Last week I was working w a trached toddler who had been recovering from a severe cold w fever. I worked w her Monday night, her o2 sats were WNL (97-100). Tuesday I was somewhere else. Wednesday I returned, dad reported she was feeling a lot better and had a great day. However, her sats were not good: 92-95, mostly at 93. This was really, really abnormal for her. Her lungs were congested and I heard crackles, so I texted her mom at work (also an overnighter) who called the MD. MD told her to go in for x-rays in the morning. Turned out the girl had pneumonia (as we both suspected) and she got the treatment she needed, two nights later when I returned again, her sats were WNL again.
Here's where I'm not sure what I should do: that Tuesday night I was not there, the night before I noticed the problem, the other nurse on duty recorded low sats all night long, on the vitals record sheet: 92, 93, 93, 93.... her nurses notes said nothing about it, nor did she report to the parents in the morning that the sats were low. This is one of their regular nurses, too, she's been w them for years. THEN, her nurses notes for the night of her ER visit and x-ray, there was nothing mentioned in her notes about the visit or the diagnosis (also bronchiolitis, tracheitis, some collapsed aveoli, plus she got a positive diagnosis that her bad cold w fever the week before was influenza) so I'm outraged by the balls this nurse dropped. All her notes said was that she had a bad cold. I KNOW the parents reported everything to her.
Would I just be a tattle-tale if I told the clinical manager about this nurse's failure to report a change in status, and delayed this girl into getting the treatment she needed? Is it my business? Is it my duty? Or do I just do my work the best I can, and not be the busy body getting the other nurse in trouble? The vitals record page stays with the chart for months, nobody will ever review it seriously. The nurses notes are not detailed and generic. Nobody will ever notice this failure. The parents are aware of it but I don't think they realize how serious a mistake she made. What would you do?
I wouldn't do anything. What happens if this nurse is the agency "favorite"? She might even be the family favorite,and even if you did do the right thing family might turn against you? One thing not mentioned in your post is if the parents observed low sats. Most parents are aware,and unless this kid gets 24 hr nursing I'm guessing the parents knew either before her shift started or after. I find that leaving the parents to call the Docs is a slippery slope. Some parents won't do it,and I'm not sure why. One of my parents refused to call doctors until it was a real emergency for ex kid turning blue. Others called the Doctor if Jr sats were 98 instead of 100%.
**** In the case of the first set of parents who never call the Doctor,and something serious happens,who gets blamed for it,the nurses or the parents? Who will the board chase after? I usually call the supervisor and put in my notes "parents refused to go to ER". That might work,but will it REALLY work if I'm called in front of the BON?
In that first case, nursing judgement wins; call 911 and let emergency services handle the parents. I rather my nursing judgment be disagreed with and be "fired" off a case than refuse to intervene emergently.
On one of my casesyou can't call 911 unless parents allow you to.[/quote'] And like I said, nursing judgment can trump it; you can always discuss with your clinical manager putting on the 485 "flexible upon nursing judgement"-remember 485s ARE nursing care plans.
Specializes in Peds/outpatient FP,derm,allergy/private duty.
I would err on the side of my patient and call 911 in an emergency situation unless it was clearly spelled out in the chart what the Advance Directives are. We need to make sure our butts are covered, but I fully understand families who see resuscitation as an actual assault on their child, depending on their condition and prognosis,
We need to have frank discussions with the families from the beginning so we know under what circumstances we will intervene.
You must not do PDN. Many parents won't allow the nurse to call the PCP until the parent has been contacted. Some parents don't want to nurse to contact the Dr for anything. Maybe at the point that it was obvious that the kid had more than a cold, it was on the other nurses shift. And maybe you are right about a few things. But one thing I agree with the OP about is that if the parent wants a call/text first unless 911 is needed, then you contact the parent first. Its ultimately up to the parent to take the child for treatment, so if the nurse contacted the parent, the nurse placed the responsibility back to the parent.
Sadly, many of the parents I've experienced in PDN/HHA over my illustrious nursing career wouldn't have even thought to bother themselves with calling a physician about their sick child- they had more important (tongue-in-cheek) things to concern themselves with. . .
Specializes in Pediatric Private Duty; Camp Nursing.
This post bothered me quite a bit. I have been on this forum for awhile and have always enjoyed the positive and safe atmosphere it provided for those seeking advice/support/etc..online. I believe the OP was asking for just that...advice or some sort of other rationale. This just sounds like a straight up starting of an argument rather than a useable answer for the OP. Maybe next time, try and be a little less accusing. Honesty and opinions are good to see in the forum as you can see other people's perspectives, but you can still do it in a respectful and professional way.
As for the OP, my advice would be, choose your battles wisely. Is investigating further into this incident or reporting it going to have a productive outcome?
