What would you do...?

SouthernLPN2RN, MSN, RN, APRN, NP · Jan 31, 2005

I am in my 3rd semester of an ADN program. This semester we are doing Pedi, OB, and Psych. Right now we are in the midst of the Pedi rotation at the local Children's hospital.
On Friday, I was assigned to work with a nurse that our instructor had previously warned us about. We were told that if we had to do any procedures to get the instructor - not this nurse - to go in with us. Well, I had to give medications to a CF pt via g-tube. One of the medications was Guaifenesin 600 mg - aka Humibid LA. All drug books that I referenced stated not to crush or chew this medication, so needless to say, she could not get it in her g-tube. I told the pt, who told me that they "ALWAYS" crush it and put it in her g-tube. So I called the pedi pharmacist, who told me "ABSOLUTELY DO NOT CRUSH the medication." So I told the nurse with whom I was assigned. Her reply? "Crush it and give it in her g-tube."
Thankfully, my instructor was present when I told her that as a student I could NOT crush the medication. So, guess what she did? Crushed it and gave it via g-tube.
My question is... what's the point of having the pharmacy for a reference if the nurse(s) aren't going to follow their advice? And to make matters worse, this is a teaching hospital and an entire table of residents was sitting there. Any of them could have changed the order to a liquid form to be given more frequently. She didn't even bother to ask.
We won't be going back to their unit next week, so I won't run into her again. I hope that my instructor will bring it to the unit manager's attention. Someone needs to know about the dangerous practices of this nurse.
Would any of you have done anything differently?

I think you acted in the best interest of the pt. You stood your ground and this experience will make you a better nurse.

CarVsTree · Jan 31, 2005

You did all that you can.

Unfortunately, you will see this behavior a lot in clinicals and throughout your career. I've seen it where I work.

I just plan on doing things the right way for my patients.

akcarmean, LPN · Jan 31, 2005

Good for you ! You did what you needed to do stand up for the pt and you.

*PICURN* · Jan 31, 2005

GOOD for you! I know as a student it is hard to not be intimidated by the actual RN, or to think that what she is doing is wrong...

RedSox33RN · Jan 31, 2005

I'm glad to read that you were not intimidated by this RN. Hopefully a supervisor or charge nurse will set this RN straight before she hurts someone.

LadyK82 · Feb 1, 2005

I personally think you did the right thing. What would you have done if you crushed the med and something happened to the patient? It would have been your name tossed around as the one that made a med error. Kudos to standing up for the patient. Hopefully some of your nursing practice rubbed off on that nurse.

meownsmile, BSN, RN · Feb 1, 2005

You absolutely did the right thing. You did not succumb to pressure from another nurse to do something that you know wasnt correct.

You will also see this type of thing with IV medications. Dont ask about rate to give,, look it up and do as the IV book recommends. You will see some nurses slamming IV demerol, morphine etc with the midset that it wont hurt a thing. Well the book gives a ml/min rate for a reason. Way to go,, keep up the good work.

NurseFirst · Feb 1, 2005

You absolutely did the right thing. You did not succumb to pressure from another nurse to do something that you know wasnt correct.
You will also see this type of thing with IV medications. Dont ask about rate to give,, look it up and do as the IV book recommends. You will see some nurses slamming IV demerol, morphine etc with the midset that it wont hurt a thing. Well the book gives a ml/min rate for a reason. Way to go,, keep up the good work.

Is when I've advocated for my pt; I'm glad you had a positive experience, so it will make it easier next time. Last term I got two of my pts switched from MS to dilaudid--with great results. Today (gulp) I was on the outside of rounds and when the teaching physician said my patient was getting nutrition via tpn -- I blurted out that she was not (maybe not in the most tactful way), that she had 1 line in and it was just carrying an IV solution. After checking, they discovered she hadn't had any nutrition in 2 days! The only thing anybody (RNs and MDs) had been concerned about was how much she had peed in the last 24 hrs. Well, duh. Needless to say, the attending was in her room within 30 minutes!!

Can I suggest that you keep your own personal "brag book"? I don't do it so much now (though I might start again!)--but I found it really helped when I felt down or discouraged--I could go back and look at the positive things I've done. I kept reference letters, things like that. Kudos, awards, etc.

NurseFirst

PS -- When I first gave drugs via GT my instructor, she carefully instructed me to find all the meds that shouldn't be crushed. I found two. I found out months later when another student had my patient that there had been three. The Lesson: it isn't just the drugs with XR or LR or EC...at least one drug (protonix) comes in ONLY extended release form . All I can say is, everyone there had told me all the nurses had been crushing ALL of her meds and putting them down the GT.

Aneroo, LPN · Feb 1, 2005

Great job in standing up for yourself and not doing something you knew was not right! We've had problems lately with nurses not letting students do some care (piggyback's, labs...). One big problem last week was nurses signing off meds before giving them :uhoh3: :angryfire I've decided I'm standing up this week (did not encounter this nurse last week, was another student). I researched the NC BON (http://www.ncbon.com) and they have a link to disciplinary actions taken to the state. Most of the charges related to drug use (how sad), but there were some that included sleeping on duty, or false documentation. Included in the false documentation were several cases where nurses had charted on a pt before doing whatever they charted on. I just wanted to sit this nurse down and point it out to her, kinda be like "I know you think it's ok, and it's "real world nursing", but you can lose your license over this. It's just such a small thing to lose that over." I hope it works. Check out your BON website to see if it has similar things. -Andrea

llg, PhD, RN · Feb 1, 2005

There is some information missing in your story that I am curious about... Before I can "pass judgment" on this nurse and/or the situation, I would need this information.

What is the rationale for not crushing the tablet? Is this rationale applicable to this situation? Does the fact that the medication is being given via G-tube make the rationale irrelevant?

How long has the patient been receiving the medication in this crushed form? Has crushing it caused problems in the past for this patient? ... or has he been able to tolerate it in the cruched form just fine?

What is the cost of the liquid form vs the tablet form? Is that why they are crushing the tablet rather than giving it in liquid form?

Sometimes, patients with chronic conditions have found ways of doing things that work well for them -- but that might not be the standard, recommended procedure. With a CF patient, that might be the case. Giving the liquid may be more expensive and/or less convenient for the patient for some other reason. If the reasons for not crushing the tablet don't cause a problem for this particular patient, then crushing it might be the best option.

I think you did the right thing for the situation ... but the nurse who crushed the tablet may also have done the right thing. Without more information, you were right to not crush the tablet and give it yourself. However, I would recommend getting more information before passing judgment on the nurses who have been crushing the tablets. They might be doing the best thing for the patient.

One of the differences between beginner-level practice and expert practice is that the beginner tends to strictly follow rules and guidelines. An expert is able to adapt the rules to the situation -- recognizing when it is safe to "break" and when not to.

llg

joemoe · Feb 26, 2005

the nurse my know this pt and be aware that the pharm is out of the liq form. most nurse do not have the time to explain the normal routine things that are done. i work in a teaching hospital and sometimes it is hard to get a resident to do anything. remember they have to clear it with the r3 or attending doc. like we do in clinic. or maybe she/he had something else going on that had priority and she could deal with changing the med order later. and you dont have enough knowledge to determine if her actions were justified. leave it alone your heart is in the right place but as an RN we have enough things to look out for without watching our backs around students. just so you dont screw yourself later best if you deal with your job doc anything you think you need to but as a student if you cause the hospital to loss nurses because they dont want students getting in their way and preventing them for give there full attention to the pt than u the studnet will not be allowed to return this goes for the future classes as well. just do your school work and pass the nclex then try to chance the world if you want