DJ-Adia

A new grad RN started on our med/surg unit approx 4 months ago. Her goal for the unit, as she stated @ at our last unit meeting, is to change the unit by reorganizing supplies as "SHE" feels would best promote efficiency on the unit. I think that that would be great...but her ideas aren't practicle. Our nurse manager thinks she is the "ideal" role model for the unit. I have come to live by the belief "I trust everyone 100% until they give me a reason not to". After being an RN for 15 years, you just get the intuition that "something just is right" She (Allison) informed us at the last meeting, that she recently had a patient, who was on a cardiac diet, where her family brought her in a Cheeseburger from McDonalds. Allison did not hesitate to throw the meal the meal in the garbage and told the family that she would reimburse them for the cost of the meal, but as long as she was ordered to be on cardiac diet, the patient will comply with orders whether she liked it or not. Secondly, I was informed by allison that one of her patients were c/o pain & nausea, however Allison did not feel that the patient's was having as much discomfort as she wanted staff to believe. She told the pat. that she was giving her zofran IV to help treat the nausea, but instead only gave her an injection of normal saline. 15 minutes later the nausea was gone . Are placebos legal especially when a patient is aware that they are receiving it?

At this months unit meeting, we were informed that we'd be starting Bedside Report to increase staff accountability & decrease shift "Dumping". We were told that only "abnormal" findings would be communicated to cut down on the amount of time. I'm completely receptive to making changes if it promotes efficiency, patient safety and/or improves staff morale. I work part-time 3p-11p (6 days every 2 weeks) which significantly affects the continuity of patient assignments. Most times having new patients each time I work. I consistently follow the same Day Shift RN each time I work - which is the basis of my concern. The pertinent information she communicates in report is minimal. She often times does not know the recent vitals, pertinent daily labs ie; elevated INR's Low K+, Low Na, elevated creatinines or the telemetry rhythm they were in for the duration of her shift. If a patient is admitted w/ CHF or Pneumonia - she doesn't remember her lung assessment or I&O. She often answers "I'm not sure but I'm think they were fine". When I start my shift, I find a patient with a Potassium 2.0, Urine output of 100 cc/shift, BP 80/40's etc. It's very frustrating and not to mention sets me up for "liabilty" issues. I can't trust the info she gives in face to face report, much less at bedside where only the "abnormals" are communicated. I've spoke with the nurse supervisor numerous times about this RN & completed many incident reports for situations involving this RN. Any suggestions on how to address this situation?

Do you feel as if I handled the situation "unprofessionally" by not Representing the hospital & in turn caused the patient & her husband unnecessary distress. ? Who is suppose to represent the patient if nurses can't. It seems to me that a hospitals reputation is the role of the nurse to defend. How do you suggest I handle this situation? Any advice would be very much appreciated. Thanks for your response.

It wasn't until today that I got to thinking, "Am I really in the nursing profession for all the right reasons." I've been an RN for 15 years and believe that nurses are a patients best advocate until today..... I have been caring for an elderly patient who was admitted status post dehiscense of a portion of her incison from a fem-pop bypass arterial graft that was performed 1 month prior. The portion that is open has been debrided several times , with a few times while the patient lay in her bed & premedicated with nothing other than 20 mg of Oxycodone given several hours prior. The patient has reported repeatedly that the medication she been given since in the hospital has not even come close to relieving the pain she has. The last few shifts that I cared for this patient, her husband has been sitting at her bedside crying. He says, "I can't handle seeing her in so much pain - it just tears me apart". I have been trying to advocate for this couple much as I possible can, relating to them with professionalism, & empathy. The patient was referred to a pain specialist for management of her generalized pain r/t bone Cancer & recently has seen him for management of post-op pain r/t dehiscense of her inscision located on entire top portion of her left foot. He reccomended a medication that currently is not a part of our hospital formulary so attempts in obtaining this med have not been pursued. A wound vac has been recently applied to the area with dressing changes scheduled every 2 days. The pain is excrutiating each time the physician removes the dressing that is adhered to the exposed wound bed. I decided to meet with the Director of patient care services for the hospital to make her aware of the issue. I told her that I could nolonger continue to watch this patients husband cry each time he visits his wife because if it were my loved one I'd be irrate!!. Her response was: that I acted unprofessionally by empathizing with this patient & her husband. It is my job as a nurse to represent the hospital & assure them that we are doing all we can do to assure that her pain is effectively managed. By empathizing with this couple I was implying that the hospital was not doing their job thus createing more tension. Needless to say, I left her office being accused for advocating for the patient and not professionally representing the hospital. What are your thoughts on this issue?

