Doing No Harm

[WereBadger]

I'm on my final week of clinicals as a soon-to-graduate LPN, and I had an experience last night that I can't seem to come to terms with, and I'm hoping to ask the community here for guidance. Ideally, I feel that my clinical instructor should be supporting me with this, but he's overstressed, checked-out and seems more ready for this year to be over than anyone (background: he's supervising two clinical groups, working FT as an RN and also attending a Masters program, it's no excuse, but I'm trying to be understanding).

Last night, while on clinical, I was asked to assist with an in and out cath on a very disoriented elder female patient. She didn't seem to understand the purpose of the procedure, despite many of us (students, an RN, the clinical instructor and a passing RRT) all attempting to explain it to her. The RN (along with my clinical instructor, who remained at the foot of the bed the entire time, not assisting) decided to proceed regardless, and the patient became combative. There were three of us students in the room, and we were asked to "keep her (the patients) hands out of the way", which I came to realize meant holding her arms, almost as a physical restraint. The patient was *extremely* upset, there was no order for restraints of any kind, and I'm left feeling as if I've participated in a form of battery against her. Not wanting to step on any toes, and recognising that I am inexperienced, I'm not sure of how to proceed here.

Is this situation representative of some kind of grey area that I need to "get used to" as I gain experience on the floor? Should I bring this incident to the attention of someone at the hospital or within my nursing program? How could this procedure have been accomplished in a less traumatising way for the patient? Should we have requested an anti-anxiety or some other kind of med for our patient? I guess I'm just at a loss here, and really want to understand the best way to approach a similar situation in future. Thank you so much in advance for your thoughts.

[ktwlpn, LPN]

Certainly is something to discuss with your instructor.In long term care this would be considered abuse.We would pre-medicate if not contraindicated,try a clean catch or treat a suspected UTI if symptomatic.This is why dementia is a terminal illness.You can't force care on someone like this and you can't reason with someone with a broken "reasoner".

[NICUmiiki, DNP, NP]

In the case of a disoriented patient, I'm assuming that someone other than the patient is making the medical decisions for her.

As far as holding her arms to do the cath, the Joint Commission says this:

A restraint does not include devices such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets, or other methods that involve physically holding a patient to conduct routine physical examinations or tests, protecting the patient from falling out of bed, or permitting the patient to participate in activities without the risk of physical harm (TJC, 2011).

[ktwlpn, LPN]

That's per the Joint commission.If this occurred in long term care we have a different set of regulations.

[JustBeachyNurse, LPN]

One thing to know a common cause or exacerbating factor in altered mental status or confusion is a seemingly asymptomatic UTI. Dozens of seniors have been saved doses of strong psych mess by an astute experienced nurse that was aware of this and requested a clean catch urine to r/o UTI. Must be an in/out to get a clean specimen.

This could very well have been the case and benefit outweighed risk and as such you did not participate in battery. It's possible the scenario described above applied but as a student you did not realize it.

[ktwlpn, LPN]

One thing to know a common cause or exacerbating factor in altered mental status or confusion is a seemingly asymptomatic UTI. Dozens of seniors have been saved doses of strong psych mess by an astute experienced nurse that was aware of this and requested a clean catch urine to r/o UTI. Must be an in/out to get a clean specimen.

This could very well have been the case and benefit outweighed risk and as such you did not participate in battery. It's possible the scenario described above applied but as a student you did not realize it.

A large percentage of elderly nursing home residents are colonized(asymptomatic baceteriauria) Our physicians don't treat with antibiotics in the absence of a number of symptoms.We push fluids for a number of days and in most cases this is effective.Another reason for a post conference discussion-lots of variables to consider.

[WereBadger]

Thanks, all. As a little more background, it was a clean catch in effort to rule out a UTI. The patient had been transferred to our hospital from a nursing home.

As an update: I was able to have a quick conversation last night with the RN who had asked for the sample, and she echoed the statement made above that it was for the patients greater good. I felt that asking her about the situation from a "is there anything that I/ we could have done better in future" position would be okay, and she was receptive.

I think that this situation will be in the back of my mind for a little while yet, generally because I still feel as if it could have gone better and maybe there's something more that I need to learn from it. Thanks again for all of your thoughts, it's so helpful to have them.

[HouTx, BSN, MSN, EdD]

Luckily, there are resources available to help with situations like this. Don't be afraid to pose a question or ask for guidance from the hospital ethics committee. That's why they exist.

[WereBadger]

Thank you for this suggestion! I've been feeling a little strange about this clinical setting, and as a result have been trying really hard not to create waves, but I will definitely seek out this committee. There seems to be a bit of hostility towards students in this setting: things such as healthcare providers stating outright to us that they dislike LPN students, calling us "lazy" for not choosing to enroll in the RN program instead (the majority of us do plan on bridging to RN), claiming that we don't know enough not to be a danger to the patients there (and yet not making any constructive suggestions about where they feel that our knowledge is deficient, so that we could work with our instructors to remedy this), starting rumours about unsafe practises (again, without substantiation, discussing concerns with us directly or in a way that might imply that there is much truth in it). I guess it's just been pretty frustrating to be in an environment like this, and has left me questioning how best to address any concern without it being misinterpreted or gossiped about, especially since I will be precepting there over the summer. If nothing else, I guess it's good experience in working in a difficult environment.