Safe Nursing a thing of the past?

[butterball1980]

2 weeks ago, my 60 year old mother, for only the 4th time in her life, went to an ER in a moderately sized hospital, part of a large statewide hospital system. Her symptoms/age and recent medical history, were suspicious of stroke activity. Not blatant, but with a bit of critical thinking it would be considered. Although my mother walked in, she gave the "right words", let alone her general presentation, that should have had her whisked to a room immediately, if not a stroke alert called, she was placed in a waiting room, by an RN, due to a "full unit." No triage, No VS, no assessement but immediately dismissed to the waiting room out of view of the registration nurse. After sitting in the waiting room for 30 minutes, she was taken to a room, initial VS done (high blood pressure present) triaged and continued with possible stroke symptoms. Again, not blatant, but many factors that should have been alarming. My mother was in the ER for 8 hours. And not a single nurse or doctor physically examined her. The only physical touch by another person was when the LPN took her BP and an IV was started. No neuro checks, no circ checks. Nothing. No continuous monitoring, not even a cardiac monitor. I was shocked and embarrassed to be part of the profession. If my mother, the mother of a seasoned nurse in the same hospital, could be so poorly treated, what about all the other mothers out there. My father, an LPN, sat at her bedside. He told me he did not intervene because he "assumed" that at any time, she would be examined. He was also interested to see if it would be done after her testing was completed. Had he not pushed for a CT, it would not have been done, after all, her 10/10 head pain was likely a "migraine" It was only at her transfer that he pointed out that no ER staff member had done a physical assessment. And my mother left the hospital for the same pain she arrived in. The "migraine" cocktail did not work and the dr. lectured my father of the pitfalls of opoids when he requested more treatment for her pain.

It's led me to a great deal of thinking and sadness over the last few weeks. I've tried to dive deep and figure out what in the world is happening to our profession. Are we so reliant on machines that we no longer need to touch and assess? In the ER, are we so reliant on protocols that we no longer critically think? Are we so hung up on patient satisfaction that we miss key factors? Are we no longer teaching the importance of physical assessment? Are we too management top heavy and working too short as the front line nurses? Are we more worried about presenting a KPI board to 4 administrators then doing a pupil check on a possible stroke patient? Are we too worried about "real time" charting and meeting parameters that we can't get off the keyboard and look a patient in the eye? Are our up and coming physicians no longer taught to examine a pt? Do they rely on protocols, machines, results and e-med so they no longer need to think either?

I know without a doubt that this is in no way an isolated event. I have seen nurses chart lung sounds, when they haven't had a stethoscope on hand for 8 hours. I've watched nurses chart a complete neuro check, when all they've done is hand grasps. I could go on and on and on. I, for one, will call out a nurse when I see this. I remind a nurse that it's falsification of records, in the least, to chart what we haven't done. I have also reported it to management.

I would greatly appreciate thoughts, opinions and experiences with our new trends in nursing. For me, it's terrifying. To the point that I vow to leave a profession that I have been in for 19 years because I know there are wrongs I can no longer right. I have loved being a nurse and used to be so proud. As time goes on, I find myself feeling more concern, more fear and more disappointment.

[NurseCard, ADN]

That's so sad and scary; my dad was taken to the hospital about 3-4 years ago

with stroke symptoms. He did indeed have a small stroke and fortunately there

were interventions in place so that, he did not suffer long term damage. I am

thankful for that.

So your mom did have a CT? What did it show? Did she indeed have a

stroke, a TIA, or..?? Sounds like it could have been done much sooner.

I believe there's a certain window of time for confirming that someone

is having a stroke, and administering clot busting medication?

Shaking my head... I dunno...

[LovingLife123]

I'm sorry you had a bad experience for your mother. I know, I myself, have had bad experiences at ERs. Especially when it gets dismissed as a "migraine".

You have to be an advocate for your family as well as your patients.

My mom recently had a TIA. As a stroke nurse, i questioned the heck out of her and made sure all appropriate tests were completed and make sure she regularly sees her neurologist. She lives in an area of the country that is rated top ten likely to die due to the horrible medical care.

Fortunately, the physicians did everything correctly in her situation.

[LovingLife123]

That's so sad and scary; my dad was taken to the hospital about 3-4 years ago

with stroke symptoms. He did indeed have a small stroke and fortunately there

were interventions in place so that, he did not suffer long term damage. I am

thankful for that.

So your mom did have a CT? What did it show? Did she indeed have a

stroke, a TIA, or..?? Sounds like it could have been done much sooner.

I believe there's a certain window of time for confirming that someone

is having a stroke, and administering clot busting medication?

Shaking my head... I dunno...

There is a 3 hour window for administering TPA. CTs will not show an ischemic stroke early. Protocol should be a CTA of the head and neck. But often, we administer TPA based on symptoms only.

[NurseCard, ADN]

There is a 3 hour window for administering TPA. CTs will not show an ischemic stroke early. Protocol should be a CTA of the head and neck. But often, we administer TPA based on symptoms only.