The subject of waste/sharp disposal of IV tubing sets has recently been brought up at our facilty. I thought I'd ask if anybody had an answer. When disposing of an IV bag & IV tubing after discontinued from a patient, - what are the guidlines for disposing of the tubing given the "Spike" @ the end of the tubing?

At the hospital I currently work at, Joint comission reviewed all the Nursing documentation and sited us on not having all enteries date & timed thus making us non-compliant. Our Nursing manager is now requesting that staff go back & "time" all enteries for medical records dating back 3 months ago. My concern is the legal liability if we go back and make additions to the medical record (which is easily visible by variance in pen inks etc) and add times (for care we provided 3 months ago) are we setting ourselves up for legal implications if the chart would happen to go to court?

Our Medical/Surgical unit was informed yesterday that the Emergency Room was nolonger addressing the medication reconciliation forms seeing as though it is too time consuming. I was under the understanding that Joint Comission had enforced the Med Rec forms as a strategy to maximize patient safety as it relates to the medications they take on a routine basis. I feel that the ER should be asking about meds & their doseages to reveal if the patients presenting complaints could be related to a side effect or a contibuting factor causing a medication interaction. To avoid this step during triage - could the healthcare professional be held liable if a "medication-related" precipitating factor was misdiagnosed which resulted in a lengthy inpatient stay? In Addition, the majority of families that accompany a patient to ER "ususally" bring in the medication bottles and often times leave before the patient is transferred to our unit. Not only do we not know the medications - but also are at a loss in completing the Med rec without accurate information. Has anybody experienced a similar situations?

Has anyone experienced difficulty when changing a PICC dressing that has a Biopatch @ the insertion site. Last evening, I spent 15 minutes just trying to remove the tegaderm transparent dressing from the biopatch which is also adhered to the PICC cannula & Hub- without dislodging the PICC catheter. Am I doing something wrong? or have I completely missed the boat? Also, what are the guidlines for flushing Power PICCS with heparin. I have 2 patients currently with these PICC's - one is ordered to flush with heparin & the other is not. (Neither patients have anticoagulation issues contraindicating the use of heparin)

:idea:Everyone has been so helpful in guiding me to make informed decisions re: my dad's medical care (the result of a MVA involving an Armoured Security Truck that ran a stop sign & broad-sided my dad's car). Currently, we are being forced to make a decision that, in my opinion, doesn't appear to be in the my dad's best interest. 3 weeks ago my dad had a G-tube placed. 2 weeks ago they began using the tube for feedings. Whenever he was tube fed, within 2 hours of starting it out @ 10 ml/hr, his abdomen would become firmly distended & he'd be respiratory distress r/t the pressure that pushed up on his diaphram requiring mechanical ventilation. A colonoscopy was performed with decompression x 2 which relieved the distention .....that was until they resumed feedings again. He's having soft formed bowel movements on a daily basis, which lends me to believe there isn't an obstruction. They inserted a rectal tube to assist w/ decompression. CT shows large amounts of gas in the lg. intestines & stomach. The the dialated portion of the lg instestines measures 7 cm. which is said to not be that abnormal. 2 days ago, they simply andministered 2 water flushes of 60 ml/each and the distention restarted. A surgeon consulted yesterday for placement of a cecostomy tube but given the chances of occlusion & leakage - he's reluctant to do it. He's highly recommending placement of a colostomy. He claims it's the "ideal" solution. Doesn't anyone think that a colostomy is a rather invasive approach for someone who doesn't have a bowel obstruction? The surgeon diagnosed it as "Ogilvie Syndrome". Is there a chance that the G-tube might have migrated and thus causing a gastric outlet obstruction? If a colostomy is indeed the only treatment available - fine! but I have a hard time believing that. Any recommendations or ideas?

