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?
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.
PDN that happens in the home 'is' home health care.
I didn't say that CPS was the only reason possible for a parent not wanting a physician called.
As far as any baby of mine, much less one with a trach, 'no' call to a physician would I ever consider to be 'silly'.
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.
If parents only get 10 hrs of Pdn, that means the competent parents sat there and equally observed 14 hrs of low sats before the nurse showed up.
For parents so involved I'm surprised they don't pop their heads in the room from time to time during the night.
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.
i'm a stickler for getting comprehensive reports and i'd be very unhappy
with having events such as this not on the report
in my case i'd pick up the phone
but given this situation, i'd probably leave a note for the other nurse
in a sealed envelope asking for confirmation of receipt
a simple "please report spO2 of .... "would do
having said that,
it seems in this case, care is delayed on a routine basis per
the parents choice
also, i don't understand while this case requires skilled nurses
when monitoring is all that is needed, all the caregiver has to do
also, i don't understand while this case requires skilled nurses
when monitoring is all that is needed, all the caregiver has to do
is report when the alarm goes off
It does seem odd, considering the expense, to have skilled nursing 10 hours every night for a baby that is labeled as normally healthy, despite a trach, being treated with ABTs for a week, then ultimately being diagnosed with pneumonia. Then again, Dad sleeps at night, and Mom works at night, so what to do?
It's likely that Mom is exhausted (sounds like she works at night then stays up during the day while Dad is at work?), and has been through so much for so long, that she weighs her options before proceeding with calling the physician. But a lot can go wrong, and fast, with a trach baby or anyone else with pneumonia (which was suspected even before the diagnosis was confirmed), and if anything awful happened, there's plenty of questions to be asked of everyone involved. And I doubt, really, that Mom would hold the nurses harmless in the event anything awful happened.
PDN that happens in the home 'is' home health care.
I didn't say that CPS was the only reason possible for a parent not wanting a physician called.
As far as any baby of mine, much less one with a trach, 'no' call to a physician would I ever consider to be 'silly'.
Actually it is PDN. Even on the boards here, its that way. Medicaid/medicare call visits home care and PDN is hourly. You may want to do your research.
A rose by any other name is a rose. But are you suggesting there's a different standard of care between, say, a half-hour visit, and and an hourly night shift? Does it matter how long a nurse is in the home, or who pays for it, or how it's classified? Would OP not have the same concerns about a delay in treatment for a patient (alleged against a fellow nurse), whether OP was there for a half-hour visit, or for a 10 hour shift? Would the BON? A lawyer, if something awful happened to the patient? The story remains the same, call it what you prefer- a sick baby at home, a visiting nurse, and an admitted delay in treatment.
also, i don't understand while this case requires skilled nurses
when monitoring is all that is needed, all the caregiver has to do
is report when the alarm goes off
Welcome to the world of glorified babysitting. Not saying that I haven't taken care of sick PDN kiddos but anyone who has done PDN for any period of time probably knows where I'm coming from.
Welcome to the world of glorified babysitting. Not saying that I haven't taken care of sick PDN kiddos but anyone who has done PDN for any period of time probably knows where I'm coming from.
Maybe a babysitter is in fact more appropriate in this case than a nurse that probably costs a few grand per week? After all, it's required to 'text' Mom before proceeding with care issues, and OP said that that the parents do all the trach care, and etc.- this does seem to reduce the nurse to babysitting tasks. Makes me wonder about the qualifying criteria for this particular case for to be reimbursed by any $ource, more so since there doesn't appear to be any urgency in obtaining medical follow up?
Maybe a babysitter is in fact more appropriate in this case than a nurse that probably costs a few grand per week? After all, it's required to 'text' Mom before proceeding with care issues, and OP said that that the parents do all the trach care, and etc.- this does seem to reduce the nurse to babysitting tasks. Makes me wonder about the qualifying criteria for this particular case for to be reimbursed by any $ource, more so since there doesn't appear to be any urgency in obtaining medical follow up?
Makes sense. But I've seen some cases like that where the family gets the hours because the parents think they know best, but really they need teaching by the nurse. Or ins hasn't caught on yet. Hard to tell from the details. Meanwhile, some family who really needs the hours is going without. Crazy how it works. I have a case where feedings are for 16 hours and meds are q12. Only a feeding tube. But somehow its a nursing case. The parent has us play the same couple of wheel of fortune DVDs all day...painful to watch/listen to. The mom watches the camera from another room all day. But she gets nursing 16 hours a day. Maybe some parents just know how to work the system and how to work the nurses.
Maybe a babysitter is in fact more appropriate in this case than a nurse that probably costs a few grand per week? After all, it's required to 'text' Mom before proceeding with care issues, and OP said that that the parents do all the trach care, and etc.- this does seem to reduce the nurse to babysitting tasks. Makes me wonder about the qualifying criteria for this particular case for to be reimbursed by any $ource, more so since there doesn't appear to be any urgency in obtaining medical follow up?
Honestly, yes, you could pay a HHA 1/3 of what the RN/LPN is getting and the family would still get what they really want which is mostly help with ADLs and a bit of time-off to work or do other things. Like SDALPN, I have one case that stood out where the kiddo had a g-tube and was MR and a total assist. Family did the feedings, there was no meds. I got paid $17/hr to watch her bang on toys. It was frustrating that there was funding for THAT but not for what the family really needed -- their wheelchair van fixed, and a lift to get the kid from her bed to the wheelchair.
Qualifying criteria is a matrix with a heavy emphasis on "technology." G-tube, trach, vent. It's based on what a nurse should be doing in theory - which for a simple case should be a few meds and feeding through the g-tube, trach care, and monitoring for anything from seizure activity to the trach suddenly coming out to skin issues - but you'll often find families that aren't comfortable with the nurse doing many of those things. (Not necessarily the family's fault, either. High nurse turnover rightfully leads to issues of whether the next new nurse is competent.)
Sam J.
407 Posts
PDN that happens in the home 'is' home health care.
I didn't say that CPS was the only reason possible for a parent not wanting a physician called.
As far as any baby of mine, much less one with a trach, 'no' call to a physician would I ever consider to be 'silly'.