Feeling Like I Know NOTHING!

[Jw1724]

I graduated in May 2010. I've been working at an assisted living facility on overnights since the beginning of November.

One night, I had a lady fall. She whacked her back pretty good and also hurt herself when trying to catch herself. Called the MD on call and had to wait for a call back. Called her daughter/DPOA in the meantime. The daughter was super upset I hadn't treated her for pain. She was demanding I give her tramadol TWO tabs. Her order was Tramadol one tab. She argued me on this. I told her we should wait on pain meds in case her mother is sent to the ER. Long story short, I ended up giving her Tramadol one tab. Received an email from DON today stating that I should not have done so.

Apparently- this was the wrong decision. I didn't expect the doctor to want her sent to the ER. She asked me if I thought she should be sent and I said I didn't think it was necessary- but she still ordered her to be sent.

Meanwhile, my aide had gone up. Patient requested a heating pad for her back where she hit. The aide got it. I didn't know until I went back up and removed it. But had to chart that she received it. So I also got an email from DON saying always apply ice first, not heat.

My question- can the DPOA get me for "not treating" her mother if I hadn't given the pain med?

...None of this was ever brought to my attention until today. This fall happened about 3 weeks ago. But my DON was auditing the chart today and read my notes from that day. And that leads me here...

[INLPN93]

Wow.

In LTC, which isn't that different from Assisted Living (i have worked both) and it is one of our nursing interventions to offer pain med to person after a fall especially with injuries no matter how minor.

Now if there are major injuries that you know will lead to a visit to ER, we ask the MD if they want us to medicate at facility or wait for eval et tx at hospital.

And occasionally, there isn't a way to give meds or its a 911 situation and pain meds are the least of your worries.

But for your typical fall, like you mentioned pain meds are offered & administered.

Its part of our intervention process.

No family can order you to give a med outside of what is ordered per MD. Ever. As for being in trouble for not medicating, simply document your rationale for not medicating. Inform MD that you did give med and what it was or that you didn't and ask if they want to change their PRN or order a routine.

My advise, keep the DONs e-mail, print it & keep it with you @ work. You will be faced with this again. Use the e-mail for guidelines and if you get another e-mail with different what you should have done's, forward the original back to them.

This is why I make it a top priority when starting a new job to be instructed on policy procedure for a fall. Every facility does it different. Why????

I don't know. So, I would also go to DON & state I want more education on this process to meet facility policy.

[Jw1724]

Wow.

In LTC, which isn't that different from Assisted Living (i have worked both) and it is one of our nursing interventions to offer pain med to person after a fall especially with injuries no matter how minor.

Now if there are major injuries that you know will lead to a visit to ER, we ask the MD if they want us to medicate at facility or wait for eval et tx at hospital.

And occasionally, there isn't a way to give meds or its a 911 situation and pain meds are the least of your worries.

But for your typical fall, like you mentioned pain meds are offered & administered.

Its part of our intervention process.

No family can order you to give a med outside of what is ordered per MD. Ever. As for being in trouble for not medicating, simply document your rationale for not medicating. Inform MD that you did give med and what it was or that you didn't and ask if they want to change their PRN or order a routine.

My advise, keep the DONs e-mail, print it & keep it with you @ work. You will be faced with this again. Use the e-mail for guidelines and if you get another e-mail with different what you should have done's, forward the original back to them.

This is why I make it a top priority when starting a new job to be instructed on policy procedure for a fall. Every facility does it different. Why????

I don't know. So, I would also go to DON & state I want more education on this process to meet facility policy.

To me, this WAS a typical fall, with some obvious scrapes on the back from where she hit her back. Her back seemed to have hit the hardest but she was mainly complaining of pain in the hand she caught herself with. No bruising, no swelling, was able to move all joints. said she felt like she jammed it.

To me, I would have medicated her for pain and skipped the ER. She was sent back from the ER within 2 hours. They splinted her finger, which she refused.

