Nurses discretion to hold Tx?

TheCommuter, BSN, RN · Jan 18, 2017

It is within the realm of your nursing judgment to hold medication, treatment, wound care, or any other prescribed modality. However, you cover yourself by notifying the physician of your intention to hold it.

If you had called the physician to inform him/her that the ACE wraps were held, the oncoming morning nurse would not have had a leg to stand on when she complained that you should have carried out this task.

LessValuableNinja · Jan 18, 2017

Depends on your state and facility. With that said, it's your responsibility to hold any treatment that your professional judgement indicates will cause further harm to the patient. The textbook answer is that when you do this, you notify the attending or attending's representative (whomever is on call). I won't comment on the real world application/how that normally works out, depending on time of day or night, but really it's a question best answered by the DON in a LTC facility. When I worked in LTC, I always asked for policies in writing to protect myself. If it didn't exist in a policy, I asked for an email that provided instructions.

LessValuableNinja · Jan 18, 2017

It is within the realm of your nursing judgment to hold medication, treatment, wound care, or any other prescribed modality. However, you cover yourself by notifying the physician of your intention to hold it.
If you had called the physician to inform him/her that the ACE wraps were held, the oncoming morning nurse would not have had a leg to stand on when she complained that you should have carried out this task.

I also agree with this.

brownbook · Jan 18, 2017

All answers are correct, but the reality, are you going to call a physician at midnight to ask if you need to put ace wrap over the opsite? Or get an e-mail? Certainly no policy is going to cover it. There is no easy answer.

I am confused, I can't figure out what the ace wrap's purpose was? Something to do with the blood blister? Something like ted hose to prevent blood clots?

Yes you can always hold treatment, yes you have to always notify the doctor. The day shift should have explained why it was important that the ace wrap be put on. Maybe there was a good reason. The day nurse could have been more understanding and more helpful.

I hate perpetuating the NETY myth, but obviously I am wrong, it is not a myth, your co-worker is a prime example.

chare · Jan 18, 2017

[...]
I hate perpetuating the NETY myth, but obviously I am wrong, it is not a myth, your co-worker is a prime example.

From the OP

[...]The morning nurse came in and said I should have put them on...
[...]

How exactly is this an example of NETY?

brownbook · Jan 18, 2017

From the OP
How exactly is this an example of NETY?

Yor are correct, I assumed the day nurse was abrupt and or less than pleasant in telling this new grad night shift worker what he should have done.

We we will have to hear from the original poster to correct my assumption.

Being a 17 year night shift nurse I admit I get my hackles up when day shift tells "us" what we "should have done" at two in the morning.

Unitedlife · Jan 19, 2017

You are correct, I assumed the day nurse was abrupt and or less than pleasant in telling this new grad night shift worker what he should have done.

This sums up exactly what happened. She stormed off to the room and put them on, with no real reason given. It has happened a few other times, I usually just laugh it off. In the end I see it as my judgement vs hers.

amoLucia · Jan 19, 2017

It's something minor but it got me thinking, when do I have the discretion to hold a Tx?

What was your rationale for declining to wrap the ACE? There needs to be a reason.

Usually, ACEs are off at HS and re-applied in the morning. Application is best facilitated while the pt is in bed. And much more smoothly & evenly applied before they get OOB with legs being dependent then.

I can't imagine applying an ACE soooo tight that it would impact a blister the size you describe.

To me, a good application of the ACEs while pt is in bed trumps its application when pt would be OOB.

PS - 11-7 nurse here about half of my career.

HeySis, BSN, RN · Jan 19, 2017

You do have to weigh the choices and the consequences.

You can withhold a treatment, but it needs to be justified. If the reason she was getting the ace wraps was to prevent DVT or for lymphedema, then it maybe a better choice (depending on this patients history and your assessment) to risk irritating a blood blister and apply them.

In reality, if the choice is between an irritated (although covered, so protected) blood blister and a DVT that could become a PE, then the blood blister is a lower priority.

If the patient had a lower immune system or was known to have a antibiotic resistant bacteria colonizing her skin and disruption could lead to a bad infection, then the choice might be different.

Even if you didn't make the call to the ordering provider at 2am, (real world vs text book) It would have been good to do so as soon as morning hours came around and before you left work. Even when a patient refuses a treatment we need to inform the ordering provider.

I would ask the nurse that took you to task, what she was concerned about. And I'd ask in an honest, non-sarcastic manner. Such as "Can I ask why the ace wraps being applied is a higher priority for this patient then concern over the wound being irritated?"

Not because you're the night nurse and the day nurse knows better... but because you are a new nurse and new to the facility. I would ask to see if there was some part of the critical thinking process you missed.

If there was, then admit you hadn't thought of that and learn from the experience. If there wasn't a reason, just a nurse trying to make you feel bad, then learn a cover your *** from that, either way you'll learn something. Good Luck!

GM2RN · Jan 20, 2017

What was your rationale for declining to wrap the ACE? There needs to be a reason.
Usually, ACEs are off at HS and re-applied in the morning. Application is best facilitated while the pt is in bed. And much more smoothly & evenly applied before they get OOB with legs being dependent then.
I can't imagine applying an ACE soooo tight that it would impact a blister the size you describe.
To me, a good application of the ACEs while pt is in bed trumps its application when pt would be OOB.
PS - 11-7 nurse here about half of my career.

This is what I was thinking. You always need to have a good rationale for withholding a treatment or medication and make sure you chart it.

taivin · Jan 20, 2017

This resident is having ace wraps at night? Do they scratch at night? Why are they wearing ace wraps at night? Am I reading it wrong? BTW; look up your own state's Nurse Practice Act, to find your scope of practice in the state you live. :)