Scary Med-Surg Floor?

[Elle.p.enn]

Hi everyone,

I'm doing my preceptorship for RN on a medical-surgical floor. I've learned so much it's amazing, I have a great preceptor.

But, so many things I've seen the other nurses do are so far from what I've been taught.

The first thing my preceptor taught me is not to believe what the other nurses are charting in their assessments. I thought this was to get me to think for myself and really look at the patient, but I found out that a lot of these assessments are NOT ACCURATE in the least. Not even minor things that can change from day to day, but major, hard-to-miss things that I'm shocked an RN would miss.

THis may seem nit-picking, but:

1. A patient had his IV d/c'd once he was placed on hospice, but some nurses were charting that it was still in days after it was taken out.

2. Another patient had a foley d/c'd, but according to some nurses, had it for days after it was taken out. I received report from a nurse who told me it was in two days after it was d/c'd.

Now, I know it's not a life-threatening situation, but aren't these assessments legal documents?

Some more things I've found:

1. A confused patient was often wandering to other units, his nurse wrote "I belong to ****" on a big piece of tape and taped it to the front of his gown. This was last Thursday. Yesterday, this patient was still wearing the same gown, with the same piece of tape announcing to the world that he was mentally incompentent and being treated like a piece of property.

I wanted to do something, but I'm a student, and am not received well when I have a new idea or want to change something.

2. From what I've seen, patients don't get turned q2 hours, bathed every day, ambulated, or other basic nursing care.

The nurse/patient ratio is 1:6. The tech/patient ratio is 1:13-18+. The patients are often complex, and need a lot of care, but it seems like the level of care is very poor.

Does this shock anyone, or is this pretty much status quo for a med-surg unit?

[gr8rnpjt, RN]

This happened to me as well when I became a new graduate. (many years ago). Well, all I can say is you do your personal best. Set your own standards and don't pick up bad habits from bad nurses. When you are given report on something you know is wrong, passive confrontation is the best way I have found to handle it: "Hmm, I thought Mr X's foley was dc'd 2 days ago, I will check that on first rounds." Do your best to write your own nurses notes and don't rely on the entry above you (this is what I believe is the biggest barrier to good documentation, and is directly related to plain laziness. Make your own notes during rounds and pay attention to detail. Set your own standards and do not give in to the lazy patterns that seem to surround you.

As far as that pt with the tape on his gown, well that is not appropriate at all. I think I would have a private talk with the house Supervisor about that one.

[meownsmile, BSN, RN]

These things do happen. Thats unfortunately another side effect of computer charting. Although they are available to take to the bedside to do assessments with there are a LOT of nurses that dont move from their chairs and actually go LOOK at the patient. They pull up the last assessment and chart off of it. Unfortunate and im sure there have been major things missed for hours because of it. I'm sure its not just the med/surg floor, you just havent seen it on the other units YET.

Remeber the addage,, "Dont do as I do, Do as i say". would be a good motto to live by in your situation.

[Daytonite, BSN, RN]

elle.p.enn. . .you ask "does this shock anyone, or is this pretty much status quo for a med-surg unit?" no, this does not shock me. i have seen every one of these things in my years of practice. is it status quo? it is for some nurses. in all areas of your life you are going to find people who don't follow all the "rules". what are you going to do? you can't force anyone to do anything. you could become a member of the police force, hunt criminals down and see to it that they are put away. you'd have a job forever because just as one was caught, two more would pop up. just driving down the street you will find people breaking the driving laws. but, the things you've described are not crimes. they, are, however, bad nursing practice.

in the very early years of my nursing career these very same discoveries drove me nuts. i believe it came out of the fact that i had an authoritarian mother who demanded we obey her and when we didn't--it was the belt! well, you can't spank or corporeally punish people at work! i had to learn that only i was responsible for my own practice and proud of it. you will find that it takes extra effort to do the correct things in those situations. obviously, those people are lazy and don't care to put in the extra effort to be accurate. as for people charting iv's long since removed, i can't tell you how many hundreds of times i would read a previous nurse's charting, get up off my tired rear end and double check the patient to make sure i had correctly seen that they didn't have an iv site and chart, "no iv access noted. patient states iv was removed on ____". i often wonder what goes on in the minds of these nurses who chart these things having never observed them in the patient. but, as a staff nurse, it's not my immediate problem or priority. aggravating and maddening? you bet!!! want to get that belt and start wailing on them? oh, yes!!! where's a mom when you need them!

i would specifically chart that i assisted patients or observed patients going to the bathroom to void when others were charting they still had foley catheters. i removed those "return to . . ." signs from gowns and threw the gowns in the dirty laundry. and, god help any smart alec nurse who came back later and confronted me about doing that! that was a guaranteed invitation for her and i to end up in the manager's office discussing the issue. as for patients who weren't getting turned every 2 hours, bathed every day, ambulated, or other basic nursing care, i just made sure that it got done on my shift. because, you see, once you find something like this out, then you are obligated to correct the situation. that means that if the patient wasn't bathed, then you bathe them or delegate someone to do it. if you let it go on your shift as well, then you are just as guilty of neglecting the patient. being someone who wants to see the rules enforced can be very fatiguing on you because it puts a great deal of responsibility on your shoulders to also do the right thing for the patient who must come first.

