I'm an RN on an ortho unit at a large hospital. We recently admitted a patient with a chest tube. Several days went by without the dressing being changed. I cared for the patient on the 7th and 8th days after admission. The general surgeon, who was the admitting, did not include any orders for dressing changes. Pt's family got very upset, especially after I paged the MD for change orders, and he didn't call back. Because we're an ortho unit, we don't see a lot of chest tubes, but apparently on the respiratory unit, it is common knowledge that this MD likes daily dressing changes on chest tube pts, so he never puts in orders for changes. Family contacted the director of med/surg for the hospital about this, and the director contacted shift supervisor, who then contacted me. I did page the MD, and I also left a note in the electronic chart for him indicating that the family wanted to speak with him about care, and included a phone number. He didn't contact them until he found out that they were upset. He didn't respond to my page (he's notorious for this). I feel like I did my best, but this matter has gone all the way to the chief medical officer, my unit supervisor, and the med/surg director. In an email, it was stated that our ortho staff needs education on chest tube dressing changes. I feel like we're being thrown under the bus. The MD should have put in dressing change orders. The MD should have responded to my page. The patient shouldn't have been on an ortho unit for over a week when he could have been transferred to the respiratory floor. As I said, I cared for him on the 7th and 8th days after admission. Maybe one of our nurses who cared for him much earlier in the week should have asked the MD about change orders. As it turns out, the MD is pissed off at me, the family is pissed off at me, and administration is pissed off too. Sometimes, you do your best and it still doesn't work out.
I worked on a floor with a lot of thoracic surgery some years ago at a large teaching hospital. Fact is that patient with chest tubes got admitted to that floor (if not in the ICU, PACu or similar) because of the special knowledge required to provide best care to patients with chest tubes. That includes the assessment of the drain, drainage system, air leak, subcutanous air, drainage. There needs to be special knowledge about how the dressing should be done and what to do in emergency situation like disconnected tube/tube falling out/ sudden subc. air/ reps problems.... . In very rare cases a patient sometimes had to go to a different floor but nurses on that floor were familiar with chest tubes , eg. cardiac surgery step down or similar.
Chest tubes are somewhat "special" in the sense that training is required. There are also different drainage systems from the old fashion bottle system (probably not in use in the US anymore) to Pleur evac and other systems which are more mobile with valve.
I think the lesson learned from this event is that nurses who take care of patients who require special knowledge or dressing changes need to identify the problem and speak up on day 1 - latest day 2. If a physician does not get back with an appropriate order the supervisor or manager has to get involved. This is just not good - what if somebody gets an infection? what if something happens and staff is not trained?
Patient care is a shared responsibility between teams - nursing and physician as well as PA/NP/residents need to work together to establish best care.
Of course the family is not happy about this situation.
Perhaps it would be best to have patients with chest tubes only on designated floors with staff that is trained.
Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
As far as documentation goes, you did your job. Something tells me when things are not going good for administrations or supervisors, they go to others to blame to make themselves look not so bad. I am not a nurse, but when someone comes to me and says 'something needs to be done', I say 'it was already done. Look at the computer and look at the faxes'. And I don't worry about it for the rest of the day.
This makes no sense. And if you're not a nurse, you don't get it.
Order to change a chest tube dressing? Honestly, its just chlorhexidine, split gauze with out without xeroform, gauze, and cloth or pressure foam tape. It's not rocket science. I have dealt with hundreds of chest tubes and the dressing orders I have seen were only for trauma patients...
The doctor rounds every day and no one brought this up during rounds? C'mon now....
I don't believe that a large facility with a unit that routinely admits patients with chest tubes does not have P&P for chest tube care in place. "I don't have an order" is a pretty lame rationale to give a family member concerned about why something isn't being done. It behooves the RN caring for a patient with a chest tube to do a little research and learn about how to properly assess and care for the patient. I agree that if the policy is that the physician writes the order for dressing changes and he failed to do that, then the physician is also culpable, but that doesn't erase the nursing staff's responsibility to educate themselves on proper chest tube care, and be able to communicate appropriately with the concerned family.
I guess I am in the minority here, but I would have changed the dressing. I don't think I have ever seen an MD order for a chest tube dressing change. I just follow the policy of the facility I am working at. I would think it would be a standard of care to have a clean, intact dressing. I can't imagine not changing it simply because the MD didn't tell me to.
Hey, surgeons can be picky about their chest tube dressings, especially if they are on a trauma patient. Some - especially in teaching hospitals - want to do the initial change themselves & thereafter will only allow residents to do it. But I do agree that there needs to be some sort of clarification. If there is indeed a facility standard for daily chest tube dressing changes, it needs to be in writing & nurses need to be aware of it.
The policy always was that the MD needed to do the first change, thereafter the resident. Chest tube dressings can be of the occlusive variety--with the goal of not upsetting and dislodging the tube, as well as to keep it occlusive. And if any air gets in, then what when patient goes into resp distress?
It is not like a abdominal tube where there's a split 4x4.
I would be more curious why on day 8 a chest tube was still in, and if there was serial chest x-rays, and the tube is classically pulled if the lung is inflated? Not that I have experience with it other than with pneumos. But interesting.....
Just make sure your policy is not the MD does the first dressing change...
Specializes in Infusion Nursing, Home Health Infusion.
I think you are thinking about this as if it was similar to a medication order. You had no order so therefore you are not responsible to change the dressing. This is simply not true. You must think of it in terms of what is the expected standard of care or in other words what would a prudent nurse do if they found themselves in a similar situation. A prudent nurse would be expected to keep a clean dry and intact dressing in place and perform regular dressing changes. The nurse must assess for infection and look for any drainage,the amount and its characteristics and to assess for subcutaneous edema,air leak etc.. In other words it's not just a dressing change it is an assessment too!