Okay. Thank you. Truly, I know practically zilch about ER nursing.

[offlabel]

Wait a second. You asked "Are we so reliant on machines that we no longer need to touch and assess?" Fine,but you insisted on a CT. It showed nothing. Your mom was having a bad headache with no overt symptoms of stroke. She wasn't treated for stroke. She wasn't having a stroke. It is regrettable that you were "parked" in an ER for such a long time, but the reality is, when people that need TPA present to the ER, their family or the medics say things like, there is facial droop, she's slurring her words, her right side is newly flaccid. There is no teasing out nuances in the neuro exam. I suspect were that happening you and your family members would have made more of a point to be sure the staff was aware. And the response much different.

If folks with bad headaches were crashed into a room for labs, CT's and TPA consults every time they showed up to the ER, the whole system would seize up and collapse.

Glad your Mom's OK.

[LM NY]

"Her symptoms/age and recent medical history, were suspicious of stroke activity."

What symptoms exactly did she have? I work closely with the neurology team, because we have 10 beds designated for stroke patients on my med-surg unit. I am glad your mom is ok and thank God she did not have a stroke. There are certain things that warrant a stroke code, but a migraine is not one of them. You mentioned a high blood pressure. How high? If it was high enough to be a hypertensive emergency, I'm sure other things would have been done. Was she answering questions for herself? Her orientation is part of the neuro check, so if she wasn't slurring her speech and no apparent aphasia while answering then these are more reasons to believe there is no stroke. Of course, there are more indicators of a stroke, but from what you described it doesn't seem like they were worried that's what it was.

[MunoRN, RN]

I would agree there are legitimate criticisms of ER treatment, but that doesn't mean everyone who thought their family member wasn't appropriately treated was in fact not appropriately treated, this appears to be an example of that.

A headache by itself or more specifically a migraine is not indicative of a CVA, particularly of the type of CVA where time to treatment is definitively restricted (embolic CVA). If your mother was seeking an MSE and truly never received one, then that's an appropriate reason to lodge an EMTALA violation complaint. If the concern is that your mother wasn't more quickly treated for a severe headache and other non-specific symptoms to CVA, then no, that's not a valid complaint.

[CX_EDRN]

I'm going to have to agree with what's already been said. As an ED nurse, we truly get a bad rap for literally everything (including what's not in our control) and while it can definitely be frustrating for patients and their families sometimes you don't get the care you want. Sometimes I don't have time to sit down and discuss things, much less pee. What were her symptoms? What is the recent medical history you referenced? Because as an ED nurse, what you (general you) think is relevant often isn't. I think the take away here is yes, it is awful to wait in the ED for 8 hours but that's just reality sometimes. It sucks but that's what it is. Also, thankfully, she wasn't having a stroke so I am not sure why you seem to be upset about not getting an incredibly expensive stroke work up? Unless I am misinterpreting your post. You never want to be the one we're rushing back. Ever.

I have no idea what went down during your mom's stay. I know that at any of the five EDs I currently work as float pool, there is no way she would not have had an assessment by someone, much less not having separate ones by the MD and the RN. If that's true, that is alarming. Now about not getting neuro checks, there are many different ways to assess neuro function and it doesn't sound like your mother warranted a NIHSS or something similar. Also, it does not sound like you were present for this so you are hearing everything second-hand and sometimes things are lost in translation.

Also also, our TPA timeline is 4.5 hours. It's definitely regional on the window.

[butterball1980]

My point was, literally nobody in this ER did a hands on, physical assessment. I wasn't looking for a diagnosis of my mother, the main point in my comment was that this ER did not do an appropriate "triage" upon her arrival, unless standing behind a glass window and entering a complaint into a computer is considered triage. My mother had a 10/10 headache, dizziness, facial tingling and left arm tingling. No history of migraines. Recent history of DVT, on blood thinners. And a BP of 210/110, without a history or high BP. My mother stated all this and when the nurse repeated that she would have to wait for a room, my father repeated and emphasized it.

I found some of the responses defending the behavior of a health care team that not only ignored some serious issues, but did not lay a hand on my mother for a physical assessment, irresponsible. We can not use that excuse of "if we reacted to every migraine as a stroke...." This is the exact thinking that will cost a patient their lives. We are in the ER to do just that. We are trained to triage, not make assumptions and treat the worst case scenario - and maybe that treatment is as simple as a 5 minute triage and neuro check. I pity the patient that shows up to any ER that does it any differently, as I pitied my mother. But again, I know this is in no way an isolated case.

A CT was done and thank God was not a stroke, since that CT took over an hour to get to.

