is this really bad nursing judgment?

[mlss94]

Hey everyone! This is a half vent, half needing advice post. I promise to get to the point though! Well I'm a new RN working only less than 3 months off of orientation. I come to work one night and assigned a very combative pt in bilateral restraints. This pt was very strong and was agitated all night. Typical nightmare right? When trying to give medicine, the pt was able to swing and hit me in the stomach many times. This pt had a triple lumen central line placed in the groin. When the CNA removed the mittens to get a sugar check, the pt somehow snagged one of the lines. When the pt finally let go after holding it super tight, I saw that the top part was off. Like the port and lock. The CL was still in place and the other lines were flushing and pooling back blood fine. But I immediately thought, this is introducing infection big time and possibly a pulmonary emboli. I called the nocturnist who was baffled and clueless and told me to call the surgeon. The surgeon of course was pissed. He ordered to clamp the line and add a hemostat for extra protection. Not to d/c the CL which is what I thought he would order but hey I'm just a nurse. I even asked our nurse supervisor for her opinion and she didn't oppose to the surgeon just said to do what he ordered. I did what was ordered and told the dayshift nurse what had happened. The dayshift nurse takes it upon herself to d/c the CL. Come back to work to hear that that very nurse (who I have followed after many times, who has event reports on her, and many complaints about the way she practices) told everyone on our unit what happened and criticized my nursing judgment. I believe the nurse said I had bad nursing judgement. Mind you, after she shared with me that if anything happened that that would be on the surgeon and never said anything to my face about her two cents on my nursing judgment. Totally two faced me. Anyway, I'm asking if ya'll think she was justified? Honest but respectful opinions appreciated. I'm new and I want to correct any mistakes I make and be a better nurse.

[Kooky Korky, BSN, RN]

One thing stood out at me:

"Hey, I'm just the nurse"

You clearly did not agree with the physician's order/judgment, which is why you questioned it with a few people. Always remember that you have your own license to protect. Did you do the prudent thing by following the physician's order when you were concerned about an infection risk? If that patient gets sepsis and dies, and there is a malpractice lawsuit and you're deposed, would not pulling the CL, or following the chain of command, be defensible? Just something to think about.

With regards to your coworker's behavior - no, gossiping about a coworker and badmouthing him/her to others is never okay.

Going against the surgeon's order would not, IMO, be defensible unless a new order to do so had been obtained.

OP, what's this about the pt hitting you in the stomach? Too bad you didn't get an order to sedate him. Or some help to hold his arms and hands while you were giving meds. Don't allow patients to do this to you any more. Being beaten is not part of your job.

[jdub6]

It can't be bad nursing judgement if it isn't nursing judgement at all. The doctor knew the circumstances and ordered you to maintain the line a certain way. Nursing judgement allows you to depart from that and pull the line, with no effort to get an order, only if there is an immediate need and obtaining orders would jeopardize safety. If the patient had the line half out, nursing judgement could be used to safely remove the rest and manage the site. And inform the doc immediately once done.

Your coworker performed a task that should have been done with an order. While there was infection risk, the time needed to obtain orders would not have caused an infection that otherwise would have been prevented. If we're nitpicking she was practicing outside her scope. That is usually considered poor nursing judgement.

In this case the risk of leaving the line had to be balanced with the risk of pulling it (needing new access, a new insertion which carries risks, maybe there were no preferred sites left...). The surgeons judgement was that leaving it was the better risk. If you, your coworker or any other nurse felt he was wrong, there was ample time to discuss it with him and if there was still a concern to take it up the medical chain of command. That would have been the appropriate use of nursing judgement. ignoring his orders in the absence of an immediate threat to the patient was not appropriate.

Regardless, gossiping is not good. I agree that this can be addressed with a direct "Jane, I heard you ended up pulling that line. I know we both had some concerns about Dr D's orders to leave it in place with a hemostat. I was a little worried also. Did I miss something that lead you to pull it yourself, or did you get that order from Dr D's superior?"

[Accolay]

Don't allow patients to do this to you any more. Being beaten is not part of your job.

That's where the line is drawn with me too. Do not let yourself or coworkers be hurt by anyone. Ask for medical restraint in the future.

Otherwise, let stupid roll off your back cause it's going to happen again. Don't let it get the best of you and continue the good fight.