I reported to the ER that I gave the pain med, they didn't say a word about it (for or against) and I never heard a word about it until today.

I think I may take your suggestion about requesting furthur training on their policies.

My training? I sat in a room alone and watched a dozen videos. Then I trained on dayshift for 3 days (where no falls happened) and trained on nights for 2 days (again, no falls).

[mentalhealthRN]

One thing to get in the habit of asking a patient who falls is--do you remember hitting your head? --also always put on gloves and inspect and palpate the entire head for evidence of a head injury. Blood, hematoma, etc. I have found that more often then not a doc will want a pt in LTC sent out if they hit their head. If the pt did hit their head you would not want to give anything to eat or drink. Including meds. You should also ask how the person was feeling just before the fall. Dizzy? weak? lost balance? I have had a lot of residents in LTC fall and end up finding out quickly it was a really low BG that caused the fall. Low BP, and even a heart disrythmia and seizure. So asking questions is really important and documenting your findings. So often it isn't "just a fall"--be thourough. Don't ever let a family member bully you into doing something you are not comfortable with or that is illegal--giving more of a med then ordered. If this pt hit her back it is a good chance she could have hit her head so sending her out may have been a good idea. We once had a woman who fell and didn't get sent out and ended up dying in less then 24 hours from a head bleed. After that a lot more pts got sent out to be safe. As far as the ice and heat--general rule of thumb is cold x 24 hours then heat. Cold to stop any swelling and then heat to increase blood flow for healing. And of course, especially with the elderly, be careful with the hot and cold packs as it's easy to cause damage to the skin (hypothermia/burn) so don't put the pack directly on the skin.

You will learn--you will. None of us started out knowing it all--and hopefully all of us are still learning something everyday. But really you will learn more in your first year or two as a nurse then you did in nursing school. Find a nurse you like who has a good amount of experience and who seems to be knowledgable and learn as much as you can......the little tricks you can get from fellow seasoned nurses will stick with you. And give yourself credit here--you know more then you think you do!! Good luck and keep your chin up.

[Jw1724]

One thing to get in the habit of asking a patient who falls is--do you remember hitting your head? --also always put on gloves and inspect and palpate the entire head for evidence of a head injury. Blood, hematoma, etc. I have found that more often then not a doc will want a pt in LTC sent out if they hit their head. If the pt did hit their head you would not want to give anything to eat or drink. Including meds. You should also ask how the person was feeling just before the fall. Dizzy? weak? lost balance? I have had a lot of residents in LTC fall and end up finding out quickly it was a really low BG that caused the fall. Low BP, and even a heart disrythmia and seizure. So asking questions is really important and documenting your findings. So often it isn't "just a fall"--be thourough. Don't ever let a family member bully you into doing something you are not comfortable with or that is illegal--giving more of a med then ordered. If this pt hit her back it is a good chance she could have hit her head so sending her out may have been a good idea. We once had a woman who fell and didn't get sent out and ended up dying in less then 24 hours from a head bleed. After that a lot more pts got sent out to be safe. As far as the ice and heat--general rule of thumb is cold x 24 hours then heat. Cold to stop any swelling and then heat to increase blood flow for healing. And of course, especially with the elderly, be careful with the hot and cold packs as it's easy to cause damage to the skin (hypothermia/burn) so don't put the pack directly on the skin.

You will learn--you will. None of us started out knowing it all--and hopefully all of us are still learning something everyday. But really you will learn more in your first year or two as a nurse then you did in nursing school. Find a nurse you like who has a good amount of experience and who seems to be knowledgable and learn as much as you can......the little tricks you can get from fellow seasoned nurses will stick with you. And give yourself credit here--you know more then you think you do!! Good luck and keep your chin up.

