Pet Peeve

[SleeepyRN]

This is random but I just wanted to get this off my chest. First, before a CNA gets offended, I have to say I love CNAs. I was a CNA myself, and it is hard, under appreciated work. My pet peeve? I work in a LTC/SNF. The aides are constantly saying with an attitude "he needs a prn."

It's not the aides job to tell me what med to give and when. I simply want to hear what observations they made of the resident, then I, the nurse, will assess the resident and decide what action I feel is best to take. I remember one specific time, a CNA told me her resident needed her "prn." This resident had no psychotropic meds. The CNA snottily said "well the doctor needs to know he needs one." No, the doctor needs to know my assessment, and he/she can decide from there the best course of action to take. Many types of sedatives are contraindicated in the elderly especially combined with their diagnoses, which could cause an adverse reaction or even make the resident more agitated.

I just want to hear from the CNA what he/she observed, and I will take it from there. I've only experienced this at one place, so once again, no offense to CNAs. Just a handful at my facility.

[iluvgusgus]

Sharpeimom I love your name and your pic :)

[sharpeimom]

I worked in a state psych hospital for 20 years armed with a MSN plus extra grad credits which I feel prepared me well for my job.

I always wanted to hear what the psych aides had to contribute about any patient, but about the time one of them had found me and

ordered me to administer a PRN med which that patient may or may not have had an order for, it would absolutely NOT have happened

unless and until another nurse or I had done an assessment. It isn't as a putdown to aides, it's because I have a very hard earned license on the line. I'll delegate many duties, but final pre-meds assessment ain't one of them.

I always thanked my aides for coming to report on ___'s behavior. It's just how I was reared. I think, to this day, if I ever forgot to thank someone for something, my mom's ghost would immediately appear before me!

I wasn't putting aides down or attempting to diminish their knowledge. I really was not. I'm just very protective of my license.

[applewhitern, BSN, RN]

I sometimes work extra shifts on our psych unit. What I have noticed is that the mental health aides, CNA's, or techs, will tell me that so-and-so needs some Haldol, Ativan, etc. What they don't realize is that I cannot just blindly run and administer it, no matter how much I trust their input. I have to assess the patient, look to see what they already have "on board," and document it all. We have had a problem with our patients getting over-medicated, and/or medical issues being overlooked because the patient was too sedated, or had meds that masked other symptoms. Nobody wants a patient to hit or hurt someone, but we want them safe, too.

[la_chica_suerte85, BSN, RN]

I think that a lot of it is the language -- it's forgetting that the nurse requires an actual SBAR/SOAP/SOAPIE (SOMETHING!) standard format of report regarding the situation, the CNA's attempts at intervention within the scope of their job description and then a recommendation....but, even still, I think making a recommendation to a nurse that a patient needs such and such without the nurse, the one licensed to dole out meds, doing their own assessment is out of line.

[Mn nurse 22]

I work nights on a dementia unit. I work with the same CNAs and residents every night.

I don't mind if they ask for a PRN but I then go and do an assessment, try my own interventions (Mitch Miller on my iPod is surprisingly helpful) before I give any PRNs.

I would certainly be irritated if they demanded it but since our nursing station is behind closed doors they are the ones spending every night with these residents while I pop in and out between 2 units and mountains of computer work.

I trust their input and try to give them my respect and appreciation for their hard work. They do come to me with every little change in our residents and see things way sooner than I would most of the time.

[pixiestudent2]

I'm an aide in a psych hospital, and whenever something seems to be brewing I tell a nurse.

Often I do hear my co workers telling nurses to give prns. I don't, but I think because I'm in nursing school I have a better understanding how things work, not all patients have them ordered, might be a medical condition that I don't know about.

But I have seen nurses, following a techs order about a prn with no assessment, but that's another thread.

[FaithGurl93]

I'm a CNA but I understand where you are coming from. A patient was getting a little restless and constantly getting out of bed EVENTHOUGH he was very weak. I didn't tell the nurse what to do I just suggested and said "does this patient have anything because he is very restless..." They would look it up or even call the doctor to put in orders so it's about how you say it. I would never tell anyone how to do their job and they're in a higher position than me...NO WAY LOL

[courtneyyyBSN]

I can totally see where you are coming from. I was also a CNA before becoming an RN and would notify the RNs of any changes, which is totally acceptable.

However, I worked on a floor as a RN, and there was a PCT that ALWAYS would ask the patients if they needed something for pain after she woke them for midnight and 0300 rounds. This could be appropriate if the patient demonstrated pain by nonverbal cues or through their vitals. However, she'd ask the patients that were VERY dependent on their medication, you know, the ones you already give pain meds q2h anyways PLUS additional scheduled meds... Then they'd want additional medication. Well, if she hadn't of asked them if they needed their "pain shot", they probably would actually sleep and not need it as frequently. I am a firm believer of making sure my patient is comfortable, and a firm believer that the CNA or whomever should notify the RN of any changes. BUT to intentionally awaken every patient and FIRST ask... DO YOU NEED A PILL? That's ridiculous, especially when a good handful were given their pain meds maybe an hour before, BUT she wouldn't know because she can't access the EMAR.

