Advice needed: Follow instructions if you dont agree it's the "right" thing to do?

[RNnightshift1]

I have a question - I'd like nurses with experience to let me know what you would have done in this situation please! Do you go against the care manager's instructions if you feel it could harm the patient? Here's what happened -

Night shift at work : We had a new admit who arrived about 1 pm that day to a group home skilled nursing facility. Our night shift was 7 pm - 7 am. We had very limited information about his h & P (the orders he arrived with, as well as full h & p were locked in the manager's office so we had little info to go on). The pt was in very poor physical condition, vast skin breakdown including a fist-sized pressure ulcer on coccyx, an open pressure ulcer on scrotum from catheter tube pressure, and several other areas of skin breakdown along all creases (obesity) and yeast rashes in various areas.

The pt had an occluded catheter and as a result urine was continuously leaking around the catheter which resulted in 3 complete bed changes in 3 hours. By 10 pm it was determined it was occluded. Attempted to irrigate the cath twice. We decided the cath needed to be changed out. The pt had a latex allergy. All the caths in facility of the correct size contained latex. The charge nurse called the care mgr at home to ask what she wanted us to do. Care mgr said just use the latex cath. Her reasoning was that she's more concerned about taking care of his skin integrity (including open sores on the swollen scrotum) and didn't want him in an incontinence brief which would allow urine to irritate his skin.

Should we have used the latex, knowing his latex allergy (no info available to us just what allergic reaction it causes him), or should we have pulled the indwelling cath out, and used the incontinent briefs for the night until a latex-free cath could be obtained the next day? Have you ever gone against the manager's instruction because you disagree with her judgment? What should we have done??

[westieluv]

I have been an RN since 1990, and I would have pulled the catheter and used the briefs and just made sure to give excellent peri care all night until a latex free catheter could be obtained the next day because he could have had a very bad allergic reaction on top of all of his other problems. Why do we even collect allergy information if we are going to ignore it in our patient care? I mean, wasn't urine irritating his skin anyway, since the catheter was leaking? That catheter wasn't doing the pressure ulcer on his scrotum any good either.

This man sounds like he needs extensive specialized wound care from a certified wound care nurse. I hope he gets it. He also sounds like a possible candidate for a suprapubic catheter to avoid all of the skin breakdown in the peri area. Poor guy!

[netglow, ASN, RN]

Group home or skilled facility? I wonder admit from where? I bet he's got some even more serious issues in addition and should have refused admit and sent to hospital. No access to his H&P? Who the heck knows what is going on with him. And I'd be willing to bet he was never assessed completely at your place on admit.

[iluvivt, BSN, RN]

No! I would not have used a latex catheter. That is like saying ...we know you are allergic to penicillin but we are going to give it to you anyway. I would have called for an ambulance and sent him back to the hospital for a catheter reinsertion and a wound evaluation. I sure hope he did not come from a hospital in that condition.