he is lying to you about critical patient information. He should be immediately let go (via the chain of command, of course)... except you don't have solid proof. Discuss it with your manager. John is within his 90 day hire date and (at our facility) can be let go for any or no reason.

Should I discuss it with John first? If I'm pretty darned sure he lied about the vital signs... nope. He's lied. What could he say in a discussion that I can believe and trust. Besides, he put every one of my patients at risk and I'd be p*ssed.

[RescueNinjaKy]

As a rn you have to protect yourself too. Provide appropriate documentation that you have spoken to John about this issue. For instance, send an email to your supervisor with the scenario and what your intended action is and then ask for input. That way the issue is shown to the higher chain of command and you have documentation to prove it.

[Esme12, ASN, BSN, RN]

I would let the charge nurse know about your discovery. I would recheck all of the vital signs after him or with him the next time to see if he is performing them properly.

You do not KNOW per se that the vitals are not correct you see that they appear different from the tends for the patient after checking and they seem too similar. You report these findings to the charge nurse/manager/educator to they may formulate the best plan for re-education orientation of this new employee. You will bring to the CNA's attention that the vitals appear similar and that is concerning as they are not in line with the patients usual trends /your findings. You will state to him clearly that in this facility policies are to be folloed and he is not to remove any IV's here....find the policy and show it to him. Let him know that you need to let the manager know that he may need further orientation for this facility.

YOU will write an incident/occurance report on the IV removal and your conversation for the paper trail for education/plan of action.

[Ruby Vee, BSN]

It may be that John doesn't know how to do vital signs correctly, and that part of it may be an education issue. However, I'd still be concerned about his charactor -- it he doesn't understand hot to do vital signs correctly, why not just ask for help rather than pretend he's doing them?

[mg1303]

I can't thank you enough! Leadership is my last class for Nursing school and your inputs are extremely appreciated!!

[Esme12, ASN, BSN, RN]

You are welcome....show us you ahve done some work and we will help you!