Advocated for PT against the on-calls orders

[optimist]

I do wound care in LTC. I had a pt admitted 6 weeks ago following surgical intervention for hip osteomyelitis. During that hospitalization he suffered many complications from infection including sepsis,prologed ICU stay and intubation.Came to me with a beautifully healed incision to that hip, no dressing needed no complications. So yesterday the CNA calls me to look at a puddle of fluid that had collected under him. I found a pin hole opening in that beautifully healed scar that was spurting massive amounts of blood tinged pus. It was a tiny hole but had significant depth to it.He had a low grade temp but couldnt feel any pain secodary to other DX. I call the on-call service and the NP gave an order to culture,xray and pack. #1 I can culture but we dont have an onsite lab and the sample wouldnt even be picked up until Mon afternoon. #2 I didnt feel comfortable packing such a small opening that obviously had a large cavity under it, I couldnt be positive that all of the packing would come out (he wanted an alginate product in there that turns to gel when its wet). I explained to the NP that I didnt feel we could adequately treat this in house and the pt has a history of severe infection to this area. The NP says "well those are my orders, if you still want to send him out please document it was against my orders". So I talk it over with the pt (he is A/O and his own responsible party). He is very distraught and worried and wants to go to the ER, he asks what I would do. I told him if it were I, I would want the best care possible. He says "well send me out please, I dont want this to get bad again". So out he goes and I had to document Pt sent to ER against NP orders.

I just feel so wrong going against what the NP ordered. I know I did the best for advocating for him but should I have pushed for him to go out or treated it in house like the order said. This is just really bothering me today, like I did the wrong thing.

Last I heard the pt was admitted to start IV abt until he could get an ortho consult monday a.m.

[SandraCVRN]

You did the right thing in my opinion.

[NickiLaughs, ADN, BSN, RN]

You were there, the NP was not. Sometimes those who are on call do not listen. The NP may regret having you write that he was sent out against your orders. As he is A/O I believe if he is concerned, he has the right to seek emergency care regardless of a physician's orders.

[Kooky Korky, BSN, RN]

I don't know. It might depend on who your bosses are, how much power the NP has and how good his connections are, and how well the pt does.

I sure wish you the best. Why does it have to be so da++ed difficult being a nurse.

For the future, could you bypass the NP and get to an MD who might listen better?

You are the wound care expert, right?

another way to handle it might be to say you don't have those supplies available.

[Dixielee, BSN, RN]

As an ED nurse, I say you did the right thing. You were looking at the patient, the NP wasn't. It is easy to sit behind a phone and write orders, but as the bedside nurse, you and the patient have the final say. Thank you for being the patient advocate. I learned a long time ago that just because someone has more education, you have the right and obligation to do what you think is right. Good job!

[canesdukegirl, BSN, RN]

So the NP never actually SAW this pt?

I think you did the right thing. I know what you mean about packing in such a small opening. I wouldn't have felt comfortable with it either, especially since the culture would just be sitting there for a few days.

[maelstrom143]

You did precisely what you had to do for this patient. Too bad you had to go against NP wishes, but so be it. Had it been the NP who had the injury I am sure he would have been singing a different tune. The fact of the matter was excessive drainage, tunneling, no way to know how deeply it extended or structures involved, already has hx of sepsis and complications...AND was admitted for further care. That alone tells you your decision was the right one.

God bless and best wishes for your patient.:redbeathe

[CoffeeRTC, BSN, RN]

They are trying so hard to prevent readmits to the hospital, this could be one of those cases.

After working LTC for a big number of years, I listen to my gut. We can do alot of stuff in house, but sometimes they need to get going back to the hospital.

If the resident/ family wants to go....they go.

[coast2coast]

For the future, could you bypass the NP and get to an MD who might listen better?

Korky, are you suggesting that MD's "listen better" than NP's? I'm not sure what aspect of this situation couldn't be appropriately handled by an NP. It sounds more like an individual or institutional attitude problem than one of education. I just found your statement very odd.

OP -It sounds like you absolutely did the right thing. Perhaps the NP didn't really understand the pt's history with osteo?

[merlee]

You did the right thing. I'll bet the wound dehisces and the pt ends up with a wound-vac of some type.

If the pt was admitted, well, that is your confirmation that you did the right thing.

Good for you!!!

[mazy]

You did the right thing. Maybe someone else can add some insight into this because I've worked with several NPs and MDs who flat our refuse to send patient's out to the hospital unless they are at death's door. I don't understand the reasoning. Others will accept the nurse's assessment and send them out. I've had a few who have flat out asked me if I think we should send them out and if I say yes, then they sign off on it.

[canesdukegirl, BSN, RN]

After reading this, I got to thinking a bit regarding the culture order. Do any of you know how long a culture is good for after the sample has been taken? I looked up my hospital's policy regarding culture swabs, and there is nothing in either the policy or the SOP that addresses this.

I understand that the swab is taken and then placed in the agar at the bottom of the tube, but wouldn't time/temperature/light, etc. compromise the integrity of the culture itself?

The reason I ask is that a million years ago when I first started my nursing career, a culture swab was taken intraoperatively by the surgeon, and handed off to me by the scrub tech. I had several things to do and after an hour had lapsed, the surgeon asked if the lab had gotten the culture yet. I told him that I hadn't had time to tube it down. HE HAD A FIT!!! He said the longer the swab sat in the room, the higher the risk of compromising its integrity.

Because of that experience, I send specimens to the lab IMMEDIATELY when I get them. If the OP was ordered to take a culture and the lab wouldn't receive it for several days, would the specimen still be good?