I'm the Only One Doing Assessments?

[SunnyPupRN]

I have a pt who is chronic. Per MD orders we assess 02 sats, dorsal, tibial, radial pulses q shift, as well as temp, mucous membranes, sclerae, and the other typical assessment stuff. I've been seeing this pt about 6 months, and last weeks he gets all frustrated and says, "WHY are you doing this?!" I says, "You know the routine, we all do this....the doctor needs to know how you are doing. I know it gets tiresome to have us all checking you everyday, but-" he cuts me off.

"No! YOU are the only one who insists on doing this! Nobody else does this!" I'm perplexed, because the orders are clear. The pt changes from day to day as far as lung sounds [sometimes sonorous rhonchi, sometimes coorifice crackles..] and has a defect of the aorta which is why we check the pulses in the feet.

So I go back through charting, and as far as I can SEE, other nurses have charted that they checked these things....but then then some stuff makes zero sense. For example, one nurse checks under 'Genitourinary System' that the pt is circumcised, and in other places a nurse says he is not.

Some places say he has a neonatal trach, other places say a peds trach.

At any rate, it's clear to me that the pt is irritated and surprised by my assessments. I do not want to call anyone out, but the pt makes complaints about me and says things like I told him not to move and be quiet, which sounds bad...but it was taken totally out of context, because I was trying to listen to his heart and lungs, and I asked him not to move so I could hear. I think he just doesn't want the assessments, and the other nurses might be obliging him. Thoughts?

[Rose_Queen, BSN, MSN, RN]

Well, patients do have the right to refuse. However, falsified documentation is still not okay.

[AliNajaCat]

Well, patients do have the right to refuse. However, falsified documentation is still not okay.

Nailed that one. I would have a little chat with your facility risk manager who will be very interested in this, and may reinforce the idea that patients can, in fact, refuse, but that falsified documentation is a road you do NOT want to go down.

If something happens to this guy and his family sues (he won't be in a position to say what he wants anymore because he'll be dead) all that contradicting documentation is going to mean YUUUGE money for them. And that will probably end up translating into fewer staff for you...cuz you know they won't cut management salaries, right?

[caliotter3]

The easy approach is the term "patient refused" or "patient refused assessment". Or, you could communicate to your supervisor(s) that the patient has complained that you are the only nurse bothering him with assessments. I might do this one time in order to cover my rear. You do not have to investigate or name names, just report what the patient told you. Then let the chips fall where they may. Either write "patient refused" or continue with the status quo. You also need to report the situation to the physician. S/he needs to know that the patient is not happy with being bothered. Perhaps the physician will modify the orders.

[mrsboots87]

At my facility, we can fill out incident reports for stuff like this. If I find that there appears to falsified documentation (wound dressings that weren't changed in 3 days but charged for those 3, assessments that are vastly different from mine just a shift later, whatever) I fill one out. Then I am released from any further investigation. The facility can then look further into if they please. If not, I have at least done my part.

See if you can do the same. Then you can inform management this is happening without calling out any particular person.

[SunnyPupRN]

All good info. I think I probably was not clear in my post [i only wrote that the trach was peds] - but he is a minor, with some developmental delay. He still has the right to refuse, correct? Personally, I'm not comfortable forgoing his assessment; his feet are often swollen and cool to the touch and the dorsal pulse is often diminished or not palpable. I think with these reasons, I'm comfortable being insistent on following through with the assessment, especially since he complains but does not outright say NO to me. Thank you for the thoughtful views.

[caliotter3]

Oh, thanks for the clarification. With a peds patient like this, I would not forego the assessment. Usually, all it takes is a "little" encouragement to gain some semblance of cooperation.

[SunnyPupRN]

Oh, thanks for the clarification. With a peds patient like this, I would not forego the assessment. Usually, all it takes is a "little" encouragement to gain some semblance of cooperation.

Indeed!