liability??

[jennrn01]

Recently the LTC I work at admitted a person with a trach. Pt is on RA with humidity, is a FULL code. This PT has a diagnosis of recurrent respiratory distress and seizures. According to the care plan written by the RN the patient is not to be AMBU bagged until breathing stops or PT's o2 sat drops below 60. The RN does not feel 24hr Oximetry is necessary however there is no other way to ensure PT is stable because PT is checked on only every 30minutes at most.

This is very concerning to the other RNs who work for this agency d/t on call duties. Not only that but what is the liability side of this situation and could there be criminal charges made if the PT should die?

[bill4745, RN]

According to the care plan written by the RN the patient is not to be AMBU bagged until breathing stops or PT's o2 sat drops below 60.

Is there a doctor's order for this? It does not seem appropriate for a full-code patient.

[canoehead, BSN, RN]

I think the questions about monitoring are best answered by the doc, and if the patient is able maybe he can express his preferences.

As far as using an Ambu bag, if I think the patient needs airway support and he's a full code, I'll bag him no matter what number the care plan has on it. Perhaps she has to write something specific about sats to fulfill paperwork requirements.

[systoly]

Of course every situation is different, but in general I wouldn't worry about 24 hr oximetry so much, but rather concentrate on managing secretions, as long as you have a known baseline of sats. Is humidification adjusted by RT? I've seen a lot of humidifiers in LTC set up by the delivery person and sometimes it's too much or not enough. What is the pt.'s hydrational status. Most likely swallowing is not possible, or difficult with a trach in place, especially if it's a cuffed one, so hopefully you can provide hydration via PEG. Suctioning is usually a more frequent concern than obtaining sats - gotta maintain the airway first. If the pt. desats and in the absence of mucus obstruction and poor positioning, supplemental oxygen delivered via the humidification circuit or directly to trach, if neccessary, is usually the next step in which case you'd want more frequent sats.

[jennrn01]

Bill - no this is not an order it is what the RN wants for this full code patient. However the family (the Pt is nonverbal d/t brain damage) wants the Pt to have rescue breathes(via trach) and CPR.

Canoehead - Pulomonlogist wants 24hr oximetry with alarm, according to this Pt's RN the doc did not give any parameters - which I find hard to believe as I have known and worked with this doc for many years.

systoly - Pt used to receive suctioning every am when living at home now has order to only suction PRN. Pt is adequately hydrated with feeding tube. We do not have RT on staff so you were correct when you stated that humidification was set upon delivery.

[bill4745, RN]

Bill - no this is not an order it is what the RN wants for this full code patient. However the family (the Pt is nonverbal d/t brain damage) wants the Pt to have rescue breathes(via trach) and CPR.

I understand it is what the nurse wrote. Is there a doctor's order to do what she wrote?

[systoly]

Thanks for the follow up post jenn. If there is any indication that the pulmonologist wants continous oximetry, I'd certainly be concerned about liability as well as providing appropriate care so why not get it clarified. Sometimes there is a problem with getting reimbursement for such equipment, but that's nothing new in LTC.

[Flare, ASN, BSN]

if the doc wasn't 24 hr oximetry then let him know that he needs to specify the order. This ends all debates with the other nurse.

[jennrn01]

no it is not a doctor's order.