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.
Our lab throws out cultures if they've sat more than 2 hours.
OP, in hospital I would request the provider respond to the bedside to assess the wound themselves, and document the request. Then we can also go up the chain of command- can you call someone else in LTC if the first person does not respond appropriately?
You should have a chain of command you can go through, although with LTC's the chain is usually pretty short (maybe one other person you can call).
If the NP really wanted it documented that going to ER was against their orders, you could have also asked when the NP planned on actually seeing the patient, and document that as well.
canoehead, BSN, RN
6,909 Posts
Our lab throws out cultures if they've sat more than 2 hours.
OP, in hospital I would request the provider respond to the bedside to assess the wound themselves, and document the request. Then we can also go up the chain of command- can you call someone else in LTC if the first person does not respond appropriately?