Inaniel

Emergencies I've run into in my 11 months.... -Severe respiratory distress. I ALWAYS call 911 first. Then the family. Then the doctor. I think that's technically the opposite of how it's supposed go, but it seems to be the best way of getting things done. I guess it just depends on your DON. If they're DNR and I KNOW the family doesn't want them sent out then I call the POA first just to make sure they haven't changed their mind. Otherwise I call 911, THEN call the family (or simultaneously...I'll have another nurse make the family call or vice versa.) The doctor's rarely answer calls/pages (I work nights) and in my experience don't call back for several hours. If pulse ox. is low 90s or high 80s I'll start O2 or increase it, give PRN neb and elevate HOB, monitor and keep trying to reach the MD. Protect your license. Know what's in your crash cart and where the back board is for CPR. Know how to overhead page. -Chest pain....nitrostat and 911. -Gtube comes out....Before that situation arises I'd find out if your Gtube ACTUALLY is a Gtube and not a PEG. I recently had a resident room-change to my wing; he'd been in the facility about a month, nurses were charting on his "gtube". I checked his orders for his gtube size and it wasn't there. Awesome. I checked his uploaded documents (hospital transfer paperwork). I couldn't find anything specifying whether he had a Gtube or a PEG tube. Turns out it was a PEG, in which case you'd send them out for replacement. I was taught to insert a foley in the meantime to keep the insertion site open. -Critical labs...I always check lab results that came back that day. Often the PM nurse I follow will just fax all her labs to the MD regardless if they're normal or low/high. We're supposed to call on labs if they're low/hi or critical. On a busy lab day the nurse you're following might have missed something. I've call the MD in the middles of the night for several critical labs the previous nurse had missed. -Falls. Skin events. Power outages. Find out the policy on these before you start. Good luck!

Thanks to everyone's replies.

-Yes this resident was/is hospice. Ativan/MS Q2hrs PRN, Haldol QID PRN, and ABHR cream scheduled QID + another narcotic added BID since my post. -The thing is, she doesn't really seem to be in much pain. She is advanced alzheimers and screams a lot. If she's in pain she will tell you, but mostly she just screams nonsense and can be quieted down with a little 1:1 and TLC. It was in the works to have her sent to a psych facility but the family was very adamantly against this, so it seems to me the AM/PM RNs and DON just dose her around the clock to keep her quiet and keep the family happy. -But YES - lesson learned - always give scheduled narcotics (if you don't have an order to hold it). I WAS written up, but understandably so....I should have documented that I held the med and called the doctor to have an order to hold. Being the crazy night it was, I just circled it in the MAR. The AM nurse (longevity RN + notorious facility bully) took it to the DON, instead of taking a second to TEACH me what I SHOULD have done. -We get admits up until 9:30. One even came at 10pm during shift change. We are a 120 bed facilty. 5 nurses & 10 CNAs on AM/PM, and 3:6 on NOCs. Usually always a call-off or two with CNAs evry shift, and very few residents are independent. -While I try to keep in mind [re: CNAs] that they can't do my job, I'm the one who's held accountable by the AM nurses when people are wet or not toileted or not up for breakfast. We are usually short-staffed, have a high staff to patient ratio, and each night CNA is expected to get up 6 resident's for the morning. We start get-ups at 4am, breakfast isn't until 7:30 am. It's a lose-lose situation for me whether I'm behind or they're behind in their work, because either way I'm still charting after 6am and they're off the clock, and I'm the one catching flack from the morning shift.

- however this resident was, IMO, "snowed" from the previous shift. She was responsive/easily arousable but denied having any pain and had been given her PRNS -moprhine, ativan, haldol, tylenol - at every available I say she was overmedicated because this resident generally is screaming out at night but this particular night she was sound asleep.

Do most med error incident reports result in a write-up? First post, new grad, NOC charge nurse. Had a crazy night the other day...We were short -had 4 CNAs for 100+ residents, as well as three 9pm admits; I come on at 10p and have to get admit paperwork, observations, and my own full-body assesment b/c i don't "trust" the PM/admit nurse's assessment, plus TBs done ...I spent a lot of time helping CNAs with morning get-ups (hoyers) and completing several time-consuming day/PM TXs due to our wound nurse resigning..plus toileting/changing/turning residents during my midnight and morning med pass; more-so than usual d/t being short. Busted my butt and did a great job that night. Written up the next day for not giving a resident scheduled morphine cream - however this resident was, IMO, "snowed" from the previous shift. She was responsive/easily arousable but denied having any pain and had been given her PRNS -moprhine, ativan, haldol, tylenol - at every available time d/t her family being in the facility during the PM shift and requesting her be medicated even when not warranted. (This resident can be sound asleep and her family will request her Ativan/Haldol/morpine be given all at once). I'm worried about this med error/incident and kind of find it ridiculous that I might get written up for this. Comments/suggestions? I understand I was technically at fault for not giving a scheduled pain med, however this person was sound asleep and when I gave the AM meds she denied having pain. It's silly to me because there are long-term residents there that are non-verbal/non-mobile and probaly in pain but don't even have PRN tylenol?!? Despite e faxing MDs and asking the day nurse to f/u it never gets done. I DO understand pain management and when signing out my morning Narcs (I offer pain meds to my resident's in the morning b/c they go to PT early before breakfast and I don't want them to be hurting) I find that I'm usualy the only nurse they've gotten pain meds from that 24hrs.... Should I even make my case in opposition to this write-up or just take it as a lessoned learned? Meeting with the DON this week. Thanks.