Either way, best of luck!
brittne, thanks for your empathy w these posts. I usually find that the PDN board is a safe place to ask for opinions of all kinds to give me food for thought and enhance my overall professional performance. My thanks to all the regulars here who know me and gave me the benefit of the doubt, and offered good advice without trying to make me feel bad.
I strongly suspect that my inquiry struck a nerve with the poster of that comment you refer to... There was so much anger and accusation that seemed out of proportion with what I was describing, that I inferred that it's not so much directed to me personally. It seemed that the poster likely had a mistake of her own reported at some point by a coworker and identified with this situation. My question may have opened up some old wounds, to which she felt justified to lash out.
Oh, and I wanted to address the accusation that I was just after that nurse's shift: I already work 6 nights a week (3 with this client) and have no interest in a 7th. So much for that theory.
In any event, the child made a full recovery within a few days, and I never said a word to my supervisor. The parents are more careful now to review the vitals page and nurses notes each day. They used to all the time, but they've gotten complacent, which is very easy to do when a client is relatively healthy and stable most of the time. I'm going to keep a closer eye on this nurse's notes and data from now on, since she obviously needs a safety net.
What happens if this nurse is the agency "favorite"?
She might even be the family favorite,and even if you did do the right thing family might turn against you?
One thing not mentioned in your post is if the parents observed low sats.
Most parents are aware,and unless this kid gets 24 hr nursing I'm guessing the parents knew either before her shift started or after.
I find that leaving the parents to call the Docs is a slippery slope.
Some parents won't do it,and I'm not sure why. One of my parents refused to call doctors until it was a real emergency for ex kid turning blue.
Others called the Doctor if Jr sats were 98 instead of 100%.
In the case of the first set of parents who never call the Doctor,and something serious happens,who gets blamed for it,the nurses or the parents?
Who will the board chase after?
I usually call the supervisor and put in my notes "parents refused to go to ER".
That might work,but will it REALLY work if I'm called in front of the BON?
OP left out many possibly relevant details- does this baby have 24/7 care? Or, are we talking about 'visits'? Are there other (even spooky) details, such as CPS involvement that might make Mom want 'texted' about the baby's condition, before she does or does not decide to call the doctor?
OP left out many possibly relevant details- does this baby have 24/7 care? Or, are we talking about 'visits'? Are there other (even spooky) details, such as CPS involvement that might make Mom want 'texted' about the baby's condition, before she does or does not decide to call the doctor?
Its a PDN board, not home health...PDN hourly, home health visits. CPS isn't the only reason a parent would want that. I've worked in places where the family has had a string of bad nurses who panicked and called 911 for silly things or would call the Dr so much that the Dr would say something to the parent. So the parent makes the decision to be asked first. Put yourself in the parents shoes on that one. Its not what we like as nurses, but it happens and we have to be creative in dealing with that request. The parent is the "primary caregiver" and they have that right to make that choice. I see more of the overly involved type doing this rather than the CPS type requesting this.
I had a client one time that demanded to be called first. It was so she could refuse to allow the child to be moved to the hospital. It was pointed out to me that hospital days were days she wouldn't see on her check.
Specializes in Pediatric Private Duty; Camp Nursing.
OP left out many possibly relevant details- does this baby have 24/7 care? Or, are we talking about 'visits'? Are there other (even spooky) details, such as CPS involvement that might make Mom want 'texted' about the baby's condition, before she does or does not decide to call the doctor?
Nah, nothing odd or spooky, the parents are very competent, but controlling. They have insisted from the beginning that they do ALL the trach care, the changes, the stoma care, it's ALL them and it's in writing in the MAR that we are not to do anything except suction. If she needed an emergency trach change the protocol dictated that the parents were to be awakened immediately for one of them to do it w nurse assist. If she needs even ibuprofen, we are to check w them first.
She gets only overnight hours, 10 hours a night. She's an otherwise healthy, typical toddler, just with a trach. We give no meds, no trach care (other than routine suctioning, which is minimal), the main duty is to sit bedside and MONITOR THE POX FOR CHANGES. I put this all in caps because the other nurse sat there for 10 hours and documented low pox levels all night (q2h) and did NOTHING about it. She had one job, and made no attempt at a nursing intervention. Didn't even let the parents know something was amiss. And yes, it did cause a delay in care, because she would have gotten her scrip for antibiotics 24 hours earlier if the parents were told that morning that something was wrong.
Sam J, not all of my comment here is directed towards you, I guess I am still sore at some of the comments I received.
LadyFree28, BSN, LPN, RN
8,429 Posts
In that first case, nursing judgement wins; call 911 and let emergency services handle the parents. I rather my nursing judgment be disagreed with and be "fired" off a case than refuse to intervene emergently.