The Flip Side - When you're the patient/family

[jennaolds]

This is a long post. I'm not sure if this is the right place, but I need advice. I've been a nurse for 5 years. Not long enough to be completely confident, but long enough to know when something isn't right and ask for help. I've been involved in countless situations with families and patients where education can make the difference between a good situation and a bad one.

My conundrum now involves MY family. MY love. My primary concern. And how to not be one of THOSE families that drive us all batty. But perhaps I need to.

You see, in Aug 2015, my husband experienced a perfed bowel. It was sudden, painful, terrifying and culminated in an emergency colectomy and temporary colostomy (Final verdict is bowel perforation related to migrated hernia mesh tacks...).

He's 50 years old, and fortunately very healthy. No heart disease, DM, HTN, etc, so he was able to have his elective reversal yesterday. His original surgery was performed at my former facility where he received excellent nursing care. His reversal was performed at the main campus of our facility and his nursing care could not be more different.

Last night, he came up to the floor from PACU with understandably saturated dressings and a full JP drain. He was transferred to his hospital bed from the stretcher using the PACU stretcher bedding. Although he had a dilaudid PCA, he was uncomfortable, so the nurse decided to wait to jostle him in order to change his gown, saturated dressing and remove the bulky bedding from under him. I get that. He was transferred at about 1930 in the evening, a crazy busy time for nursing. I left the hospital to get some sleep around 2300. He was resting and stable. I returned late the next morning after talking to him and letting him sleep after a dose of Benadryl (dilaudid PCA made him itch like crazy). When I returned, he was still in his bloody gown, still on top of his bunched up sheets, and STILL had the same saturated, dirty outer dressing in place, with a completely full Foley in place, although he had been asking to have it removed because it was starting to hurt as it filled up (this particular medical care center has a nurse driven protocol in place to remove unnecessary Foleys for CAUTI prevention. He met protocol). This was well past the really busy time from 7a to 10a. I helped him get comfortable by removing the excess bedding, changing his gown, and untangling his many different cords. WHen his tech came in, she was indignant about the dirty laundry. She didn't seem to care that he had no water, no toiletries, no clean linens, but of course, it's a busy floor. I asked to speak to his primary nurse to find out his plan of care.

When his primary RN came in, I asked about his saturated dressings. She looked at them and said "they weren't like that this morning". #1) it was old blood from the night before and #2) if he had bled that much in just a few hours, i would expect her to be more concerned. When I told her that these were the same dressings from the night before (they were marked), she said "oh yeah, this blood is dry" and backpedaled quickly and changed the outer dressings and reinforced the primary surgical dressings. Long story short, she hadn't assessed his abdomen after abdominal surgery.

WHen I asked about the foley, she stated she had to wait for the Dr. I'm sure this is just a case of needing to reinforce education, but again, this facility has a nurse driven protocol to remove the foley POD 1, particularly when the patient is independent, wants to walk and a/ox4. Hm.

Several small things happened in between, but in general his care improved throughout the afternoon. However, at shift change, when he asked his night shift nurse to check his dressing (his former stoma site is packed, but still bleeding), she stated that she didn't "have an order to change his dressing". He asked her again to please check it and she refused. My husband can be a total pain in the butt, and I freely admit it, (especially s/p open colectomy reversal. you know...pain), so she eventually told him that she would get the charge nurse. I get it. I don't like ornery patients either, but shouldn't she have performed a focused assessment for the beginning of her shift anyway? Without the patient asking? And certainly if the patient presents a concern, don't you address it? Especially for a patient that has quite a few risks for complications? GRRRR.

Anyway, another nurse took over his care, checked his wounds and changed his dressings because, yes, they were saturated.

My question is: How do I address this situation? I know nurses are under immense pressure. I also know at least one nurse in his care was probably negligent. This is my family. I'm relying on the quality and reputation of this profession to keep him safe. What do I do?

[Karou]

I don't think you would be overreacting if you asked to speak to the manager about this. Let them know you are a nurse. Normally someone throwing their title around is annoying, but it could help your husband receive better care.

[Been there,done that, ASN, RN]

I was a nurse with 25 years of experience. My father died from sepsis following a bowel surgery evisceration , that was was totally botched. Took 10 hours to get him back to surgery to put his guts back in. I feel for you, I tried my best.. it was not good enough.

Looking back, I would have had both the surgeon and management at the bedside to address my concerns.

Looking back,it still may have not been enough, hospitals are dangerous places.

[ProgressiveActivist, BSN, RN]

I would inform management and the surgeon that that the care leaves a lot to be desired and that your spouse would prefer different nurses in the future.

Put your concerns on the Press Ganey survey and do list the staff by name.

[Susie2310]

I have found it necessary to stay with my family members by their bedside throughout their hospital stays to advocate for their needs, and to prevent errors in care that can harm them, with the exception of leaving for short periods of time when everything seems to be under control.

I have seen the phone numbers of the Charge Nurse and Manager posted in the patient's room, with a statement that encourages patients/family to call if they are concerned about the patient's condition, or about the care given. I have also seen a Rapid Response number posted in the room that patients/family may use. If I had a concern about a family member's nursing care that I could not resolve with their nurse in a timely manner, I would ask for the Charge Nurse. If a solution was not forthcoming in a reasonable time, I would ask for the Manager.

