advice on being written up when I dont think I should have been...

[anniegirl1988]

I was told today that I was written up for not notifying a dr about a patient situation.. here is a little of what happened.

I picked up a patient in my shift with 4 hours left to go. This pt has 3mg scheduled dilaudid Q3 and 50mg of Benadryl Q6 with orders to hold for sedations. nurse that gave me this patient had given the 0000 dose which both were due at that time.. he said that she wasnt waking up but pushed it anyways... okay so that irritated me right away because I knew the orders and had had this patient a few days before and she was A&O... so went in to see the patient and she was lethargic and not really responding just groaning. So I told my charge what happened and held her 0300 dose of dilaudid and continued to monitor. When I went in at 5 to do my nurse draw I messed with the patient did my draw pulled her up in bed blah blah blah. still only moans to answer. This patient by the way gets lots of narcs and usually dose okay. Kidney function and liver function good and vital signs good. I told my charge again that it was bothering me that she was like this and we decided to call our rapid team to see if she possibly needed narcaned or something. When I called I told the nurse So I just needan opinion at this time I am not calling this as a rapid response. She said okay and came up saw the patient and decided also that it did not need a rapid response. However she filled out her paper work which since I had only called rapid response twice before thsi and they were actually rapid responses I did not know she did not need to fill out paperwork for this visit. I however assumed it was just part of their charting. Since nothing more than just continue to monitor patient was done we did not notify the MD even more so because it was still our on call doctor and not her and she would be in in a few hours. We did leave her a note telling her hey maybe think about order changes.

Now I find out I was written up because I did not notify the Dr about a rapid response on her patient. But again I was only calling for an opinion per my charge nurse. Is it right for me to have been written up for this or should I protest it like I want to do?

[Emergent, RN]

I think, if you were worried enough to call for help, seek support from your charge nurse, because the pt was lethargic, then you should have notified the doctor. If the charge nurse advised you to only leave a note on the chart, then you definitely needed to chart something like 'Pt very groggy at 0300, held Dilaudid. Notified charge nurse. Called RR team for further assessment. Jane RN stated that no other action needed at this time. Charge nurse advised to leave note for MD in AM, note left on chart. Pt arousable, but groggy. Follows commands, but seems sleepy. PERRLA, grips equal and strong, oriented x 3, will continue to closely monitor, placed on continuous O2 sat monitor'. After that, document every hour checks to show you followed up.

[toomuchbaloney]

I agree that many nurses work in relatively hostile environments which contain administrative policy which is punative rather than pragmatic. When I discover that is the nature of my workplace I begin looking for other work.

Having said that, you MUST notify the medical provider if the patient is experiencing an unexpected change in condition which is requiring an alteration in the POC. You must do this, not to follow some rule or procedure, but because you are charged with coordinating the care of the patient in order to achieve a return to a previous or improved state of health. This requires collaboration with medicine, you didn't collaborate in a potentially dangerous situation.

The charge nurse should be accountable as well for the lack of communication with the MD, IMV.

[Altra, BSN, RN]

As I see it, you are not being disciplined for calling a rapid response ... you are being disciplined for failing to inform a physician of a significant change in a patient's status.

I have worked in hospitals with robust, well-regarded protocols on rapid response practices. But they are not ever intended to be a substitute for communication and treatment with the patient's provider(s). They are a crisis management tool to supplement interventions being directed by the provider(s).

[nurse4ever08]

You should have called the doctor. Dilaudid is more prn not scheduled even on pain management people. Any change in condition warrants an FYI to the MD. It is just to CYA you

[Momma1RN, MSN, RN, APRN]

If you were concerned enough to ask for a second opinion from your charge, you should have notified the doctor. Take it as a learning experience and don't make the same mistake again.

[nrsang97, BSN, RN]

You should have notified the physician as well as called a rapid response. Sounds like this patient needed narcan at 0030, not waiting until 0500. I have to fill out a rapid form for seeing a patient. I can say it was a consult only, but it is up to the primary nurse to notify the MD.

[VANurse2010]

Going against the grain a bit - I don't think you should have been written up, but you did not handle that situation in the best possible manner. A little educational talk from your NM should have sufficed.

[LadyFree28, BSN, LPN, RN]

Are you being written up for not notifying the physician.. or not addressing the change in LOC?

Either way, you did not manage the patient correctly. Can't assume it was the narcs and just hold them. You need to KNOW why the patient is now obtunded. What were the vital signs and why are you counting on the charge nurse for direction?

I'm wondering the same thing.

Moving forward, have confidence to call the doctor...trust your nursey-spidey sense and advocate for your pt, even if it means calling a RR, the provider, SBAR, and stick to your guns.

[LadyFree28, BSN, LPN, RN]

Going against the grain a bit - I don't think you should have been written up, but you did not handle that situation in the best possible manner. A little educational talk from your NM should have sufficed.

Maybe, but then again, we do not work wither OP, meaning, we do not know what criteria constitutes a write up; if that means not managing a pt correctly, which could've turned into a real emergency, then that may justify a write-up.

[VANurse2010]

Maybe, but then again, we do not work wither OP, meaning, we do not know what criteria constitutes a write up; if that means not managing a pt correctly, which could've turned into a real emergency, then that may justify a write-up.

A little bit of overnarcing - I mean, it's not good, but I didn't read anything here that indicated true instability. Granted I'm an ICU nurse who's used to patients on 4-5 pressors, CRRT, and bleeding out of every orifice.

[been there,done it]

A little bit of overnarcing - I mean, it's not good, but I didn't read anything here that indicated true instability. Granted I'm an ICU nurse who's used to patients on 4-5 pressors, CRRT, and bleeding out of every orifice.

The patient does not have to be unstable to warrant a write up. A change in LOC is a significant finding. Can't just assume" A little bit of overnarcing".

Your overnarced patients are on a vent, big difference.

[icuRNmaggie, BSN, RN]

I have been to too many rapid responses, stroke codes and code blues in which there was a young nurse very upset looking guilty and scared and who had been slammed all night with an unreasonable patient load. This new nurse may have never even seen hypoglycemia, resp acidosis, septic shock, a person in a stupor or a stroke in evolution.

We all made mistakes or bad judgement calls when we were new at this, or trusted the wrong people.

What I would like for new nurses to understand is that "she told me to do that" will not hold up in court. Gather the facts, call the MD, and go on up the chain if needed.