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Cdonocdo

Cdonocdo

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Cdonocdo has 7 years experience.

Cdonocdo's Latest Activity

  1. Cdonocdo

    Asked to change my Nursing Note...

    @Wuzzie three nurses were involved. It was myself, the patients nurse and the weekend supervisor. I’m glad I was able to get that across. @Been there,done that I have access to their documentation system for looking at progress and screening for readmissions. I’m ending this thread, I totally appreciate the responses. I was looking for constructive criticism and thank you for feedback. Yes being more concise in notes would be ideal but our facility does not have a chart by exception policy. It’s 100% free text so I have to include all vitals etc. I’m going to use something I learned from one of the comments regarding some of the latter comments- I believe the feedback could have been conveyed in a much constructive and respectful manner 😊.
  2. Cdonocdo

    Asked to change my Nursing Note...

    @Wuzzie You're not going to upset me at all, I've been a nurse 10 years but I'm willing to learn. They did end up doing narcan x 4 once he got to the ER, the hospitalist note stated primary issue opioid overdose and secondary issue afib.
  3. Cdonocdo

    Asked to change my Nursing Note...

    @JKL33 I appreciate all feedback, both negative and positive. Thank you for taking the time to respond to me. I love how nurses can all learn from each other 🙂
  4. Cdonocdo

    Asked to change my Nursing Note...

    @Wuzzie Thank you for your response. The policy at our facility for narcan administration is the following: Prior to administration: • Assess for respiratory dysfunction/ depression (character, rhythm, and rate of less than 10 breaths/minute.) • Assess for LOC and pain before and after administration. How could I better support the intervention in my documentation? I'm not being a smartass, I'm just curious and want to know what other documentation I should include- so next time I'm better prepared. Thank you!
  5. Cdonocdo

    Asked to change my Nursing Note...

    OK, thank you for your feed back. I just wanted a sounding board, but you are right I'll remove it from my note. I'm just frustrated because if I fill out an incident report, it just goes to the DON and nothing will be done.
  6. Cdonocdo

    Asked to change my Nursing Note...

    OK here is my redacted note- I took out all PT identifiers... I kept the charting professional and discussed facts only. This nurse assisted in response to PT's change in status, PT was in his room at 930am sitting in bedside chair. CNA working with PT alerted PT's nurse that PT had an acute change in status, PT's nurse entered room and PT was sliding out of bedside chair. PT was convulsive and tremulous, diaphoretic, pale pallor, RR irregular and shallow 8-10/min. PT's eyes were bulged open, pupils enlarged and fixed, PT stated he did not feel well. FSBS collected by PT's nurse, 263. PT's nurse collected vitals, POX 99% on RA, 134/98 HR irregular, showing range from 39-74. Palpated by nurse, pulse fast and thready. PT c/o 9/10 pain to lower back, had received PRN Dilaudid 2mg at 8am. PT currently has an order for PRN Dilaudid 2mg Q4h, PT received max dosage yesterday for c/o 8-9/10 lower back pain with little to no relief from Dilaudid. PT currently has spinal stim implant for pain management. PT has PRN order for Narcan nasal spray. This nurse, weekend supervisor and PT's nurse attempted to locate Narcan on the floor in the medication cart, the rapid response pack and the medication room- Narcan was unable to be located and not present on the floor for administration to be possible prior to EMT arrival. Emergency services called, EMS arrived approximately 3 minutes after call- EMS unable to get rhythm strip, HR thready and irregular. PT continued to be diaphoretic and speech rambled. DON contacted regarding Narcan not being readily available on the floor for emergency use, stated to weekend supervisor that the Narcan was in an E-kit and the pharmacy had removed the E-kits from the building recently d/t change in pharmacy. STAT order for house supply of Narcan sent to pharmacy to have medication available in house. This nurse contacted ER, spoke with Dr. AJFAJFLAKJFLAJK- PT was found to be in A-fib upon arrival to ER, HR 180-190bpm. Dr. AKJFLKAJLDK stated that the PT is being admitted to CCH. Pt's wife contacted and updated regarding acute transfer to ER.
  7. Cdonocdo

    Asked to change my Nursing Note...

    I’m going to redact my note so you can see what I charted, I did not include that the DON had not informed staff.
  8. Cdonocdo

    Asked to change my Nursing Note...

    That is why I’m reluctant to change it. I’m the SDC/ADON so it is my role to do the investigation. It may be over the top, but when I was charting I was infuriated that when I called the DON to let her know what was going on- she very casually stated she had the pharmacy remove them... this really needed to be communicated with staff. The patient had received a total of 16mg of Dilaudid in the 24hrs prior and NEEDED the narcan.
  9. Cdonocdo

    Asked to change my Nursing Note...