i found in later years that as i realized the extent and authority of my power as an rn supervisor and manager of patient care, i learned better strategies to delegate and supervise the patient care by the subordinate staff. when i was working in ltc on the night shift, i had aides doing complete bed baths and linen changes on patients we knew weren't getting this care during the day or evening shifts. we knew because we marked the sheets or the patient's gowns. and then, i followed up with written documentation to the don so she could follow up with the cna who had been assigned to originally do the patient's care and had failed to do so. i was relentless in this and i didn't much care if the don disliked me for it or not. i worked hard for my wage and i think it's only fair that everyone else does too.

half the fun (not sure that's the right term to use) of working in any career, i suspect, is learning just what your scope of authority and responsibility are. you've barely started your career. i've been at it for 30 years. you're probably going to see a lot more questionable things. (1) think about the patients first and correct the wrongs done to them, (2) do what you've been taught are the right things to do. you will find that the right ways often take a little extra time and effort. deal with it. (3) strive to be a role model for those who are coming up through the ranks, and (4) work on getting that legitimate authority so you can effectively do something about sloppy practitioners.

one last thing. . .sloppy job performance like you've described goes on in all professions. nursing isn't the only career where it happens.

[Antikigirl, ASN, RN]

OUCH! Well...I don't necessarly not trust what another nurse has documented...I go in thinking "clean slate"...because when I go in I assess and treat like it was their first ever time! I will catch things others didn't, and if I see a probelm like charting something was there and wasn't...that leads me to think they didn't fully assess the patient properly (I got accused of this last week when I accidentally wrote my dressing assessment on the line for drains which the pt didn't have...oh did I get it!..but I said "shadow drainage yellow/brown dime sized" on that line should have clued them in that YES...good assessment of a DRESSING...I was cleared...sheesh...the line is below the dressing assessment and small..I just missed the tiny line when I wrote...my goodness!).

"Tagging" a patient isn't all that nice, however there have been times when I have done it for my residents in an ALF. HOWEVER...I had nicely printed iron ons for their clothing and tastefully done with permission from family (this was a administration intervention I helped with) using my computer print program to match the clothing items and put on the back inside collar of the blouse/shirt. I had many residents elope out of the facility...and since we had 5 different facilities in our immediate area the police didn't know where to send the people back too and took up their time! We had to do something...and this was a good way. The police were alerted to check the back inside collar :). AND the patient was always changed daily if not more than once.

I do that also at the hospital where I work now...a fresh gown on my shift if wanted..helps keep rashes and skin irritation down (and helps with my skin assessments and others). I don't 'tag' folks in the hospital because we are small enough to find them if needed, and we use ambu and bed alarms and position at risk pts at the front of the RN desk...so far so good on elopement.

Anywhoooooo document what YOU see, and alert the charge nurse to errors you come in contact with. I mean, that is still what I do if I noted that a patient didn't have a foley and it was being said they did a few days after it was d/c'd! Someone is missing the ball and it is not being addressed...

[gitterbug]

No surprises here, just remember, do your own assessments and chart what you see and hear. Do not attempt to straighten the other nurses mess, just keep your charting on course. I have been called into the NM office so many times for chart checks regarding other nurses I have lost count. But if I chart it, I have done it. So my response is always, I have no idea why Nurse Blindfolded charted about a foley I removed 2 days ago, I am sure it was charted as removed, the amount and color of urine recorded, and if it was removed early in the shift I charted when and how much the patient voided. Please discuss this matter with her. Seems to work. You can only do so much for each patient, if personal care, such as hygiene, skin care, bathing, feeding and/or ambulation is a problem perhaps it is time to have a discussion with the NM or CN. Only you can make this decision. Good luck, but remember, timely, accurate, clear charting in your only defense in court.