She said she definitely did not hit her head, which I could believe. She reached for her walker, missed it and fell backward. She hit her back on a shelf, causing some scrapes and landed on her bottom on the floor. We heard the fall and got to her before she had moved anywhere. No dizziness, etc... she had been sleeping , needed to use the bathroom and missed her walker when she went to grab it.

Thank you so much for the tips though. I would definitely rather be safe than sorry. I'm just having a hard time understanding why an issue 3 weeks ago is NOW being brought up. I wish it had been addressed THEN.

[systoly]

When you call a Dr. after hours, the doc will assume that some action on her part is required (why else would you call [ in her thinking]).

In my state, I have to report incidents involving injury to the doc immediately and to the state within one business day. If I just want to report and don't need anything from the doc I can fax or voicemail.

As said before, apply cold before heat.

You don't want analgesics to mask effect/cause of the fall so until you can reliably establish the mechanics of the fall and are certain no head or facial trauma is involved and no changes in LOC caused the fall analgesics are on hold.

[systoly]

She said she definitely did not hit her head, which I could believe. She reached for her walker, missed it and fell backward. She hit her back on a shelf, causing some scrapes and landed on her bottom on the floor. We heard the fall and got to her before she had moved anywhere. No dizziness, etc... she had been sleeping , needed to use the bathroom and missed her walker when she went to grab it.

Thank you so much for the tips though. I would definitely rather be safe than sorry. I'm just having a hard time understanding why an issue 3 weeks ago is NOW being brought up. I wish it had been addressed THEN.

If you documented the above at the time of the incident, there should be no issue with your actions. Unfortunately, the DON doesn't seem to give her rationale which is not helpful at all. I also believe an inservice for the aides is indicated. Heat application in geriatrics can have serious consequences and is not something an aide is qualified to administer.

[netglow, ASN, RN]

One thing to remember too is to take a quick gander at the med list after a fall along with the vitals, neuro checks, etc. etc. sometimes somebody's on anticoags. Also look for comorbids... any prev hx of fx due to osteoporosis or prior rad tx for cancer? Fragile LOLs! And I always almost assume they hit their head. Its hard to think what all you did when you lose balance and fall.

[systoly]

CORRECTION:

I stated above that in my state injuries have to be reported to the doc immediately. That is a facility policy. The state allows 24 hrs.

[Jw1724]

When you call a Dr. after hours, the doc will assume that some action on her part is required (why else would you call [ in her thinking]).

In my state, I have to report incidents involving injury to the doc immediately and to the state within one business day. If I just want to report and don't need anything from the doc I can fax or voicemail.

As said before, apply cold before heat.

You don't want analgesics to mask effect/cause of the fall so until you can reliably establish the mechanics of the fall and are certain no head or facial trauma is involved and no changes in LOC caused the fall analgesics are on hold.

I reported the fall to my DON that night (as I was told to) and she told me to call the MD to report the fall right then instead of faxing or calling in the AM. So whether I wanted something from the doc or not, I had to call per my DON.

[Jw1724]

One thing to remember too is to take a quick gander at the med list after a fall along with the vitals, neuro checks, etc. etc. sometimes somebody's on anticoags. Also look for comorbids... any prev hx of fx due to osteoporosis or prior rad tx for cancer? Fragile LOLs! And I always almost assume they hit their head. Its hard to think what all you did when you lose balance and fall.

I did check her med list right away because if it was unwitnessed, questionable head hit, and on anticoags- we send them out. She was not on anticoags though.

I did neuros and VS on her every 15 mins for an hour, then every 30 mins for 2 hours, etc. No issues with those, however I know issues can hide.

[Jw1724]

If you documented the above at the time of the incident, there should be no issue with your actions. Unfortunately, the DON doesn't seem to give her rationale which is not helpful at all. I also believe an inservice for the aides is indicated. Heat application in geriatrics can have serious consequences and is not something an aide is qualified to administer.

Aides can't administer heat? That's new to me... all of our aides apply heat packs.. daily at our facility.