    Hi guys, I just wanted a sounding board for this. I worked this weekend as a Supervisor, I’m an RN. We had a patient who needed Narcan, he had an order for it and we have a Narcan policy in the building. I went to the Med room to get it and it wasn’t there, 911 was called and the patient ended up getting admitted to the hospital. I documented that the Narcan was not given because there was none in the building and MD Informed. I documented that I informed the DON, who stated that she had the pharmacy remove the Narcan from the floor. I included that I sent the order to the pharmacy to be filled for house stock. I got a nasty email this morning saying to change my note to just say, “Narcan not given and unavailable”. I think that’s unacceptable, it’s a doctors prescribed PRN medication that we were not able to give because it was removed from the floors and the DON had not communicated that with any of us (and I’m a supervisor). When a patient is missing a medication, I always charted the reason why it wasn’t given and included the resolution- meaning order sent to pharmacy etc. I feel like I protected myself and my license, but I’m uncomfortable changing my note. Let me know what you guys think... thanks
  10. Hi guys, I just wanted a sounding board for this. I worked this weekend as a Supervisor, I’m an RN. We had a patient who needed Narcan, he had an order for it and we have a Narcan policy in the building. I went to the Med room to get it and it wasn’t there, 911 was called and the patient ended up getting admitted to the hospital. I documented that the narcan was not given because there was none in the building and MD Informed. I documented that I informed the DON, who stated that she had the pharmacy remove the narcan from the floor. I included that I sent the order to the pharmacy to be filled for house stock. I got a nasty email this morning saying to change my note to just say, “narcan not given and unavailable”. I think that’s unacceptable, it’s a doctors prescribed PRN medication that we were not able to give because it was removed from the floors and the DON had not communicated that with any of us (and I’m a supervisor). When a patient is missing a medication, I always charted the reason why it wasn’t given and included the resolution- meaning order sent to pharmacy etc. I feel like I protected myself and my license, but I’m uncomfortable changing my note. Let me know what you guys think... thanks
  11. Hi everyone. I'm hoping I can get some support and maybe an answer to the situation I'm currently in. I'm a brand new nurse, and I've currently been employed by a Home Agency as a Private Duty RN. The patient we are working with has 24/7 nursing care provided by RN's and LPN's. We administer her medication, which also includes Morphine Sulfate (which is kept in a locked box) Every time a dose of morphine was used, we wrote the amount and signed inside the Medication Count log as well as the administration record sheet. Part of this count records the amount in the bottle, the amount being administered, and the amount left in the bottle. This serves as our med count of the controlled substance. I worked with her on Friday 7-3 and kept record of all medication and administration of the morphine and signed off for 3 pm at the end of my shift. The next girl administered the proper amount of morphine, stated the correct amount was in the bottle no problems etc.. and signed her signature for her morphine administration at 4pm. Please keep in mind that this is a homecare case- and the agency did not even provide us with a bound medication count book- it was a half-ass binder that the nurses put together just to have record. So the weekend goes by, and I return Sunday morning for my 7-3p shift. The nurse I was relieving was rushed to get out, and the patient was laying in the hospital bed (completely raised) with both side rails up and urine was seeping through onto her comforter. My priority was to get the patient safe at that moment, so I took 10 minutes to clean her up etc... I then go to count the meds for 8am, and the morphine sulfate was missing about 6ml's. The first thing I did was call my supervisor and inform them of the disc., I called the patient's health care proxy as well as her Doctor to inform them of the potential medication error/med diversion that I came upon. I was scared that the patient received 5ml's of Morphine instead of the 5mg's that her 0.25ml dose is made up of. Her resp. were fine, and there was no sign of opiate overdose etc. The supervisor then called the nurse I relieved, and she stated "yes I knew it was short, and I forgot to tell the on-coming nurse" But this girl has even signed off with her signature at 0600 stating there amount that there was suppose to be, not the actual amount of morphine inside the bottle. So my supervisor starts an "investigation" of the med loss, and suspends everyone (including myself) until the matter is handled. I was not given grounds for suspension and have called several times, but no return phone calls have been made to me. The brief explanation I received was along the lines of "two nurses have to double check the med count and sign each time", which I can understand. But we are alone with this woman all day, and there isn't a second RN around to account for it. I always track the last shifts morphine usage amount and ensure that it matches up to the recorded amount being in the bottle. I did research online about this, and Yes- two nurses have to sign for narcotics.. but this was only applying to Accredidations of Long Term Care Facilities and Hospitals. I would just like some opinions on the matter, I thought I was doing the right thing by reporting the discrepancy but then got suspeneded.... I'm upset, this is my first nursing job and I'm heartbroken.