[Dorito, ASN, RN]

elle.p.enn. . .you ask "does this shock anyone, or is this pretty much status quo for a med-surg unit?" no, this does not shock me. i have seen every one of these things in my years of practice. is it status quo? it is for some nurses. in all areas of your life you are going to find people who don't follow all the "rules". what are you going to do? you can't force anyone to do anything. you could become a member of the police force, hunt criminals down and see to it that they are put away. you'd have a job forever because just as one was caught, two more would pop up. just driving down the street you will find people breaking the driving laws. but, the things you've described are not crimes. they, are, however, bad nursing practice.

in the very early years of my nursing career these very same discoveries drove me nuts. i believe it came out of the fact that i had an authoritarian mother who demanded we obey her and when we didn't--it was the belt! well, you can't spank or corporeally punish people at work! i had to learn that only i was responsible for my own practice and proud of it. you will find that it takes extra effort to do the correct things in those situations. obviously, those people are lazy and don't care to put in the extra effort to be accurate. as for people charting iv's long since removed, i can't tell you how many hundreds of times i would read a previous nurse's charting, get up off my tired rear end and double check the patient to make sure i had correctly seen that they didn't have an iv site and chart, "no iv access noted. patient states iv was removed on ____". i often wonder what goes on in the minds of these nurses who chart these things having never observed them in the patient. but, as a staff nurse, it's not my immediate problem or priority. aggravating and maddening? you bet!!! want to get that belt and start wailing on them? oh, yes!!! where's a mom when you need them!

i would specifically chart that i assisted patients or observed patients going to the bathroom to void when others were charting they still had foley catheters. i removed those "return to . . ." signs from gowns and threw the gowns in the dirty laundry. and, god help any smart alec nurse who came back later and confronted me about doing that! that was a guaranteed invitation for her and i to end up in the manager's office discussing the issue. as for patients who weren't getting turned every 2 hours, bathed every day, ambulated, or other basic nursing care, i just made sure that it got done on my shift. because, you see, once you find something like this out, then you are obligated to correct the situation. that means that if the patient wasn't bathed, then you bathe them or delegate someone to do it. if you let it go on your shift as well, then you are just as guilty of neglecting the patient. being someone who wants to see the rules enforced can be very fatiguing on you because it puts a great deal of responsibility on your shoulders to also do the right thing for the patient who must come first.

i found in later years that as i realized the extent and authority of my power as an rn supervisor and manager of patient care, i learned better strategies to delegate and supervise the patient care by the subordinate staff. when i was working in ltc on the night shift, i had aides doing complete bed baths and linen changes on patients we knew weren't getting this care during the day or evening shifts. we knew because we marked the sheets or the patient's gowns. and then, i followed up with written documentation to the don so she could follow up with the cna who had been assigned to originally do the patient's care and had failed to do so. i was relentless in this and i didn't much care if the don disliked me for it or not. i worked hard for my wage and i think it's only fair that everyone else does too.

half the fun (not sure that's the right term to use) of working in any career, i suspect, is learning just what your scope of authority and responsibility are. you've barely started your career. i've been at it for 30 years. you're probably going to see a lot more questionable things. (1) think about the patients first and correct the wrongs done to them, (2) do what you've been taught are the right things to do. you will find that the right ways often take a little extra time and effort. deal with it. (3) strive to be a role model for those who are coming up through the ranks, and (4) work on getting that legitimate authority so you can effectively do something about sloppy practitioners.

one last thing. . .sloppy job performance like you've described goes on in all professions. nursing isn't the only career where it happens.

bravo....couldn't have said it better myself. i always compared charting whatever the previous nurse said to administering a med they dispensed....no way. lead by example...

[Barb101]

Hello

Scary incidents occur the world over in good Aussie we to have our problems regarding incorrect charting. It appears the bussier the ward the less paper work gets done - just an observation. It is good nursing practice to assess your patients every shift after all it is the ongoing health of our patents we should be concerned about. Or have I missed why we are here As a nurse all I can do is to conduct my care the way I would want to be cared for. If other nurses are not doing thier job it is not my job to check up on them hwoever it is my job to correctly chart what I see in my shift & if this doesnt correspond with the previous entery Then the shift super is not doing thier job in checking & mantaining standards.

Enough negativity there is more than enough to go around with out adding to it. To all the "good nurses " please keep up the good work at lest we have the satifaction of knowing we did a good on the shift we were on.

:Melody:

[SOREFEETEMPTYSTOMACH]

:smilecoffeeIlovecof I Am Not Surprised That So Many Others Are Not Surprised Either. I Think Daytonite Said It Well. And I Am So Glad You Are Angered. You Will Bring A Fresh New Outlook To Any Unit You Work On But Beware, You'll Bash Your Head Against The Wall Some Days.

[lannisz]

The "Clean Slate" thinking is a good way to go. You do YOUR assessment and chart what YOU find. Remember that a patient's status can change also during a shift. That's why you do your assessment when you take over their care.

[banditrn]

I think you've learned a lesson we've all learned at one time or another!! I used to hate it when I'd find something grossly different from their assessment. And if it was something really bizarre, I'd point it out to them.

One time I walked into a patient room in ICU to find them almost comatose - breathing shallow, lungs congested, etc., etc. In report I'd been told the guy was A/O x 3!! Well I don't think he'd been 'x3' for many years, but I also don't think he'd just become that way either! He ended up on the vent shortly after.

Another thing I learned real soon - no matter HOW much you admire a nurse with more experience - if they tell you something that just nags at your brain, don't blindly follow what they tell you! Check it out.