HOWEVER, it's important to approach the coworker with the issue. I told her that I could handle my patients but am fully appreciative of her help and notifying me of situations but to PLEASE not ask every single one of them questions that I should be asking during my assessments and my check-ins with them. She thanked me for discussing the topic with her and we still had a great working relationship.

[ComeTogether, LPN]

I get what you're saying, I do, especially in the examples you gave.

I will say though, I have often times observed patients who had so many different nurses in a weeks time, that their pain/skin issues/breathing etc. was not being noticed or addressed.

There have been times where I have had to ask the nurse if she could talk to the doc about it etc. because, just reporting what I see doesn't always work. Lines off communication aren't always the greatest, and people slip through the cracks.

Although I'd never "tell" a nurse what the pt needs, I'll always advocate for the pt, and I will speak up if I think what I have to say can be helpful.

I'm sure the scenario I've described isn't what you've experienced, as I've worked alongside know-it-all CNAs who think their 10 years of experience is equivalent to a nursing degree. It drives me bananas.

I just wanted to share my thoughts on why sometimes it's appropriate to discuss things unrelated to my scope with the nurse.

[SleeepyRN]

If I know you have done everything they could to redirect or soothe a pt then I will certainly get a PRN.

If you just come up to me and have make no effort at all to connect or engage the pt, then I will suggest some nonpharm interventions.

Hell, I'll even show you what I mean if you're skeptical (and don't doubt my gero whispering skills again;)... honestly, I want to teach everyone the Art of Gero Whispering, but you'll never learn it if you keep running to the nurse for a PRN!!)

When a pt is on a 1:1, the sitter's job isn't just to watch the pt and call for help, but to find ways to prevent having to call for help in the first place: engage them in a conversation-- even in it's not nonsensical, play some music, fuss over them: smoothe the bedding or... *gasp* give them a back rub... the list is endless and full of things that would make you go, "Yeah, right, Hygiene!", but you'll see how you need to allow yourself to be creative and slightly courageous.

Somebody else on AN pointed out that sitting is "exhausting if you're doing it right" (sorry, I don't remember who said it) but they were spot on! If someone thinks they're just going to read a book all shift because the nurse is going to give a PRN... well, no, that's wrong.

I expect staff to do their jobs before the PRN's come out... and that includes myself!

The techs may not always realize what medical issues-- on top of some serious meds-- the pt may have. I will try to explain that, sometimes, adding more meds (PRN's) on top of that can actually be rather scary.

And what does anyone do when the doctor refuses to order an PRN? Well, it's back to developing, utilizing and honing those soothing and redirecting skills... and I'll be right there with you until we can find something that works... and hopefully, no one gets a punch in the nose in the process.

But don't just tell me to give Bubba a PRN because he tried the door or poured his coffee on the floor... let's see if we can figure this guy out first.

I too was a sitter. It WAS exhausting work, because as you stated, I helped to keep from having the nurse come in in the first place. I did so by exactly as you stated. I was creative with ways to keep the patient calm.

I absolutely listen to the CNAs. When a CNA tells me so and so needs a prn, I ask what the situation is, and then I assess the resident. I don't blow off what the CNA is telling me. But I don't like them telling me what nursing intervention I should take.

[SleeepyRN]

Just making an observation but I was wondering that when you call a Doctor do you not make recommendations for care? I only ask this because after assessing/working with a pt and you notice something don't you call the doctor and say " Hey I noticed this, would you like me to order this....ect?"

In effect isn't this what your CNA's are doing with you?" I notice pt is doing this, you might want to do this?" or " So and so is hurting, they need a pain pill.

I guess my point is I am not above anyone recommending any kind of intervention about a pt be it CNA, Respiratory, or even family.

Now if this is an attitude issue as in the CNA is saying it disrespectfully then that is a conversation you need to have privately with them and expectations you have for working together. You teach people how to treat you.

If a CNA came to me and stated it the way you put it "hey, I noticed this...." I would have no problem with that. I would very much appreciate it. It is as you stated, an attitude problem, saying it with disrespect. So I am now addressing the attitude issue.

[SleeepyRN]

So my assessment skills only started when I had the RN behind my name instead of the PCTA?

Actually, yes. CNA'S can make observations and report that to the nurse, but legally only a nurse can assess. I trust the CNAS observations, therefore I immediately assess the resident, then I put into place an intervention. That is called the nursing process, which is not taught to CNAs. Again, it is the Attitude I get from SOME CNAs that gets on my nerves. I personally don't mind CNA's knowing what medications the patients are on, but if one would want to get technical, CNAs aren't even supposed to know what medications are given. It is a violation of HIPPA. I learned it the hard way when I was a sitter and I asked the nurse, "Did you just now give her Ativan?" The nurse replied, "she got what is ordered for her." I would never go to that extreme, because that was plain snotty. But it goes too far when a CNA snaps at me "he needs a prn because I'm not putting up with him like this."