In Need of Nursing Advice

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Hello,

I was involved in a very serious patient incident last week and I am in great need of nursing advice. We have this patient who is confused, agitated, unable to answer questions appropriately or follow commands, constantly ambulatory. This patient also has a 1:1 sitter for patient safety. I am quite familiar with the patient since he has been with us for a while and that I had been assigned to the patient 3 days 2 weeks ago and 2 days last week in which this incident occurred. On my last day before my day off, I recieved report from the night nurse that the patient did not sleep until 0600 that morning. Based on my knowledge of the patient, I thought it would be best for the patient to get some rest. The previous sitter had told the morning sitter the same thing as well. I walked into his room and he was sleeping but would awaken when spoken to and state his name amongst other things and then fall back asleep. I assessed that the patient was not in any respiratory distress, no pain, skin was warm, IV was patent, no swelling. This was around 0745. I charted my baseline. The nurse practictioner came in at 1030 to came and see the patient, long story short, she lifted the covers, and found a bed sheet used as a restraint. Neither I or the sitter had lifted the covers prior to that moment.

Now I am in trouble because I didn't fully assess the patient. I do understand the seriousness of the matter since that could have led to serious injury, thank goodness it didn't. I accept and acknowledge that I didn't assess the patient fully but being a new nurse (8 months on the floor), I DIDN'T EVEN THINK THAT WAS EVEN POSSIBLE! It didn't even occur in my mind that something like that could happen! Now I am getting written up, the NP filed a PSN, and a full investigation will occur.

I guess my question is: How much will I get in trouble for? How can I protect myself during this time?

This is a tough lesson to learn and I know I would never get myself in the same situation again but for right now I am so anxious, sad, and embarressed over the whole thing. Any kind of advice would be great.

Thank you for taking your time to read!

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Specializes in Pediatrics, Emergency, Trauma.

Do you have ?

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I'm so sorry to ask, but did listen to lungs etc to establish no RD. Again, I'm sorry, I have no actual working experience, so correct me if I'm wrong here, but it looks serious to me. If you charted "lung sounds clear bilaterally, active bowel sounds, pedal pulses present" etc, it implies that you assessed those things.

I'm sorry that you are paying for the mistake of someone else, hope you have a good outcome.

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We can't offer any legal advice to you, but I will say that it sounds to me like you are appropriately horrified and have learned a valuable lesson that even if you are doing a minimal assessment (which can be appropriate in certain circumstances), to always, ALWAYS look under the covers!

Good luck. Update us on what happens.

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I'm so sorry to ask, but did listen to lungs etc to establish no RD. Again, I'm sorry, I have no actual working experience, so correct me if I'm wrong here, but it looks serious to me. If you charted "lung sounds clear bilaterally, active bowel sounds, pedal pulses present" etc, it implies that you assessed those things.

I'm sorry that you are paying for the mistake of someone else, hope you have a good outcome.

You don't really need to listen to lungs to establish if someone is in (acute) respiratory distress - but it's hard to chart a baseline assessment without doing so!

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Specializes in Peds/outpatient FP,derm,allergy/private duty.

We can't give legal advice but maybe it would help if you suggested an inservice on the topic of restraints and how a sitter should proceed if their patient is so agitated that the sitter needed to restrain him.

I recall clearly the evening years ago in which I failed to wake a sleeping child when I should have. I can still remember feeling exactly like you are now but I learned a lesson I would never forget. The workplace seems to have turned so much harsher in recent years.

Wishing you all the best.

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You don't really need to listen to lungs to establish if someone is in (acute) respiratory distress - but it's hard to chart a baseline assessment without doing so!

Thanks, I will remember that.

Again OP, sorry, and good luck.

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Specializes in L&D, infusion, urology.

I have to ask, are there any repercussions on the nurse that had the patient prior to you? Or on the previous sitter? Were they following any kind of restraint protocols? They obviously failed to mention this all in their hand off, which is a pretty big omission. Surely some of the blame falls on them as well.

Sounds like a hard-learned lesson (hate them, but they happen). I hope things turn out okay for you!

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Call your ...all nurses should have it!

I am sorry this is happening to you...lesson learned. I would hope the nurse and sitter before you are in hot water for applying the restraint.

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This is a tough lesson to learn. Your patient was not harmed; some nurses are not so lucky. Forgive yourself, learn what you need to learn from this, and try to move on.

A relative of mine was in surgery when we suspect she received a big bolus of potassium and coded on the OR table. Luckily my relative survived just fine. My cousin saw an anesthesia intern being led away in tears. She was probably poorly supervised and only a month out of medical school. Sometimes I wonder what happened to her.

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