New LPN in LTC with backlash due to Res. on alert/monitoring

  1. Hi everyone!

    I sat for my NCLEX-PN in September, passed, and acquired a position at LTC with TBI/SCIs. I feel that I have been adapting well to my new role as a LPN. Previously, I was a CNA for 4 years. My pharmacology, time management, and prioritization have excelled over the past approx 5 months, though I am still struggling with necessary/unnecessary charting, if such a thing? Currently there is a resident with an indwelling catheter who has hard black stones/sand which occluded the catheter requiring it to be changed and the stones/sand is noticeable at the bottom of the collection bag. It is noted he had a 5mm non obstructing kidney stone 2 weeks ago. Due to increase of stones/sediment causing urinary retention and catheter changes, I placed him on 72 hr. alert with strict I&O with temp. and a PVR at the end of each shift to monitor for urinary retention, fever, or pain. I notified guardians and on-call doctor of situation. Resident is in no apparent distress or pain, though is nonverbal with TBI. Several nurses voiced that it was unnecessary to place him on alert and include additional treatments/monitoring each shift because guardians are aware and will schedule any needed appt. so there is no need to put him on alert. They also said kidney stones are "no big deal because he's passing them". This has been going on a week, maybe 2, and no one has charted in progress notes of any change in condition. They also are not doing the PVRs I added to treatment flowsheets. He is afebrile but output was 200mL in 8 hours, possible obstruction?? Can't these rough stones cause damage to urinary tract if it continues? I don't know if I did the right thing or if I'm just over concerned due to being a "newbie". What are others experiences/insights into kidney stones or hard/rough sediment in urine? Or LTC charting and monitoring?

    Thanks!
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    About jromeo93

    Joined: Aug '13; Posts: 3; Likes: 4

    8 Comments

  3. by   sallyrnrrt
    I do not see anything wrong with your plan of care and monitoring...I'm sorta proud of you...
  4. by   JBMmom
    You're well within your scope to place this resident on extra charting/interventions because you're concerned about a change in condition. While other nurses shouldn't be ignoring these interventions, they may see them as unnecessary after their years of experience. As long as you're doing what you know is right, there's not much you can do about others, unless you're willing to go over their heads and point it out to management. Might not be worth it to do so, that will not make you any friends. Hopefully he will not have any adverse effects. Was the 200mL output much below the patient's baseline? If so, you should notify MD.
  5. by   BrandonLPN
    There is definetly such a thing as unnecessary or "too much" charting.

    If the resident isn't having pain and is voiding, I think your interventions are not necessary. 200cc output for one shift isn't that far from what one would expect. As someone said, it's dependent on the resident's baseline and on if it's an isolated incident or a trend.

    New nurses tend to go overboard with ordering monitoring and interventions in LTC. Sometimes, it's almost insulting to experienced nurses to have all these endless things ordered in the MAR/TAR. PVR q shift? Why, if he has an indwelling catheter and he's voiding? As an experienced nurse, I know to monitor for increased sediment and/or low out put. I know to encourage fluids and consider irrigation if sediment is heavy. We are perfectly capable of monitoring for hematuria. We monitor for pain as a matter of course. We do not need all these orders placed in the TAR telling us what to do.

    As someone who has cared for people with kidney stones and as someone who has *had* kidney stones, I can tell you that if the resident is actively passing a kidney through the ureters, he will tell you! Once the stones reach the bladder, the pain is gone.

    I think alert charting for three days is appropriate. More to keep nurses monitoring to see if the sediment is occluding the catheter than for any other reason. All the interventions are a bit much. Monitoring his output and pain level is all that is needed. Adding excessive interventions in the TAR that your colleagues *have* to do is, frankly, just adding one more burdensome task to an already unreasonably long list of unnecessary tasks we have to initial every shift.

    Someone *should* have been charting on the stones and sediment, though. Document that he had them, that the catheter was irrigated and/or changed. That it is now patent with output. That family and MD were notified. That resident denies pain. Describe the output. It's not the alert charting I'd be disgruntled about as an experienced nurse, more the bladder scans in the TAR. And, really, how is it really a "post void residual" if there's an indwelling catheter?
    Last edit by BrandonLPN on Feb 14
  6. by   qaqueen
    I don't think there is anything wrong with the OP's actions.

