Input requested...

[hoolahan, ASN, RN]

This is a home care question, but I think any nurse can have a say in this question. Do you think it is appropriate to do blood cultures in the home if pt has high fever?

This is the situation. The client is very nasty and so is her dgtr. She had a mesh in her abd from a previous abd hernia repair, morbidly obese, and the mesh b/c infected, and had to be removed. She has a huge gaping wound in her abd, w a colostomy, a urostomy and a draining fistula to third ostomy bag. A nurse made a visit today, and the pt had a high fever, 102. She refused to go to the ER. Nurse called several docs. Surgeon on-call didn't know her, said call primary doc, pt refused to tell nurse who her primary was for some strange reason. Nurse called hospital to see who was listed as primary on hosp record, she calls the primary, that on-call referred her to the doc herself, said this is too much for me! Finally gets primary who tells nurse to get stat blood cultures. The nurse does not have these tubes or lab slip, she drives all the way back to office, finds out we don't have tubes for cultures. Sup says we can do them. Myself and another nurse said that is ridiculous! This nurse would have to drive to hospital get culture tubes, and drive back to house for second time that day, then drop specimen back to hospital. Two hours of time shot b/c pt didn't want to wait in waiting room. Nurse told her call 911. She refused, "can't deal with that." Finally, when sup found out we didn't even have the specimen tubes, she agreed that was a ridiculous waste of time. Nurse called doc and pt back, told pt go to er or we'd get labs tomorrow. She was warned of consequences.

Now, what do you think? Do you agree that that was ridiculous to expect that nurse to do that? If a pt is that ill, that a doc suspects sepsis, I am sorry, but they should be admited! I mean when was the last time you saw a pt come in for outpt blood cultures??!! I am just stunned that the nurse even considered it! I would have told doc and pt that I felt blood cultures are inappropriate in home care, unless for some reason the pt was being treated for a sepsis w IVAB in the home already. This was entirely not the case.

Your comments please.

[sharann, BSN, RN]

I want to answer but I have to yell at my crabby 12 yr old dear son first. We are having the "Why do I have to wear these shoes instead of my dirty everyday comfy ones, out to dinner at a nice place.

Do kids ever stop arguing? He said no one is looking at his feet anyhow, so I said "Why not just go barefoot then?" Well, that went over well.

Oh gosh, to give my opinion Hoolahan, I think that there is only so much we can do for others. Some people just will not help themselves for whatever their reasons are. Blood culturesshould be an inpatient thing initially. Ii would think possibly wound cultures and a CBC are more in order?

[RNforLongTime]

Just be sure that you document everything. Why this woman doesn't want to go to the ER is beyond me! Some people, though can be quite difficult.

[live4today, RN]

Hi Hoolahan, :)

I would have firmly, but kindly, stated to that client and her daughter: Your doctor wants blood cultures drawn, and they cannot be drawn from home, so you will need to go to the hospital to have those labs drawn...there's no way around it.

The minute the client refused to follow her doctor's orders, the nurse's job was initially over. All the nurse can do is explain the consequences of the client's actions to her, and have the client acknowledge she understood those consequences. Let her know that there is nothing more that can be done for her unless she goes to the hospital. Then, the nurse exists quietly from the home.

My dear mother is 70 years old, and has refused on a number of occasions to go to her doctor's appointments that my two younger sisters have repeatedly made for her. They have had to trick my mother out of the house by telling her they are taking her shopping and to lunch (which she loves to do). When she sees the car pulling up in front of the doctor's office or the hospital, she starts yelling at them, giving them what for because she doesn't want them controlling her life. She's the mom, and they should respect her wishes not to do so and so. And, on and on she goes. So hilarious, but sometimes elderly people have simply had enough and want folks to leave them the heck alone! :chuckle

[Huganurse]

Patients with large slow healing gapping wounds are often as you described. They have lost control of their lives and act out accordingly. Family members are angry sometimes b/c they are stressed caregivers. You as the HHC nurse are going to take the brunt of these type patients.

[hoolahan, ASN, RN]

Huganurse, thank for for the lecture on the sick role, I did attend that one What I meant by nasty is, the first day the nurse ever went to see this woman, the dtr greeted the nurse at the door saying, "You should know up front I'm a bi##h, and I will not help her with this care, she will have to be able to take care of herself entirely." Well, at least she was honest. The pt also calls the dtr a Bi##h. But, if it was a sweet loving family, I would have done the exact same thing. In my judgement, the purpose of getting blood cultutres is to see if IVAB are needed. So, if the pt does not even have a line in, I would hope that if a doc suspects sepsis, they get a culture and start a prophylactic IVAB, not a po AB which is not the appropriate Rx for sepsis. If it was a sweet lovong family, I would be the same aggressive pt advocate that I always am, and advise the pt of the consequences of not seeking appropriate Rx. If I thought the pt were incapacitated by a fever, I would tell the family member or call the emergency contact person and tell them I was sending pt 911. I do appreciate however, that not all pt's value my opinion, and if they choose not to seek treatment, than that is within their ethical right to do so, whether I like it or not. I don't loose any sleep, I always do my job so that I go to sleep with a clear conscious. It is not that I am uncomfortable at all w drawing blood cultures, I am an excellent phelbotomist. Our agency does not routinely do IVAB, so we rarely have a need to do blood cultures. Like I already said, if the pt had a line in and was already getting IVAB, we would probably have the blood culture tubes in our lab supply kit, which I do keep with me, and I frequently call the docs to recommened when labs be drawn. I think you missed the fact huganurse that 1) this is not my pt, 2) I am not the case manager, and 3) this is an acute change in status, and I felt the pt should be seen and evaluated in the ER, 4) our agency is not capable of supplying and initiating IVAB in the home. Not all agencies are alike, but it doesn't mean we do not provide outstanding care to our clients.

