when what client says conflicts with med chart

  1. Question : what do you do when the chart says something but in this case the parents say something else? I had a child that was desat to 80 and parents didnt want me to give o2 at all, saying "no,once you start giving 02 she's going to be dependent on it we already researched it" dad bagged foeven after I explained 3 minutes won't do it because that's only when its at high liters and over a long period of time. The child was bagged for 5 min but still remained 80%. Then parents said she will come up. Well she stayed like that for 30 min and I felt totally useless. Its in the chart to give 02 if sats go below 92%. Another case is when the mom of a 1 yo boy said a feeding was every 3 hours over a 24 hr period but the 485 does not have that on it,says last feeding at 9pm. Also chart says duoneb q 4 hrs prn for congestion and I gave it but mom starts yelling "no he was fine with saline and cpt and cough assist,I don't like meds at all." You should have asked me,"he was very congested. She then said" I would have told you not to give it and instead do cpt and cough assist every 30 min but no meds." (Order ssays q 4 hours prn) I'm thinking ok, if I can't use my own nursing judgement with these cases,then why am I here. Both are home care cases. What is the chart for? The mom in the second case said the book and doctors orders are there but you have to go by what I say, even if they conflict. Sorry, but if child in case1 stil is 80 after 1 hour and suffers damage and child 2 aspirates would I still legally be on the hook, esp for not following orders? Even if I document everything?
    Last edit by smartnurse1982 on Apr 21, '09
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    About smartnurse1982, RN

    Joined: Jun '08; Posts: 1,779; Likes: 1,292

    13 Comments

  3. by   smartnurse1982
    Oops should have been dad bagged for 5 min. Oh and agency knew all of this and did not say anything to me.
  4. by   smartnurse1982
    We ambubag we depend on it is a typo. Ignore it. The blackberry won't allow me to edit post.
  5. by   november17
    Obviously those parents are doing a fantastic job. So good in fact, that maybe they should take little Ty or Caylee or whatever their name is back home instead of leaving it to the professionals.
  6. by   NYCRN6
    If you document everything THOROUGHLY I don't think you would be held legally for this. I don't work with children but if my patient is throwing a fit and is A+Ox3 and states I do not want this do not give it to me. I review the consequences with them of not having this medication (we'll say for example purposes), I would notify the doctor immediately and have them come down to back me up. I also would ask the charge nurse to be involved too. This way when you document you can say you notified the appropriate people had them come and evaluate/teach also, and they still refused. However in your case... the kid can't advocate for him/herself. Now that i am a paragraph into this.. I'm not sure how it works! When in doubt DOCUMENT EVERYTHING down to the TEE. In the end you are covering yourself.
  7. by   Katnip
    They are refusing care that was ordered by the physician on behalf of their child. Document each and every word, and let the physician know.
  8. by   buttercup99
    I am not in the workplace yet, I'm a 3rd year student. But I would've thought that the parents are the legal "consenters" so as long as you explain the reason why they need this treatment (not just because they'll get sicker) and the possible consequences of refusing this medication/treatment, and document not only the refusal but the education you gave, then you have covered yourself.

    Look at the opposing side, if they refuse consent for a treatment, and you give it anyway, you could get in trouble for that.

    I know it feels like you are doing the wrong thing by not giving the appropriate care, but as long as you follow your workplace's policies, you have done the "right" thing. When it comes down to it, you have to go by the views of your workplace and the law if you want to avoid trouble and these can differ between places, so best to check that out.

    There are undoubtedly other ways to approach the situation but this is the "cover your ass" method.
  9. by   canoehead
    I would document that parents refused treatment despite teaching, and I'd teach til I was blue, but respect their decision. I'd talk about lack of rest and stress on the body if the child needed to work that hard to breathe and get physio and cough every 30 minutes. I'd also talk about air trapping in the lungs and the need to actually open the airways as opposed to just forcing air down a closed tube. I'd also ask them to provide me with links to what they were reading, and pass on a few links myself.

    To get anywhere you'll have to meticulously respect their choices as far as care for the child, be very respectful, and always approach it from what is ultimately best for the child. Don't debate as the situation is happening, you'll just end up yelling at each other. If you feel the child's life or health is in danger ask them to take over responsibility until you can both sit down and talk. (bagging for hours with low sats- if they want to do it thats fine, but I don't want to go against protocol without a good reason.)

    Let your aganecy and the physician know what is going on at home. They may change their protocols in this case, or back you up and change the parents' minds. They need to know what's happening. Ask the parents to put their wishes in writing (CYA) so you are very clear about what they want and don't want done.

    It's a touchy situation. If you can't keep the lines of communication open with the parents it's time to leave. It's OK to disagree if you can both talk about it, but you want them to be making decisions knowing how you feel about it. They might actually have some good points once you read the literature, or they might be right but taking things too far. Tell them what you think, and encourage them to keep researching a variety of opinions. That covers you and increases their knowledge about their child's condition.
  10. by   morte
    disclaimer: i am not a pedi nurse.....that said.....
    the first case i would be calling doc and considering CPS
  11. by   Purple_Scrubs
    I agree that the MD should be consulted, and you should insist that he/she speaks to the parents. Some sort of resolution should be made between those two parties and it should be clearly documented in the chart in the form of new orders or clarification of the original orders. It really bugs me that nurses get put in the middle of this. We do not make the orders, but we are the ones who get yelled at when the family does not like the MD's decisions. It screams of a lack of communication on the MD's part.
  12. by   jpRN84
    Document, Document, Document everything that was said and done and what happened. Always keep the MD and your charge nurse abreast of what is going on and you should be fine. Good luck with your situation.
  13. by   Batman24
    Document thrououghly.You can't document enough in situations like this one. You then need to get on the phone with the doctor PRONTO. The yneed to get involved and see if they can explain why what is needed or come to some resolution in this situation. Sometimes people trust the Internet more than doctors/nurses and that can be a very bad thing as those giving medical advice often aren't medical professionals. I'd follow up with CPS if the convo with the doctor didn't work. The children are suffering. And if you feel it is an emergency call 911 and get an ambulance. Don't let them bully you.
  14. by   firstyearstudent
    I would try to reason with the parents, giving them explanations about why you want to do what you want. (Maybe they are just ignorant or confused.) If they refuse care then I'd document thoroughly and notify the MD. This is why I don't work with children. I can't deal with the ethical problems involved with one person making decisions for another.

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