    BrandonLPN wrote:

    "As an experienced nurse, I know to monitor for increased sediment and/or low out put. I know to encourage fluids and consider irrigation if sediment is heavy. We are perfectly capable of monitoring for hematuria. We monitor for pain as a matter of course. We do not need all these orders placed in the TAR telling us what to do."

    As you would have done all of this anyway, why is it a problem that there are actual instructions in the patient's chart? Perhaps, other newer nurses need the instructions. As for being disgruntled about bladder scans, really? What if the catheter really is obstructed, this would be the easiest, fastest way to find out. And, it is likely that you could assign the task to a CNA.


    Perhaps the term "PVR" was not the best choice, however, was it really worth nitpicking? So, if you don't like the term the OP used, what would you use? Urinary retention?
  7. by   BrandonLPN
    Quote from qaqueen
    I don't think there is anything wrong with the OP's actions.

    BrandonLPN wrote:

    "As an experienced nurse, I know to monitor for increased sediment and/or low out put. I know to encourage fluids and consider irrigation if sediment is heavy. We are perfectly capable of monitoring for hematuria. We monitor for pain as a matter of course. We do not need all these orders placed in the TAR telling us what to do."

    As you would have done all of this anyway, why is it a problem that there are actual instructions in the patient's chart? Perhaps, other newer nurses need the instructions. As for being disgruntled about bladder scans, really? What if the catheter really is obstructed, this would be the easiest, fastest way to find out. And, it is likely that you could assign the task to a CNA.


    Perhaps the term "PVR" was not the best choice, however, was it really worth nitpicking? So, if you don't like the term the OP used, what would you use? Urinary retention?
    Well, I'd disagree that because the catheter became clogged with debris once, that justifies q shift scheduled bladder scans. PRN bladder scans based on whether or not retention is suspected would be more appropriate. It may seem nit-picky, but adding an unnecessary bladder scan to the list of tasks to be done is burdensome in LTC with 35 residents to care for.

    Plus, the OP specifically asked for the opinions of other LTC nurses. Obviously only the OP has first hand knowledge of th situation. I'm inclined to agree with her coworkers on this one. If *one* nurse had voiced that the interventions were unnecessary, I'd be more inclined to agree that the complaints originated from laziness. Since *all* her coworkers voiced that the interventions were a bit much, well, they probably were. Live and learn.
  8. by   Cream and sugar LPN
    Brandon, don't you need an order in place when placing an intervention such as scans in the TAR? At my facility other than interventions such as Q shift vitals it wouldn't be considered negligent not to sign off on a TX based on individual opinions once there's an order to do so. I agree every nurse Q shift should be charting on what's in that bag to cover their own butts in the event things take a turn for the worse.
  9. by   caliotter3
    I have found that the lazy nurses will say, "we do it anyway, that is a nursing action" when they rationalize ignoring TAR entries that were placed there at the direction of management. It was explained to me (in the extended care setting) 'we place an entry on the TAR for an action that is called for on the plan of care. The nurses' initials there indicates that the plan of care was followed and is more easily defensible in court as having been done'. Makes sense to me, lazy or not. You can't force the other nurses to follow suit. If the managers give you grief and tell you to stop doing this, then you have to worry. The time might come when you receive a poor job evaluation because workplaces tend to be unkind to thorough employees.
  10. by   jromeo93
    Hi BrandonLPN,

    The output of 200cc is concerning because the resident typically has an output between 800-1200cc each shift. As for the patient voicing pain, he is nonverbal and a quadriplegic. He responds through eye blinking, and I can notice facial flushing during times of pain but it can be difficult to communicate and observe how much pain or distress the patient is in.

    Two fellow nurses voiced being upset and stating "you're over concerned, you're just new". I felt a PVR was justified with an indwelling catheter due to it being occluded with stones and when it was changed 1600cc of output was obtained. It concerned me because the resident went through an 8-hour shift without voiding, meaning the urine backing up in the renal system and becoming stagnant increasing the chances of UTI. I also felt it was necessary to place a PVR because we have many agency nurses and communication between shifts isn't always ideal, so adding the resident on alert with a TX, I was hoping everyone on the care team could be aware of the situation.

    I appreciate the feedback and insight!

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