I think I did forget to mention that we already knew the wound is positive for MRSA.

[P_RN, ADN, RN]

Hoolahan, I think in addition to the patient problem, you also have a doctor problem. I hate it when doctors want to play shift the burden and use the nurse to do the shifting. Why can't they talk to each other???

BC are not a usual thing in home care. If you pack like I used to then you take what is usual and necessary.The aerobic and anaerobic tubes have an expiration date that would mean constant checking and replacing on the off chance some day you may need them.

I agree the patient was probably not thinking it out or maybe wanted ( or loved to ) be begged into visiting the ER. Some people are just like that and then some are just plain nasty.

But then 102 fever has been known to happen in some people NOT as a consequence of the current illness but as a result of an entirely new process. Therein would be another reason to be seen by the doc. If you got the BC, then the doc might just htink of ANOTHER thing to get on the next call.

If the supervisor had thought it out more thoroughly, then she perhaps would have come up with more than an OK to go ahead and do the BC. That's why we have policy and procedure manuals.

I hope eventually the lady did get to be seen by a doctor. Has there been any followup since then?

[hoolahan, ASN, RN]

It only happened yesterday P_RN, so the nurse was going out again today, IF the pt didn't go to the hospital.

You saw what I was saying, the big picture. Of course any nurse can draw the cultures, even if it meant going out twice and large inconvenience, but the bigger picture is, what then is done with that information, or what is done in the meantime? Why not pan culture anyway? What if it isn't sepsis, then what IS it? She needed to be seen, period.

We have a lot of doctor problems. Especially, like in this lady's case, she went to a large Phila hospital. Cracks me up when I hear pt's say "We need to go to Philly." With all due respect to Philadelphia hospitals, for a routine surgery, we have the same outcomes locally. Philadelphia pt's have just as much MRSA as our own hospitrals too. I can see for very special things. Personally I think Fox Chase Cancer Center can't be beat, Children's Hopsital, and Will Eye, but as for the rest, we do the same thing at home. We often get into problems b/c it is harder for some reason to reach those docs, if pt needs stat office visit, it is an hour ride, and usually not easy for a pt w a dislocated new total hip to get to Philly for F/U. The surgeon always inevitably says, call the primary, the primary says, "I never even got a D/C summary, I can't confirm meds." It is a big run-around. So much easier to work with our local docs who know us.

[Cascadians]

There's weird family situations and non-compliant patients out there.

We formulated our own Non-Comply Non-Consent forms to document these situations and have the patients sign, like the paramedics did, along with all the narrative and flow sheets and Dr calls and follow-ups.

It's the pt's choice to refuse after having the reasons and consequences explained to them, but you always have to CYA for the inevitable howling that follows when it turns into a crisis and they want to blame somebody else

Not only are you expected to carry a Homecare Supply Store in your car, but also a Lab, a fully equipped home office computer / fax / phone / printer / scanner, an ambulance, and who knows, a CAT scan machine pretty soon

[hoolahan, ASN, RN]

lol cascadians!

That is a really good idea those forms. Kind of like signing ama. I like it!

[Jay Levan]

A) Your Home-Health Service appears (to me) to be depriving you, of the proper supplies, to do your job effectively, and efficiently.

B) I know full well, that patients and their family members can and are frequently, Butt-Heads. However, isn't part of our job caring and concern for those patients as well as the ones we appreciate, for their kindnesses to us?

C) I have a limited amount of experience in Home-Health, and I know that my schedule during that period, would not have allowed me the time to run back and forth either. So I made sure that my car was loaded with all the phlebotomy equipment I could carry, including blood culture tubes, if I was scheduled to see ten patients that day, I carried twenty sets of blood culture tubes. I also carried a cooler large enough to hold blood samples, and all the lab slips I might need. Plus all the other equipment, I might need. I guess the point I'm trying to make is that, I attempted to be prepared for as many eventualities, that I might discover in the course of my day, according to the types of patients I would be visiting. That experience carries over into my current, occupation as an E.R. nurse. I wear a utility belt stocked with tape, bandaids, scissors, hemostats, I.V. starting equipment, and syringes as well as saline(10cc) this has saved me literally thousands of steps. I hope this response, is thought provoking, and helpful to you Hot Lips :-)

[mario_ragucci]

Hi Hoolahan - What do you mean when you say the patient is nasty. I've read this, and find all the information a great insight for a study of a difficult case. Do you approach this client in gloves, May I ask. If she has MRSA Methicillin-Resistant Staphylococcus Aureus, then I guess you would have to be careful at all times proceeding with HHC Home Health Care. What type of perscription to you give a person with MRSA?

This sounds like a horror movie...morbidly obese...does that mean the pt is near death do to their weight? I've heard "morbidly obese" used as before; Is it okay to say this, or is it reserved for informal talk only?

What is "IVAB?" I'm trying to understand that acronym.

Take care - and I wish I could offer a pointblank, insightful answer, but I can only ask questions at this time :-(