Nursing 101

[Copper4]

Nursing 101

Yesterday 01:11 AM written by Copper4 | 1 Comments

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I have found myself frustrated of late because I think bedside nurses may be missing some basic care elements-- I have not been a bedside nurse in the acute care setting for a very long time, and realize that the tasks and responsibilities are mutliple. I generally have the utmost respect for bedside nurses. Most of my clinical nursing was in homecare, but this was after a good 5 years of cardiothoracic nursing in an acute hospital setting. I now work as an acute care case manager. Often times have to place people in nursing facilities upon discharge because they have become debilitated while in the hospital's care.

The other day I was working on the weekend, My role entailed reviewing for appropriate level of care. My responsibility was to review observation patients and new admits and assure that the level was appropriate. I came upon a 92yo woman who had fallen while getting into her car, she did not meet acute level of care criteria for admission. She was placed on observation status, thankfully had not broken anything but did require a short stay to make sure all was ok--- she was chronically on coumadin and therefore the fall did cause her to look like she had been through the mill with lots of ecchymotic areas. The dilemma was what to do with her upon discharge. This woman wanted to go back to her independent living apartment with homecare. I asked the nurse to walk this patient to better determine her functional status. The nurse essentially told me she did not feel comfortable walking this woman and she would need to wait for a physical therapy consult.. I asked why and the nurse told me she was concerned about the liablity. i asked what about DVT's, ileus's, pneumonias? all the adverse complications of immobility... no response, not willing to take the risk. I called the PT and asked for an evaluation, the next day found out she walked 300 ft with her walker and supervision.

This has become a bit of a pet peeve of mine. I have also seen demented patients who have sitters with them, so that they will not climb out of bed. However, the aides assigned to them do not bother to get them out of bed. I worked as a sitter in college, and totally cared for the patient, got them up and moving if able. Tried to get them tired so that they would sleep peacefully. Perhaps the person wouldn't be climbing out of bed if they were given the opportunity to get out of bed!

Isn't it basic nursing to get the patient moving? Get the lungs ventilated, get their blood flowing, bowels moving etc... or are we so concerned with potential law suits that nobody wants to risk it? Maybe I am just old...

[Zaphod, BSN, RN]

Depends. I understand your point, however in the real world of nursing we sometimes have to weigh the risks v benefits. I will put a patient in a chair but will generally try to avoid walking anyone who is high risk for falls(especially on coumadin-big risk for a brain bleed). There are few reasons for this. First if they do fall and hurt themselves, administration will crycify me. Second, Im petite and would just end up on the floor myself if anyone fell on top of me. So, Ill error on the side of caution and if I am concerned about immobility(Not on day 1), and PT is not available I will do ROM. Just my

[fungez]

Oh, I ambulate everyone unless they're on strict bedrest. It's just as important as passing my meds. Especially if they're elderly. Even a couple of days of immobility will debilitate them to the point where they may never get it back.

I've never had a patient fall while walking them. Of course, I use a gait belt and if needed, I'll have a wheelchair right behind them.

[Dorito, ASN, RN]

I agree with you Copper. I have seen the same thing happening. Patients are not being ambulated unless PT does it or at least does an evaluation. One of the doctors I have worked with agrees and complains about this issue all the time. Especially those post op patients.

[Zaphod, BSN, RN]

I agree, although it depends what floor you are on. Where I work most people are on ventilators, so this issue doesn't arise often. And its true about post-ops they need to be out of bed asap.

[LibraSunCNM, BSN, MSN, CNM]

I work on a surgical unit and we certainly get our post-op patients out of bed, and if they're able, walk them. Yes, PT is great and takes care of this for the most part, but if it's a weekend and they're short, or the patient wants to get up after PT has come and gone, we consider it our responsibility as nurses. The only reason I would give for not doing it is being crunched for time. I wouldn't refuse to walk a patient simply because of fear that the patient would fall. That's what walkers and extra people are there for!

[livinthedreamRN]

Absolutely get the post-ops up asap. As for the rest, our docs use activity orders i.e., bedrest, bedrest with BRP, up with assist, up ad lib...you get the idea. If a patient is not ordred to get up and I get them up and they fall, I'm liable. When a PT order is written, the therapist will let me know what the patient is capable of. There are other ways to prevent DVTs and atalectasis that the doc will implement. Our case managers here know to refer to PT for progress reports.

[livinthedreamRN]

I work on a surgical unit and we certainly get our post-op patients out of bed, and if they're able, walk them. Yes, PT is great and takes care of this for the most part, but if it's a weekend and they're short, or the patient wants to get up after PT has come and gone, we consider it our responsibility as nurses. The only reason I would give for not doing it is being crunched for time. I wouldn't refuse to walk a patient simply because of fear that the patient would fall. That's what walkers and extra people are there for!

You have extra people!?!?!?! You're lucky!

[LibraSunCNM, BSN, MSN, CNM]

You have extra people!?!?!?! You're lucky!

Haha, I know, I know, there is NEVER enough staff to meet every patient's every need. But I guess what I was trying to say is that to me, "the patient might fall and I'd be liable" isn't a good enough excuse for not getting a patient OOB. There are ways to get patients up and be safe, even if it means enlisting a family member to walk on the other side of the patient while you're there too, or begging an aide, whatever it might be. What I'M afraid of being responsible for are the DVTs, pneumonia, pressure ulcers, and bowel issues that come from immobility.

[nicole109]

I don't think that you are old, but I think that the public has become very lawsuit happy, and I think that many nurses are either overwhelmed with all of their responsibilities or concerned with protecting their license. I am now a homecare nurse, so I feel your pain of seeing many patients coming home much more debilitated than they went into the hospital with, but I worked in acute care for 5 years prior to homecare. When I worked in the hospital, even the therapists required to have orders from the doctors to get the patient out of bed. As a nurse, if I knew that the patient needed to be up and it was safe for them to be out of bed and I had a previous conversation with the doctor about the patient being out of bed, then I would get them up and make sure the order was in the computer before I left for the day, but not all nurses were like that. Some nurses, and therapists too would require that the order was changed from bedrest or out of bed to chair to ad lib before they would even touch the patient. I also have a backround in medical malpractice, and it's very sad, but I have seen just as many nurses hang themselves on issues related to immobility, pneumonia and pressure ulcers as I have on falls; and the hospital doesn't back up their staff at all--they rely on the doctors orders and on prudent care. As far as the sitters are concerned, I think there has been a shift there...when I first started in the hospital, the sitters were all CNAs, so they were allowed to touch the patient, bathe them, feed them, etc. Closer to the end of my tour of duty, the sitters became just that--sitters only, they were not allowed to touch the patient, they were there to just watch the patient. If the patient moved, they would put the call light on, and call the tech or nurse into the room. It really slowed down progress on the unit because you were constantly being called into the room for things that they should have been able to handle, but hospital policy was that they were not allowed to touch the patient. It never made sense to me, because they technically were allowed to let the patient fall if nobody got to the room in time to catch them.

[Zaphod, BSN, RN]

You have walkers?lol..some nice place. But truly, we dont have gait belts for the nurses.