Am I doing the right thing???

P_RN, ADN, RN · Aug 1, 2001

I can understand how this upset you. Did the patient give permission? Did you have difficulty inplacing the feeding tube? Was it done in Radiology under fluoroscopy?

Was there a language barrier between you, the doctor and the daughter-in-law? Is the daughter-in-law a doctor?

I am sure you did what you felt was best for the patient.

P

RNforLongTime · Aug 1, 2001

Hey there,

Don't feel bad! You did what you believed was in the best interest for your patient at that time. The last hospital that I worked at, us floor RN's were allowed to place dobhoffs on the floor using a two-step method. This hospital was in PA. I now work at a hospital in Ohio. Anyhow, we placed the dobhoff to a certain point-then had placement verified by a Chest X-ray. If the dobhoff was in the proper place then we were allowed to advance it to the next mark on the tube. This step was followed by another x-ray. If by chance the dobhoff ended up in the bronchus, we were NOT allowed to remove it. Only the MD could do this--usually it was a Resident.

Back to the topic at hand. I too am wondering if this daughter-in-law is an MD/DO. Secondly, did this pt have an IV with NS in it? Was she placed on a fluid restriction? I am certain that you acted appropriately. The dobhoff can always be removed. Maybe an NG might have been a better option? I don't know.

Don' t be so hard on yourself. Nursing is a tough job. Doctors can be jerks sometimes. You did as you were instructed by the attending.

Kelly:)

Jenny P · Aug 1, 2001

The way I see it, you were following the patient's physicians orders and even IF the daughter is an MD, she obviously isn't the patients' MD. If the patient has a Sodium of 121 or 120, something must be done, and this daughter is not looking at what is happening to the patient with the eyes of an impartial clinician. I wonder if the daughter is angry more out of fear than because of what you did. I would hope that once the mother is out of danger, you will be able to talk to the daughter and remind her that your purpose of being there is not to torture the patient, but rather to help her heal. I would also try to talk to the MD about the situation in the near future when he has time and can listen calmly and rationally.

fiestynurse · Aug 1, 2001

Sounds like you assessed the patient appropriately, used your professional judgement, called the doctor, and followed-up by the correct intervention. Is the daughter-in-law calling the shots in this patient's care? Does this patient have an Advance Directive? Is she a Do-Not-Resusitate patient? Accusing you of "torturing " her mother-in-law was certainly not called for.

Also, I don't understand why the doctor that ordered the feeding tube felt that he had the right to "chew you out." You did nothing wrong, as far as I can tell. It would probably be a good idea to talk it over with your manager and fill out an incident report.

MollyJ · Aug 1, 2001

Tough one. And you have to learn and go forward.

When a family attacks you like this, you have to realize that it is not personal. It really isn't. Haul out your "therapeutic communication technique" from school and reflect things back to her. Restating, "you don't approve of this dobhoff insertion..." would have allowed you to hear from her WHY she doesn't want it. Maybe she wants mom to be a no code. Maybe she doesn't understand the procedure. Maybe she thinks the tube is painful. (And I am not sure that a person with that low of a sodium will tolerate feedings, either, but that is really beside the point....)

The fact is that if she is the medical decision maker for this elderly confused lady, you have to have some peace with her. So simply listen to her. You got caught between a medical decision and a family, so _listen to the family_ and then you will either be able to help them understand the rationale for the treatment OR you will start to understand why they don't want to follow the medical plan of treatment.

If I had an elderly parent who I realized was getting close to the end of their natural life and the doc/nurse undertook to put a feeding tube down AND I thought that this was going to be in forever and prolong their miserable life, I might be doing some chewing too. You can see that I bring to this situation my own perspectives and that fact that my parents are in their 80's. I want my parents to live well... not necessarily forever.

Hard part, no doubt, is don't take it personally.

BTW, I'm a Kansan, too.

Zee_RN, BSN, RN · Aug 1, 2001

It's a control issue, that's all. Don't take it personally.

Bao.vn · Aug 1, 2001

Daughter in-law is not on the case and I did have permission from mother to insert Dobhoff. She was not on fluid restriction and Dr. stared her on Na tablet, 1 Tid, no IVF. She was confused on admission day but very alert and orient yesterday.

Anyway, thank you so much for your support.

MollyJ · Aug 1, 2001

Bao, I understand that you had the client's permission, but her family is a undeniably part of taking care of her. Also, with this significantly low sodium you cannot assume that she has a normal sensorium.

Undeniably, you did what you thought was right and what many, if not all, of us would have done. No question there. The point is that the daughter is just part of the picture. You cannot ignore her or discount her or the rest of the hospitalization will be war. She may, at some time, come to realize that you did what was reasonable, rationale, and correct based on what information you had availabe to you at the time BUT her behavior and attitude constitutes "new information" and you must take it into account.

I realize that the info you have given is sketchy, but the doc's fluid and electrolyte management seems screwy, too. Review Syndrome of Inappropriate ADH. This woman seems like that may well be her problem.

prmenrs, RN · Aug 1, 2001

I have not done adult nursing in about a gazillion years and I need to ask what is probably a REALLY stupid question: What is a "Dobhoff" tube?

Thanks

km rn · Aug 1, 2001

You did what you thought was right, but I can understand the daughter's anger.

I agree with the above poster - the management of this patient seems wrong. In addition, what good is it to keep giving sodium tablets when the lady is throwing up. I am amazed she wouldn't be on fluid restrictions, IV fluids, etc.

I don't know if the patient's consent would hold up in court given her low sodium. I feel her daughter, POA-HC should have been called prior to the tube's placement. However, the physician also bears responsibility for notifying and educating the family re: need for tube feedings.

Try to see this as a learning experience and discuss it with the physician next time you see him - I'm unclear why he would be angry with you.

All you can do is your best so don't beat yourself up for this anymore. Learn from it and move on. You obviously care about your patients and professional obligations.

P_RN, ADN, RN · Aug 1, 2001

We didn't place our own Dobhoffs (small bore enteral feeding tube brand), as we had 2 Nutrition Support Nurses who did this.

The low sodium just whizzed right by me when I first replied I didn't even take it into account. It seems that the lady should have at least been restricted as to free water intake. And salt tablets? Our docs just had the kitchen send extra salt packs with any trays. And of course IVF for as long as there was no PO intake.