While I agree that we all must be pt advocates wether that patient is a family member or not, at what point do we hold an RN and an MD responsible for literally not listening to lungs, palpating pulses, doing a neuro check, palpating an abd or even the simplest, touching a person's skin. While I couldn't be with my mother, it is not my responsibility as a family member to make certain that she receives basic appropriate care and it's unfortunate that any nurse places that responsibility on a family member. However, I TOTALLY agree that we must be present with any family member in a hospital. Lesson learned and I will never place my trust in the system again when it comes to family. And although it is not my responsibility to instruct a nurse to do a physical exam on any hospital patient, it is now my mission to make certain these things are addressed and my family members as patients are taken care of appropriately. As a glass half full person, I had more faith in my profession than this.

Again, my question is, why are we not doing the most basic of care for our patients? What has changed in the last 20 years that makes any nurse believe that primary, secondary and focused assessments IN AN ER are no longer necessary. Incidentally, the nurses that cared for my mother, and countless other ER patients, had a wide range of experience, from 1 year to 10 years. And sadly, the physician that took her case was fairly new.

[butterball1980]

In regards to the medical professions relying on machines too much for assessments and diagnostics - if a pulse ox is 98%, do we then assume the cap refill is prompt? If the pulse ox shows a pulse of 88, do we not need to physically check a radial pulse? If the monitor shows NSR, do we not need to listen to heart sounds? if parameters per a machine are "WDL", is this all we need? Unfortunately, I've seen many nurses electronically chart a "WDL" based solely on a machine reading, even though that "WDL" also includes many other things that can only be assessed with touching or listening. In addition, in my 10+ years of ER experience, I've seen physicians not even enter a room if "protocol orders" were initiated by the primary nurse, until every report was back. The physician used no clinical assessment skills to aid in his diagnosis. It was based purely on the read out of a machine. While they may have an ESI of 4, is it fair for them to only be seen by a physican 2 hours after arrival, only after an xray reading or lab report. And I see this as common practice in every single ER I work in. And I work in several as a float. One physician in particular never carries a stethoscope and this is well known in our unit. In 5 years, I've seen him auscultate a chest one time. On a dying CHF patient.

While the situation with my mother is not only disappointing, but beyond aggravating, the bottom line is my mother is not alone. And again I pose the question, what has changed? How do we get our profession and the culture back to what is important. How do we make sure bare bones basic nursing care is done and how do we get our managers to focus on what is truly important, our human being patients.

Incidentally, my mother is a retired paramedic. She explained her lack of advocating for herself, "I was too sick. I just wanted someone to keep me alive because i felt like I was dying." Thank you to the well wishers. She was admitted for observation, her BP was managed and her pain was treated and she was disch home in stable condition. And my father not only stayed by her side, but made certain that her OBS nurses knew his observations of the lack of care in the ER.

[MunoRN, RN]

My point was, literally nobody in this ER did a hands on, physical assessment. I wasn't looking for a diagnosis of my mother, the main point in my comment was that this ER did not do an appropriate "triage" upon her arrival, unless standing behind a glass window and entering a complaint into a computer is considered triage. My mother had a 10/10 headache, dizziness, facial tingling and left arm tingling. No history of migraines. Recent history of DVT, on blood thinners. And a BP of 210/110, without a history or high BP. My mother stated all this and when the nurse repeated that she would have to wait for a room, my father repeated and emphasized it.

I found some of the responses defending the behavior of a health care team that not only ignored some serious issues, but did not lay a hand on my mother for a physical assessment, irresponsible. We can not use that excuse of "if we reacted to every migraine as a stroke...." This is the exact thinking that will cost a patient their lives. We are in the ER to do just that. We are trained to triage, not make assumptions and treat the worst case scenario - and maybe that treatment is as simple as a 5 minute triage and neuro check. I pity the patient that shows up to any ER that does it any differently, as I pitied my mother. But again, I know this is in no way an isolated case.

A CT was done and thank God was not a stroke, since that CT took over an hour to get to.

While I agree that we all must be pt advocates wether that patient is a family member or not, at what point do we hold an RN and an MD responsible for literally not listening to lungs, palpating pulses, doing a neuro check, palpating an abd or even the simplest, touching a person's skin. While I couldn't be with my mother, it is not my responsibility as a family member to make certain that she receives basic appropriate care and it's unfortunate that any nurse places that responsibility on a family member. However, I TOTALLY agree that we must be present with any family member in a hospital. Lesson learned and I will never place my trust in the system again when it comes to family. And although it is not my responsibility to instruct a nurse to do a physical exam on any hospital patient, it is now my mission to make certain these things are addressed and my family members as patients are taken care of appropriately. As a glass half full person, I had more faith in my profession than this.

Again, my question is, why are we not doing the most basic of care for our patients? What has changed in the last 20 years that makes any nurse believe that primary, secondary and focused assessments IN AN ER are no longer necessary. Incidentally, the nurses that cared for my mother, and countless other ER patients, had a wide range of experience, from 1 year to 10 years. And sadly, the physician that took her case was fairly new.

I realize when it comes to a family member it's easy to think every possible resource should be immediately directed towards them, but what you describe was handled appropriately and after ruling out acute pathologies, the most appropriate action is to defer your mom to her primary care MD for further assessment and treatment.