Nursing scope of practice/Standard of care

[singleprego]

I am a RN working at a chronic facility. The FA spoke with me concerning a decision I made a few months ago. Some background on the clinic for you- Most of the nurses have been working there a very long time, maybe 10+ yrs and havent been working anywhere else during. The FA is not a nurse but a very intelligent business man. The mentality of all the teammates is "each man for himself"!...very unfortunate. Here is the decision, I would like your opinions nurses....

I took care of a pt that ended up septic after a c-section landed her with renal failure. After being in the hospital and on a vent for about a month she recovered enough to go home and came to us at our facility. During the admission assessment process she mentioned that she was breastfeeding. I was later instructed to administer her PPD. Just as I was about to stick her I wondered if the medication enters the breast milk and could cause harm to her newborn. So I stopped and went and asked the C.C. if she knew. She said that she didnt know, so at that point I began checking med guides- which there wasnt one there, online information, we paged the MD-who never returned the call, called a pharmacist- whom wasnt sure either. Well, the C.C. and the charge nurse thought that my judgement to withhold the med until I was clear about its pharmacokinetics, thought I was being over reactive. Things were said to me like "Its sub-q (intradermal, i know), how would that enter the blood steam"? "Why are you making a big deal, just give the medication"!

I finally rec'd clarification from her ID MD and the med was administered.

Recently when the FA talked with me in his office, he stated that I am to do what the charge nurse says and to not give them a hard time. If she said to give it, then you should have given it. I was floored by that! I explained how I would be liable if harm had come to that newborn and how the company would be as well. He said that the charge nurse would be liable. If I am not mistaken, I should never give a medication I dont know about. It is my job as a RN to protect the pt and I feel the FA should have applauded that fact that my thinking had not become institutionalized.

However, I am offended that the FA didnt stick up for me. There has been other incidents like spiking the bath with CA without a recent lab value. I have been told to falsify documentation reguarding the new heparin infusion policy.

Is this all a common practice in dialysis facilities?

Thanks for reading, I know it was long.

[Lacie, BSN, RN]

You made the correct decision. One of the reasons I left my previous clinic is the old adage "It's the way we always have done it". Your FA is giving you the INCORRECT information to say the charge nurse would be responsible if in error. It's your license on the line when you give a medication. I hope you documented in the nursing progress notes very well all your actions and why you came to the conclusions you did. I would have done the very same thing. If one of my nurses (I'm a DON by the way) with the same question and I didnt know then I would encourage her to take the very steps you did. Pat yourself on the back and kudos for putting your patient and her child first!!!!! Also pose the question to your state board of nursing for documentation and put it on his desk!!!!

Also check out this article for Ceu's. The entire course is online and worth the reading just for the info. You dont have to take it to get the wealth of information it provides. It helped me alot in making alot of decisions in my practice.

http://www.nursingceu.com/courses/147/index_nceu.html

[wordsmith]

That FA had his head you-know-where...don't do anything to endanger your license--it's your livelihood. Good for you for sticking to your guns.

[CocoaGirl]

You must work for Fresenius, I personally don't feel that someone without a nursing background should be in a FA position. You did the correct thing, after all the FA doesn't have a license to lose, but you do.

[Valerie Salva, BSN, RN]

All of the large dialysis companies pretty much suck.

[traveler RN]

Had a similar experience with an FA, I stood my ground for all I was worth! As nurses we are taught to be a strong patient advocate and I still believe in that. The end result was the med I had questioned was clarifed by a pharmacist and comfirmed my gut instinct. It is not a policy in clinics to add lytes to dialysate baths without a recent lab and to falsify records. This FA is clearly out of line, your license is on the line the every day you step into the clinic and you are the one who is hung out to dry.

[krups]

If you don't know a lab value and add lytes to a bath you could kill someone. I can't imagine a clinic following this type of practice. I also never heard of falsifying records. These are not common practices.

[workingmomRN]

Your FA evidently does not understand the liability that he is taking on, or the risk to your license. I wonder if the doctors that round in your clinic know that falsifying documentation is going on. As a nurse, you did the right thing. If anything had happened to the patient, it would have been your license on the line, not the charge nurse, because you actually administered the medication. And you can bet that if it ended up in court, the FA & charge nurse would not back you up at all. I think it sounds like a place waiting for a disaster to happen. You might want to think about exploring your options somewhere else.

[woknblues]

"Its sub-q (intradermal, i know), how would that enter the blood steam"

I would have backed away at that point, physically and mentally.... Wow. So, this person is either saying that all teratogenic / harmful to baby substances are only such if administered via the blood stream, and/or that somehow, subcutaneous tissue has no relationship to the circulatory system?... Astounding. I will have to check my anatomy and pharmacology books again. What an ass.