I am fairly new to Private Duty nursing. I just began working with a patient who has muscular dystrophy and is on a vent. She is on a continuous pulse oximeter, which alarms and if she needs something during night shift she can flick off the finger probe to get the nurse's attention. However, she is not always able to manage this movement. My problem is, the patient gets "really freaked out" according to her mother if the nurse is in the room with her at night. So the patient sleeps in her bed and I, the nurse responsible for her airway, am supposed to be in the living room. The patient also wakes up at the drop of a hat and does not like people checking on her too much. I was told to go check every hour by looking in the doorway at the pulse ox monitor. It's dark in the room so you can't see the patient and the floor creaks so she doesn't want you walking in there. Also the vent has an auto dim so you can't see that either. The patient has an order for all alarms to be turned off on the vent. So, my only way of knowing her status is the pulse ox and a baby monitor I have. This arrangement apparently works well for the family, but having little ventilator experience, this kind of freaks me out.
How would you manage this situation? I want to provide good care consistent with the patient and family's wishes but I feel like most of the tools of assessment have been stripped from me. I certainly don't want to be neglectful. The family fired the last nurse for going in and checking the vent every 2 hours (which is my agency protocol).
Jan 13, '17
I would not consider the case safe and would consider myself not a "good fit" for them and ask my agency to reassign me to another case.
If they are asking the nurse to violate protocol the agency should address the issue with the family. If there continues to be an issue then the agency may discontinue their services (provided they are reputable) due to lack of compliance. We don't assess our patients based on machines. When one alarms, we check the patient first to determine their condition and if the alarm was accurate or not. Alarms can also fail, which could be tragic in this case if we are relying on only the pulse of to determine the patients respiratory status. Personally, any respiratory case that I've had the family had the nurse stay in the room with the patient.
Jan 14, '17
You must follow protocols. If the agency wants vent checks every 2 hours then You must document them. If the family refuses document the refusal and then notify the oncall clinical supervisor. I have never met a MD kid who couldn't sleep through a train passing. It has never been an issue waking one up for me.
Jan 15, '17
I'm also a private duty nurse. If you are being asked by the family to do something outside the written protocols in the plan of care, then document that in your chart and contact your clinical supervisor in the agency. It may be possible for new orders be written that align with the family request. If this does not happen, however, leave this case. The family and your agency won't protect you if something happens and you are in court trying to explain why you didn't follow the written protocols!
Jan 15, '17
Last edit by caliotter3 on Jan 16, '17
: Reason: Duplicate
Jan 16, '17
If you can get the 485 to state more than two hour checks are ok, then maybe. If not move on. There are limits to how much you should allow the family to tie your hands without backup on the 485 and from your management. I doubt you will get that change approved by the doctor. Two hour vent checks are standard.
Jan 18, '17
Thank you everyone for your advice! My nursey senses were tingling that this just didn't feel safe to me. I brought up all my concerns with my nursing supervisor, unfortunately the family is not willing to budge on most things. They are willing to have an order written for the auditory vent alarms to be turned on, but the 485 still says breath sounds/neuro checks q 4 hours as well as vent checks q 2. The family still does not want the nurse in there to check on those things though. So I told my agency thanks but no thanks! Since I worked my shift in the home one other nurse has been oriented to nights--and from what I understand she told them the same thing. I think it will be an ongoing concern for night shift coverage but you know what? I'm not willing to risk my license over it.
The agency is trying to find me a new client now. And it's really slim pickings. So I'm back to the drawing board in terms of finding work. I'm glad I stood my ground but I'm unbelievably frustrated right now.
Jan 18, '17
I tried to explain this to my husband--God bless him, he's not medical. He wasn't understanding why I was having such a hard time with it because it sounded like "easy money" because the family would allow you to watch TV, etc. while working. I was like screw that--if something happens, I could lose my license and we could get sued for our livelihood over this. NOT WORTH THE RISK.
Jan 19, '17
Good thing you left, I wouldn't accept that case either.
Who do you think the family will blame if something happens to their child? The nurse. You will get thrown under the bus so fast. Because there are orders to physically check on the patient. If something were to happen the family will blame your lack of checking on their child for the death. So always make sure to have bullet proof documentation. Doctor's orders always trump family wants.
I hate PDN. I had so many different cases with so many rude family members that I'm burnt out of it. Yes, I know we deal with family but if I worked anywhere else & the family was being rude or irrational *they* leave. Can't do that when we're in *their* house.
Jun 20, '17
Is it a video monitor? Some of them have cameras you can move remotely to check on the display readouts and patients without going in the room. That might be a good option.
Jun 20, '17
Neuro checks Q4h? What the heck for????