Correcting Others mistakes?

jadelpn, LPN, EMT-B · Oct 21, 2015

You could most certainly ask your pharmacist about the IV medications--If it is a large bore IV (or is it a central line/PICC/Port?) and the meds are compatible (which is the key to all of this) I may not think it my best practice, but again, I would be sure with using your resources and asking. Also assessing the IV site, and making sure you are flushing appropriately.

Heparin has a specific protocol. And bears watching. Which may not be in line with say an antibiotic. What is the policy regarding obtaining a second IV site? Use your resources and ask. You do not have to involve anyone else's practice when you take over a patient. So just ask for your own practice.

As far as the CNA--I would have just made sure there were 2 basins as well as plenty of washcloths. One specific to the peri area. Before you begin doing anything. And say "I did up a basin for the peri area--here's one for the rest of the body". Sometimes I think that some CNA's don't realize what they are doing as it is so "robotic" for them. Plus for any number of years, disposable wipes were used for peri clean up, and sometimes even wipes for baths. So they would use and throw out. Then they have gone back to basins and washcloths. But then there's always a conversation about "laundry" and laundry expenses, and the unsanitary condition of laundry....and then things sometimes revert back to disposables.....

Sending best wishes. It is going to take awhile before you get your own groove. And look at it that way--you want to refine your own practice so that you are correct. And that is what I would say should anyone balk at your need to know.

Karou · Oct 21, 2015

In the heparin scenario, I would have asked the nurse why she didn't insert a second IV, and why she was leaving the heparin drip off to infuse the antibiotics. If they weren't compatible then the patient needed a second line placed for the abx. Pausing the heparin for an antibiotic (30 minutes, 2 hours? How frequently?) concerns me. It will alter/skew the PTT, which determines the dose... That's just a mess.

When I was new and afraid to "question" anyone else, I would pose it like I was trying to learn. "Nurse, I haven't had a lot of experience with this, so I'm unsure. Can we pause heparin that long? Should I put in a second IV?". I would also ask my charge nurse for clarification.

About the bed bath... ICK! That's disgusting. You tried to hint and offer her more towels... And she didn't get it. Does she have a good reputation on the unit? You could try hinting stronger, "let me get you a new wash cloth so we can clean the patients back again".

That's hard because your relationship with PCT/CNA will make or break your shift. If she is well established and has been there a long time, you need to work well together.

Karou · Oct 21, 2015

Oh I just noticed that I had assumed she was pausing the heparin and hanging the antibiotics. Silly of me!!

If they are compatible, it may be necessary to infuse each on their own pump, y-sited over one peripheral line. Only if compatible. I have done this a few times when the patient was a difficult stick. If antibiotics will be long term and the patient is a hard stick then a PICC may be indicated. It's easiest to just place a second line (if possible).

Pharmacy is our resource for this, hopefully they are easily available to you too.

remotefuse · Oct 21, 2015

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About the bed bath... ICK! That's disgusting. You tried to hint and offer her more towels... And she didn't get it. Does she have a good reputation on the unit? You could try hinting stronger, "let me get you a new wash cloth so we can clean the patients back again".
That's hard because your relationship with PCT/CNA will make or break your shift. If she is well established and has been there a long time, you need to work well together.

she is a great cna to work with. She does an awesome job on just about everything, and I've learned that if I delegate something to her, it WILL get done and correctly. That is also part of the reason I don't want to upset her. I would much prefer her to be on my team.

Cricket183, BSN, RN · Oct 21, 2015

I agree with Karou that posing scenarios in the form of a question often is a good way to approach these type of situations, especially with colleagues who may have more experience than you. Being a new nurse it is expected you'll have questions and posing it that way prevents you from coming across as a know it all. In the example you gave of the heparin drip, you could have said something like, "I'm not familiar with what the policy is on heparin drips. Can we stop it to infuse antibiotics or do IVPs or do I need to start a second line?" Our hospital policy stated a second line was always required for a heparin drip and nothing else was to infuse with the heparin regardless of compatibility.

The example with the CNA, yuck! In my opinion even though it may be uncomfortable to do so, it needs to be addressed. It's difficult because like you said being the new person you don't want to come across as the know-it-all and you want to keep a good working relationship between you & your support staff. CNAs can make or break your shift. They are an invaluable asset to the team. I think taking a straight forward approach is best. Take the person aside, away from patients & other staff, and simply state what you observed and why it's an issue. Maybe something like, "CNA Susie, I appreciate you helping me give patient X a bed bath. I noticed you used the same washcloth on his behind that you used on his back and legs. For infection control it is important to switch washcloths to prevent cross contamination."

