Refusing a Clinical assignment

AgentBeast, MSN, RN · Jun 27, 2012

I had a student refused to give a Coumadin because the INR was "elevated". It was 2.4.
Pt had Atrial Fib.
I tried to help her think through the reason the INR was elevated and she just repeating to me "Normal INR is 1.0. This is 2.4. Its elevated".
So - before you "refuse" to do something, think it through long and hard.
Also, remember once you are in the real world you may not be able to refused to take care of someone. So the earlier you learn to deal with difficult situations, the better.

That's just stupid. Of course it's "elevated" the patient is on Coumadin! 2.4 is actually pretty good.

OB-nurse2013, BSN, RN · Jun 27, 2012

I don't think theres ever a skill you do for the first time and feel confident about it, so I suppose its always scary the first time or even first couple times even. If you mean something thats unethical or something you are religiously opposed to then thats different. We were told in OB that we didn't have to be involved with an abortion on the floor, which really I never heard much about it at my placement. Although in my psych rotation I did have to care for a pt. that was there until his trial the next week for molesting two of his grandchildren that his wife of 35 years had found tapes of. That was hard for me, very hard.

RLtinker, LPN · Jun 27, 2012

I don't think I could respond to this without knowing why or what you wanted to refuse.

funky monkey · Jun 27, 2012

I guess it depends upon why you refused. If you're unfamiliar with a procedure or an order, ask your instructor for help. The instructor can "walk you through" the procedure and in no time you'll be proficient.

chevyv, BSN, RN · Jun 27, 2012

Of course you can refuse, but you'll most likely be repeating the clinical next semester if you can make it that long. Why would you refuse a clinical assignment? It's all about learning. When else are you supposed to do the learning if you refuse now? Someone has to care for your pts now and when you become a nurse. Whats up?

Merlyn · Jun 27, 2012

As students, do we have the right to refuse to participate in any given clinical assignment or proceedure? For example, if you are assigned a patient or order you are not comfortable with can you decline? Being "green" and nervous we all have to put in our chops, I get that, but what if it is an area we are really not ready for? What happens if we refuse?

Back when I was in school, if you refused anything you were out the door. But in this respect every bodies belief no matter how loony it is. Probably

CherylRNBSN · Jun 27, 2012

I feel like I must play devil's advocate here.
Don't assume you know more than a staff nurse as a student. She's passed more pills than you can dream. I'm sure she knows ER pills weren't *manufactured* to be crushed. But it's very probable that the doctor knew the pill was being crushed and was fine with it. Heck, maybe he *wanted* her to get the full dose quicker. Think about it, if they switch to the same dose of morphine in liquid form (as you suggested they were going to) how would *that* be extended release?
Once you actually become a nurse, you will see that from time to time doctors order medications to be administered in ways that were never officially "recommended" in any drug handbook. Did you know doctors in rare instances order for end of life pts to get certain pills administered rectally? Not suppositories, but actual pills! You won't find that in your drug book!

I have never crushed a time release drug. Isn't there a danger you can OD the pt? Once you crush it, it's no longer extended release? I would think a patch would be better. Anything but crushing a time release. I would seriously have to consult with a PharmD before doing that.

Just curious. Is this really done? I was always taught this is a no no, but I haven't practiced in a while.

FORTHELOVEOF!!!! · Jun 28, 2012

I have never crushed a time release drug. Isn't there a danger you can OD the pt? Once you crush it, it's no longer extended release? I would think a patch would be better. Anything but crushing a time release. I would seriously have to consult with a PharmD before doing that.
Just curious. Is this really done? I was always taught this is a no no, but I haven't practiced in a while.

I have seen this done before on my unit with stroke patients. A patient had a long history of narcotic use (not abuse) for chronic pain and was on a large dose of Oxycontin, doc changed it to a smaller dose so that it could be crushed, so I can see how knowing the patients background would help with making the decision. My only question that no one was able to answer was why not give the guy an immediate release crushed up rather than the extended release in a smaller dose. I don't know much about the makeup of the drugs so I couldn't argue it. And now some drugs come in a crush proof pill form, it gels and clumps up to keep it from dissolving too fast. Some things just make you go... hmmmmmm.......

Topaz7 · Jun 28, 2012

Talk to your instructor. I had a similar situation in my clinical. It was a Pt newly admitted to the rehab unit with active TB, he had only been on his meds for 1.5 weeks, he had no mask, no kind of isolation precautions, no masks for the nurses to wear, etc. I believe they are considered non contagious or what have you after being on the meds for 3 weeks. Anyways I brought it up to my instructor who looked into it and the hospital really shouldn't have even discharged him to the facility, she took him off my assignment and stated we couldn't take someone on without the proper precautions in place.

CherylRNBSN · Jun 28, 2012

I have seen this done before on my unit with stroke patients. A patient had a long history of narcotic use (not abuse) for chronic pain and was on a large dose of Oxycontin, doc changed it to a smaller dose so that it could be crushed, so I can see how knowing the patients background would help with making the decision. My only question that no one was able to answer was why not give the guy an immediate release crushed up rather than the extended release in a smaller dose. I don't know much about the makeup of the drugs so I couldn't argue it. And now some drugs come in a crush proof pill form, it gels and clumps up to keep it from dissolving too fast. Some things just make you go... hmmmmmm.......

Thanks for explanation/example. I am still thinking get this cleared with PharmD before doing. B/c even if a doc orders it, it's still YOUR license. YOU are the one administering med. If PharmD says no, he/she will take it up directly with MD.

If anyone else has any more light to shed on this, I am all ears.

FORTHELOVEOF!!!! · Jun 28, 2012

Thanks for explanation/example. I am still thinking get this cleared with PharmD before doing. B/c even if a doc orders it, it's still YOUR license. YOU are the one administering med. If PharmD says no, he/she will take it up directly with MD.
If anyone else has any more light to shed on this, I am all ears.

Totally agree

Pepper The Cat, BSN, RN · Jun 28, 2012

That's just stupid. Of course it's "elevated" the patient is on Coumadin! 2.4 is actually pretty good.

Yeah- the exact point I tried to get across.

I asked "What does Coumadin do?"

I asked "What it pt's hx"

I asked "What is past INRs" ( pt had been very stable, past INRs were between 2. 4- 2.5)

Nsg student could not answer any of these questions. Scariest part was nether could the instructor.

I ended up giving the Coumadin.

This clinical group gained the not so desired repretation as being the Stupiest and Most Annoying Clinical Group of the year. (unofficially of course!)