I have had an experience of a lifetime that has really put into perspective the frustrations that families encounter when a physician is too arrogant to enforce patients rights. My father is currently a patient in a local ICU & has required mechanical ventilation. Prior to today, I had highly respected the intensivist overseeing my dad's care. He seemed to really empathize with the families of patients he cared for. He kept us informed of dad's condition & explained things laymens terms so everyone understood. Yesterday evening My dad had a coloscopy and prior to the procedure, we notified the nursing staff that we would like to speak with the gastroenterologist doing the procedure to further discuss his findings & any reccomendations that he had to help resolve the issue @ hand. Needless to say, the message wasn't relayed & he never stopped to talk with us. When my mom requested to talk with him - the intensivist stormed into the family room and read us the "Riot Act". First of all, we are not to request to talk with any other physician besides himself. He's in charge - he writes the orders, consults specialists as HE deems necessary, and doesn't need to be told how to do his job. He went on to further say, that families are always quick to make reccommendations regarding what they feel should be done when really all they do is make the physicians job that much harder. Needless to say, based upon my assessment of my fathers clinical status seeing as though families always knows him best - I requested that his TSH be checked. The MD said, "whatever the result is, I will take it with a grain of salt anyway". The result was 250. He's now receiving IV levothyroxine. So far, the hospital stay has been 52 days & my mom has not left the hospital one night. Since the encounter with the MD, my mom feels that she needs to be there 24/7 because she feels insecure that he may not make decisions in dad's best interest. Given my Nursing experience, I was furious that a MD thought he could get away with treating a family in such an unprofessional manner - afterall, if he did it to us, he's obviously treated other families the same way. I contacted the medical director of the hospital but she didn't seem real concerned. Any Suggestions?

Is there a standard for how fast the infusion rate should be when a physician orders "To-Keep-Open"? Currently it is up to the nurses discretion as to how fast it should run. On an average, the rate is between 10 -25 mls/hr. Inorder to clarify the policy, I need to have appropriate documentation to support it. Does anybody have any ideas?

I work in small rural hospital & recently encountered a situation involving a 18 month old child who had swallowed a chocolate covered peanut in which he was allergic to. The ER doctor was very concerned about the child having an anaphylactic reaction and @ risk of requiring intubation so he requested he be admitted to our Med/Surg unit. Seeing as though we care for a minimal amount of Peds patients a year (probably 3-5 a year which are admitted usually for croup) and noone on staff was PALS certified, one of my coworkers had contacted out nursing coordinator to inform her of our concerns to have the child transferred by ambulance to a nearby hospital where the childs pediatrician was located. We felt that we could not provide the specialized care that this child would require seeing as though the oncall MD for hospital admission was 30 min. away & staff did not feel comfortable caring for this child in a critical situation. We do not have an ICU or a pediatrician on staff - so admitting this child, in my oppinion" would only set us up for COURT. Granted, as nurses, we are trained in CPR and have the general knowledge of the care a Peds patient would require - but why provide care at a lesser level when there is a facility more appropriate for this patient? The nursing coordinator informed us that there wasn't any reason why we should not have admitted that patient given the fact "we should not have to turn away patients for the lack of trained nursing staff". We were also told that staff should become certified in PALS (despite the fact that the hospital will not pay for the class or the staff's time for attendance). Should we have admitted this patient?

I have been an RN for 11 years and never have I encountered a situation as I did recently. I was caring for elderly male patient, who prior to admission, was independent & enjoying life with his only complaint being that he felt "tired & weak". 4 days into his hospital stay he lost his ability swallow (there was some thought that he might have had a stroke, but a definite diagnosis was not made). Given the risk for aspiration, the MD ordered that he be NPO & that plans be made for a G-tube to be inserted. The family was devastated!! This patient was the father of a co-worker (LPN) that I routinely work with. Given my experience with & research that I had done, I made the family aware of Vital Stim Therapy. VitalStim therapy is the only neuromuscular electrical stimulation that is cleared by the FDA to treat dysphagia. Clinical research has proven that by using Vital Stim: 97.5% of patients with severe dysphagia regained swallow function past the point of PEG tube dependency At three-year follow-up, over 76% had retained swallow function and only 3% reported aspiration I informed my co-worker (the patients daughter) about Vital stim & referred them to the website where they could find additional information. I told them that if they felt that Vital Stim would be a therapy they might be interested in - that they should talk further with their MD & the speech therapist to see if it would be a therapy that they'd reccommend & find beneficial. A few days later I received an email from our nursing coordinator informing me that it was inappropriate for me to inform the patient of VitalStim Therapy before first getting the ok from the MD because I was giving them "high hopes". I feel that I was being a patient advocate by simply making the family aware additional resources but regardless, they would need to consult with MD to further explore the risks of such treatment. Was I wrong by simply making my patient aware? Would I be liable in a court of law?