BM blues

[LVN_it1995, BSN, RN]

What would you do if this happened to you?

I work in a snf/rehab facility, worked there for little more that 3 months. When I came on shift one of the long term patients was having a problem since the 3-11 shift (I work 11-7). I received report that Pt.X had severe abdominal distention, had not had a bm in a couple days and was complaining of pain in his upper abdominal areas. I was informed that he had already received 2 kinds of laxatives (enulose and MOM) during the 3-11 shift and that he refused an enema and going to the hospital. I was told that the Director of Nurses was informed (as per hospital policy for change of condition) and that I was to monitor Pt.X for BM's. It was obvious the 3-11 nurse assessed he was impacted and needed to have a BM or two.

As the night progressed so did the patient's pain level and inability to move about. We put a diaper on the patient so he would not have to try to get to the restroom in a hurry. I encouraged him to drink H2O to aid in elimination. V/S were taken, bowel sounds assessed, still no BM @5:30AM. I asked to patient then if he would like an enema and explained procedure. He agreed to enema. The solution would not stay in his rectum so in effect it was ineffective. I then called on the RN in the building to please assess the patient due to increasing discomfort of patient and what I was to monitor for.

The CNA and me(an LVN) and the RN after assessing him all agreed this was serious and immediate action needed to be taken since he had been c/o pain for over 10 hours and his distention had become more prominent and no BM despite the laxatives and enema attempt.

The RN, my supervisor told me to call 911 and get him to the hospital. I did that.

I also called the D.O.N. to inform her that someone was being sent out(as per hospital policy).

Here comes the hard part -- She told me in no uncertain terms how lazy and incompetent I and the RN were for sending the patient out because all that was wrong with him was that he needed to have a BM!

I was hurt and ashamed because I thought we were using our best nursing judgement, we were the ones with the patient all night, and 3 people confirmed the severity of the problem.

It turned out that it was more than a BM problem because Pt.X was admitted into the acute hospital and is still there since yesterday.

How do I continue from here at this job knowing how the D.O.N. feels about me and my nursing?

[truern]

Guess the DON never heard of an intestinal blockage?? If you tried from both ends with no results and his distention and pain only worsened, then what exactly would she suggest you do?

[xoemmylouox, ASN, RN]

I think you two came to a very reasonable conclusion. You were being advocates for a pt who was in pain, and who had been in pain for quite some time with no relief. Don't beat yourself up over this. You did what you thought was right, and obviously it was if they kept him. DONs can get a big head occ.

[TheCommuter, BSN, RN]

At the several nursing homes where I've been employed, I've observed that management does not particularly like when floor nurses send residents out to the hospital for issues which the managers believe can be handled in-house. The reason is simple: it is all about the money. Nursing homes often have contracts with local ambulance services, and the facility must pay the ambulance bill if Medicare or Medicaid rejects a portion (or all) of the bill.

However, you did all you could do for this resident, and I think you took prudent action by arranging for him to be sent to the hospital. It is obvious that your DON is acting on incomplete information in order for her to make an insulting comment to you.

In a nutshell, your DON does not respect you.

[mama_d, BSN, RN]

First off, she was out of line for her comments...certainly someone in management can muster the skills to either keep their mouth shut with comments like that or else be a bit more diplomatic.

Secondly, I was just wondering if disimpacting the patient was attempted, and if not, why not? I don't work LTC, so I'm just curious; I've done more than my share of disimpacting patients from LTC facilities at the hospital...is there a common protocol against this at LTCs?

[TheCommuter, BSN, RN]

I don't work LTC, so I'm just curious; I've done more than my share of disimpacting patients from LTC facilities at the hospital...is there a common protocol against this at LTCs?

Well, I can only speak for the nursing home at which I am currently employed. There are standing orders in existence to disimpact the residents as needed. However, facility policy prohibits LPNs/LVNs from disimpacting any resident. Therefore, an RN must do it, and if the only RN on duty in the entire building is the DON (director of nurses), it is very unlikely that the disimpaction will ever get done.

[justiceforjoy]

Putting myself into your shoes, I'd want to know why she thought of me as incompetent. I'd hunt her down and ask her face to face what she feels I need improving on. It's my job as much as it is hers to find means of improvement, so I'd show her my willingness to improve and offer her the reasoning that the RN and I had for sending the pt to the hospital.

If she wanted to continue to act like an idiot (yep), then she can continue to be one. She won't have many people on her side when someone decides to call her out. At least you could rest easy knowing that you did all you could to rectify any outstanding issues.

[LVN_it1995, BSN, RN]

:up:thanx for all your support on this.. The pt. ended up having an ileus and getting a colostomy. If we had kept him at the snf or given Pt.X an high soapsuds enema like the D.O.N. suggested the pt. would have probably died and I could have been in real trouble maybe even earning the title, lazy and incompentent I still get a little perturbed about it, but I like the crew I work with and I have only been working there for 4 months. She does need to have more tact though, being the boss of the facility nurses though.

I have put in my mind that I work for the patients and not for the D.O.N. and none of the patients so far has a problem with me. That's how I keep going knowing despite knowing how she feels about me.

[DebanamRN, MSN, RN]

And if the pt died, she would have thrown you under a bus, while keeping her license intact.

Lesson: Don't doubt yourself. You have good instincts - and you still have a license.