Residentual school/help

  1. Please help me if anyone has some answers I can use.
    I just accepted a position as a school nurse for a 24 hr residentual school, *parents/Prob officer/guardian have given school medical permission to treat students.
    There is a protocol book for the adminstration of OTC's by a another facility who we are contracted by that sets our standards, and supposedly,(though he is not there ON SITE, nor does he see any students now as he is very eldery) there is a DR that is "covering us". I am a 2o yr well seasoned LVN, all the nurses are LVN's. There is no RN.
    When these kids complain of "HA" or whatever, we can give, or not give meds, OTC or PRN. That is a no brainer.
    PROBLEM is this- there is a thing called "SICK CALL" where the students ask to see "medical personnel".
    When the student comes in, the LVN that I observed assesses them to see if it is something that we can handle, (and supposedly covered by our protocol), or if we need to send to Dr.
    When does it go beyond nursing into diagnosising? is IT a rash, OR can we say JOCK ITCH? SEEMS if the kids WANT to see a Dr, a nurse can't make that decision, as only a Dr. has the right to decide if and when he sees a pt, and how often.
    I KNOW we can decide WHO needs to be seen first, and who is sicker, but just not sure on other questions!
    AND, is there something in black and write, AND NOT our practice act WHICH IS WAY TO VAGUE, so I can explain to the other nurses?
    The nurse I observed triaging, is so wonderful, and SO DARN GOOD, I'd be flat jealous if I weren't so worried for her.
    Don't yell, just help PLEASE!
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    Joined: Jan '06; Posts: 3


  3. by   elkpark
    You ask a v. good question, and you may want to check with your state BON for guidelines about where to draw the line, and in what circumstances you might be putting your license in danger.

    A number of years ago, I worked as weekend charge nurse (RN) in an adolescent psychiatric program. There was always a doc (psychiatrist) on call on the weekends, of course. The kids were all physically active and it was not at all uncommon for someone to get hurt playing softball, touch football, etc., or (less frequently) to self-injure by impulsively punching a wall, cutting a wrist, etc. I was amazed to find that the management of the facility expected me to make the decision in those situations about whether a kid needed to be sent to the local ED or could just be treated by us on the unit. I would telephone the doc on call, and the doc would be unwilling to drive over and eyeball the kid her/himself -- and would want me to decide whether a wrist laceration needed stitches or we could just stick a Bandaid on it, whether a hand was broken or not, whether an ankle injury was just a minor sprain or something more serious, etc. (The punchline was that, because of the way the program's services were billed, if we sent a kid to the ED, the facility had to absorb the cost, so administration did NOT want kids sent to the ED unless there was just no other option ...)

    Apparently, I was the first nurse who ever worked there who had a problem with this system -- *****???? I put my foot down and insisted to management and the docs that, just by making a determination about whether a kid needed to go to the ED or could be managed there on the unit, I was diagnosing, which was clearly outside the scope of my education and licensure. If the doc on call wanted to come over, look at the kid, and tell me that the incision didn't need sutures and to just put a Bandaid on it, or the knuckle wasn't broken and an ice pack would be sufficient, that was fine with me (because that was within the scope of her/his practice (not to mention what s/he was getting paid for!)), but those were not decisions that I was educated, credentialed, or paid enough (!) to make -- esp. when we were talking about a teenager who could possibly end up with impaired mobility/use of her/his dominant hand for the rest of her/his life (for example) if we (I) made the wrong call! I considered this situation not only a risk to my license, but a lawsuit waiting to happen for the docs and facility (something that had apparently never occurred to them before -- ), and I told management in plain English that, if the doc on call was unwilling to come in and examine the kid and they left it up to me, I would send the kids to the ED every time -- that was the only safe and responsible thing for me to do. When I made clear that I was v. serious about my position on this, the on-call docs suddenly started coming in when a kid was hurt on the weekend (and everyone survived )

    Now, obviously, there were also lots of situations that didn't involve significant acute injuries or sxs and could just be watched until Monday morning, or whatever (in consultation with the doc by 'phone). But I'm sure there are lots of other facilities out there, like yours, where this is just the way they've always done things and no one has really thought through the larger ramifications until a situation occurs where the doo-doo really hits the fan -- and then it's too late.

    However seasoned you all are, you are still obligated legally to act (only) within the scope of your practice/license. I would strongly encourage you to clarify with your state BON how the scenario you describe fits (or doesn't!) within the scope of your licensure. If the BON gives you their blessing, great. If there are conflicts, be proactive about discussing with your superiors other ways of meeting the kids' healthcare needs -- because, I guarantee you, if some situation does go pear-shaped and some kid has a bad outcome, your administration will not step up and say, "Oh well, it wasn't really the nurses' fault, we told them to do it that way -- it's really our responsibility ..."; you (whichever nurse(s) is directly involved) will be hung out to dry and left to dangle in the wind.

    (PS -- I hope I don't sound like I'm yelling! :chuckle I sympathize with your concerns because, when I found myself in a similar situation, it scared me s---less. Talk to your BON. Best wishes.)