It's never easy in these type of situations, especially for me as I'm the definition of non-confrontational. It always helped me to remind myself in those kind of situations that my first priority was to the patient and their safety and not the discomfort I felt at having to address the situation. I hope this helps.

Horseshoe, BSN, RN · Oct 21, 2015

Hey,
So I am a newer nurse and I need advice on handling things that I see that believe to be wrong. I want to say something to the people, but feel nervous about over stepping. Examples: I got a pt from someone that has been a nurse for 7 years. The patient was on a heparin drip, only had one IV site, and was receiving several IV meds. So she was pretty much giving him a bolus q 3-4 hrs.
Another example: There is a CNA that has been working at this hospital longer than I have been alive. I helped give a bed bath, and she went from wiping the behind, to cleaning the back, to cleaning the legs and toes all with the same towel. I felt sooooo grossed out just watching, especially because there were obvious skid marks. I told her I would grab her some more towels, but she didn't even bother to use them.
I have only been on this floor floor for a pretty short time, and don't want people thinking I'm a know it all. There have been other situations similar to this, and I don't know how to handle these situations.

I admit to being a little skeptical when I saw the title of your thread, but yeah, these are legitimate concerns.

And my stomach literally lurched with revulsion after reading the part about the bed bath. OMG.

ChipNurse · Oct 22, 2015

You need to advocate for your patient. Like others have said about the Heparin, ask your pharmacist to clarify. In terms of the aid, just tell her that you use a new washcloth for each body section. She may not know.

NOADLS · Oct 22, 2015

Hey,
So I am a newer nurse and I need advice on handling things that I see that believe to be wrong. I want to say something to the people, but feel nervous about over stepping. Examples: I got a pt from someone that has been a nurse for 7 years. The patient was on a heparin drip, only had one IV site, and was receiving several IV meds. So she was pretty much giving him a bolus q 3-4 hrs.
Good catch
Another example: There is a CNA that has been working at this hospital longer than I have been alive. I helped give a bed bath, and she went from wiping the behind, to cleaning the back, to cleaning the legs and toes all with the same towel. I felt sooooo grossed out just watching, especially because there were obvious skid marks. I told her I would grab her some more towels, but she didn't even bother to use them.

What were you doing helping the CNA with a bed bath? I would call that a mistake being in there with the CNA. That is your downtime!

iluvivt, BSN, RN · Oct 22, 2015

You have a legal and ethical obligation to address any concern or issues on your assigned patients or ones you are assigned to assisting with.How you do this will vary slightly depending upon the issue, the person or people involved,the exact clinical issue and how much time you have to correct it. If someone is about to push the wrong medication or push it too quickly you need to act quickly. I am not one to address everything in a pretty little bow..if I know and you need to..then I will respectfully and as privately as possible be informing you!

In the case of the CNA. I would have pulled her aside right there and then and privately pointed out that she was collecting bacteria from the perineal and perianal area and depositing it all over the patient's body. I would explain to this good CNA why this is a bad idea. If she is as good as you say than she will not want to put her patient at risk and will care!

In terms of the heparin drip it really depends on how it was set up and what the the other meds were and if they were compatible. It is optimal to have a dedicated line for drips but on patients with very limited veins I have added a micro double extension set and administered the abx via the double micro extension set and the other available micro tubing set had the heparin so the heparin is NEVER stopped or bolused..it can be done! You need to certain that something is actually done incorrectly so just ask respecfully what their rational was and go from there.

turnforthenurse, MSN, NP · Oct 22, 2015

The heparin situation is a mess. I would have asked the nurse why she didn't start a second IV. Whatever her reasoning, the patient is now yours so you would be responsible for obtaining secondary access. I was always taught that heparin deserves it's own dedicated line but I guess in a pinch you could consult with a pharmacist and ask if meds are compatible.

canigraduate · Oct 23, 2015

The CNA thing is gross. Pull her aside and tell her not to do that. Ewww. Be nice and say something like, "Always do the peri-area last so you don't spread poop." Because, EWWW.

As far as the heparin goes, I don't have enough information to advise you on that.

I had a guy go out on a hep drip with one IV site to the floor recently. You know why? The doc ordered it and his transfer at the same time. I was just happy I got it started before he left.

Also, PPs have had good suggestions. If the patient only has the one good vein, put a two- or three-way connector on there so that line stays continuous. Watch your compatibility. One thing to consider about the "bolus" is that you are just flushing in whatever is in the tube between the port and the patient - on a continuous drip, this means he gets a micro bolus and a pause. You aren't giving him any more medication. The only way it would affect your APTT or Xa is if you draw it right after from the same arm.

Best practice is to have a dedicated line, but if you can't, you can't. I wouldn't say anything to the nurse, I would ask her why. She may have had a valid reason.