If there was no order to perform a dressing change then that should have been noticed and the LIP called for orders. That is what a prudent nurse would have done and you will be held to the same standard. I do agree that everyone involved should take the heat for this and realize it is a great opportunity to learn. It should also alert you to the fact that as a nurse you do not want to just work off a list of orders and medications to give. You want to keep the big picture in mind so all aspects of the patient's care are taken care of. I know it is difficult sometimes because we have to chase down other disciplines and make sure they are doing what they are supposed to be doing.
There are so many things wrong with this scenario.
1st - the admitting nurse should have seen that there were no orders and either gotten some or rounded up the correct P&P according to your nursing resource. All units have a book that they are referred to for nursing care when there is not a specific policy in place. My current workplace has Mosby's, the one before that was Lippincott, the one before that was... you get the drift. If you don't know what book your unit is supposed to be referring to, that's a sign that there's a lot of "word of mouth" nursing going on, instead of EBP. Yes, you checked with your charge and your house sup, and that's good, but the actual book needs to be consulted. The admitting nurse needs to be educated on how to get orders and how to consult resources.
2nd - the surgeon/NP/group who is rounding should be checking the dressing and the chest tube setup during rounds. If they are not, that is on them. The nurse should have brought up the chest tube and the lack of orders during rounds. The group needs to be have an incident report filed for neglecting their duties and the nurses on days 2-whatever need to be educated and possibly written up.
3rd - As soon as the dressing became soiled, it was the nurse's responsibility to find out what to do with it. This should have been taken care of long before it was your problem. The nurse who had the patient on the 2nd/3rd days needs to be educated on how to get orders and consult resources.
4th - Paging the surgeon is good. Not getting an answer is not an excuse. You either keep paging every 20 min until you get a callback, or you take it to the medical director. You don't just stop calling and say, "He didn't call back! What am I supposed to do?"
5th - As other posters have said, if you didn't know what to do, couldn't find a resource, and didn't get a call back, then you should have contacted someone who would know. There are a ton of people who should know, such as a resource nurse, code team nurse, ICU nurse, med/surg nurse, respiratory floor nurse, hem/onc nurse, etc. You could contact any nurse eductor.
6th - Chest tube care is a basic nursing skill. This is one of those things you should be getting checked off on during yearly skills checks. Your unit manager should get together with the hospital/unit educator. Y'all need an inservice or three.
This was a total breakdown in your unit and your hospital's ability to function. The surgeon has every right to be pissed, because it was a nursing fail from the start. Yes, he didn't write any specific dressing care orders. It would have been better if he had, but he obviously assumed (wrongly) that the nurses on your unit would be competent.
I'm sorry if that seems harsh, but it is the truth. This situation never should have gotten as far as you. You can take comfort in the knowledge that you, at least, tried to handle it. You get kudos from me for that.
I just can't believe the amount of FAIL in this scenario, from house sup all the way down to floor nurse.
Specializes in Medsurg, Public Hlth, School Nurse, Acute Rehab.
Do physician's not round on patients daily? Why didn't the family bring up their concern to the doctor during rounds if they believed that their family member wasn't being properly taken care of? When I worked med surg family members bombarded the physician with questions. I also agree with the poster who asked why the physician wasn't assessing the chest tube themselves. They put the tube in. Shouldn't they check it during rounds as well? I'm not saying nurses shouldn't do their jobs, but why aren't the doctor's doing theirs?
I saw a soiled and dirty chest tube dressing on a new patient who came at the last two hours of my shift. There was no order for dressing change. I changed the dressing and the patient was complaining of severe pain. It was not the first time I changed chest tube dressing. I called a young surgeon to report pt's pain and he screamed on the phone "NO NO NO NO you are not supposed to manipulate the chest tube without telling me!!!!" I was so scared but I did it out of good intention because I did not want the patient to have infection. Well, the surgeon came to see the patient and he asked me to leave the room because "you are torturing the poor patient!!!", he said. The patient was fine and his pain went away without any pain medication after the surgeon came to talk to him. The surgeon apologized for yelling at me but that incident really made me feel nervous with chest tube dressing change.However, I did not regret my decision to change that dressing.
nutella, MSN, RN
1 Article; 1,509 Posts
I worked on a floor with a lot of thoracic surgery some years ago at a large teaching hospital. Fact is that patient with chest tubes got admitted to that floor (if not in the ICU, PACu or similar) because of the special knowledge required to provide best care to patients with chest tubes. That includes the assessment of the drain, drainage system, air leak, subcutanous air, drainage. There needs to be special knowledge about how the dressing should be done and what to do in emergency situation like disconnected tube/tube falling out/ sudden subc. air/ reps problems.... . In very rare cases a patient sometimes had to go to a different floor but nurses on that floor were familiar with chest tubes , eg. cardiac surgery step down or similar.
Chest tubes are somewhat "special" in the sense that training is required. There are also different drainage systems from the old fashion bottle system (probably not in use in the US anymore) to Pleur evac and other systems which are more mobile with valve.
I think the lesson learned from this event is that nurses who take care of patients who require special knowledge or dressing changes need to identify the problem and speak up on day 1 - latest day 2. If a physician does not get back with an appropriate order the supervisor or manager has to get involved. This is just not good - what if somebody gets an infection? what if something happens and staff is not trained?
Patient care is a shared responsibility between teams - nursing and physician as well as PA/NP/residents need to work together to establish best care.
Of course the family is not happy about this situation.
Perhaps it would be best to have patients with chest tubes only on designated floors with staff that is trained.