Depending on the situation, I would ask the nurse to let the MD know my concern (I would speak with the MD myself if he/she appeared at the bedside, or was present on the unit), and would follow up on the MD's response, and would go up the medical Chain of Command if necessary in order to obtain appropriate medical care for my family member.

[nrsang97, BSN, RN]

I would have a chat with the nurse manager and the surgeon. At anytime if you feel something isn't right speak with the charge nurse. I am not sure if this facility has residents, but you could also ask them to come see the patient too.

[PewpSmith]

Sometimes, when you have been appropriate and have tried to address things via the proper channels (Asking the aide to speak to the primary nurse, the primary nurse to speak to the charge nurse, etc.) you have little option other than to speak to the manager of the floor. Squeaky wheel gets the grease. And these aren't complaints that warrant staff becoming annoyed- you're actually wanting him to receive good care. It's not as though you're complaining because you've had to wait too long for ice or you're angry because there aren't enough channels on the TV. You're very VERY reasonable by not wanting him to get a UTI from a foley when he's already post-op and compromised. If you're wanting to seek assurance that being "the squeaky wheel" is appropriate here then ABSOLUTELY, yes. I think you're trying your hardest to just be an advocate for your family. If the manager doesn't respond/address your concerns I'd maybe speak to the CNO. If the CNO doesn't respond try to talk to the CEO. Best of luck. You're in a tough place.

[KelRN215, BSN, RN]

If I'm ever hospitalized/have surgery again, I'm smuggling in an empty 10cc luer lock syringe so I can take my own damn Foley out.

OP, it wouldn't hurt to ask to speak to the manager.

[SubSippi]

I agree with everyone else, talk to the charge nurse, and if necessary, the unit manager. Tell them you want to be able to give good patient satisfaction scores.

Although I'm sure you could find plenty of minor details to complain about, all of the concerns you've listed are totally valid. Expecting his abdominal wound to be assessed and for him to be changed out of a bloody gown is the bare minimum, you're not exactly demanding VIP treatment.

The only people who think you're being unreasonable are the ones who aren't taking good care of your husband. The bottom line is all the problems you have need to be addressed, and they are also all problems that can be fixed.

Also, people leaving in foleys for their own convenience is one of my nursing pet peeves, especially when the patient is complaining about it hurting. I bet you anything she knew about that policy. We don't have a policy, but I think of removing a foley as one of those things I can get an order for later (as long as the patient is stable!).

[nynursey_]

To address your question as to what to do, my advice is to move up the chain of command, starting with the charge RN, and then asking to speak to the NM (if they aren't one in the same person). If your concerns still aren't addressed and/or you notice a pattern in the lack of quality care your husband is receiving, then many hospitals have a patient relations department which you can call and direct your concerns to. They send a representative to see you and/or call you usually within a matter of an hour, so that your concerns can be addressed and resolved promptly.

To play Devil's Advocate ..

You say the nurse denied having an order for a dressing change and utilized that as the rationale for why it wasn't changed. This is pretty common practice. Surgeons in particular are VERY fussy about ANYONE other than the attending, resident, or intern being the first person to change a POD 1 dressing. RNs are often given orders that it's acceptable to reinforce a dressing that has become loose or soiled, but more often than not, it is ingrained in our heads that we are not to be the first person to perform an initial dressing change. On the other hand, if the dressing was truly that saturated, the RN should have been calling the surgeon to report the large amount of drainage so that it could either be assessed by the physician and/or the RN could have obtained orders to change the dressing. Either way, did you ask? I have had families request I call the physician on their behalf to obtain certain orders, and if I deem them reasonable, I often do. The first step is always to ask. By the way, leaving your husband in his blood soaked sheets and gown is completely unacceptable and you were right to feel upset by that.

Regarding the Foley catheter, if it's the facilities policy to remove it on POD 1 and there's a protocol for it, then I also understand your frustration there. However, sometimes protocols exist, and even when a nurse follows it to the letter, there are physicians that become irate at the idea of not being notified of a nursing intervention being performed on THEIR patient. I'm not saying this is the case everywhere, but there are a select few in my hospital that I tread lightly around, even if I'm following a protocol. To avoid conflict, I like to give them the heads up by saying "our protocol states Foley catheters are to be discontinued POD 1 if the patient meets criteria, so I'll be removing Mr. F's catheter early this morning unless you feel it's contraindicated." It extends courtesy for the physician and results in the same outcome for the patient: Foley out. Again, also not inappropriate to ask the nurse to check with the MD.

There are always two sides to every story, especially in nursing. Communication goes a long way into clearing some of these issues up. I notice that even though a patient's family may be in healthcare, every facility and practice area differs, and I often have rationales for the way I perform tasks or the care I provide that may not always be surface evident, but I always take the opportunity to explain, and/or welcome questions. And I think that's the difference here: your husband's nurse did not effectively communicate with you either because she did not have an acceptable rationale or she was ignorant that it would be a necessity in this situation.

[~PedsRN~, BSN, RN]

Definitely escalate up the chain of command if you have concerns. You are your family's biggest advocate for sure.

But like the previous poster said, I have never been allowed to change a new surgical dressing. Reinforce it? Yes. Call if it's necessary? Yes. Take it off? Nope. As for the foley, a patient on a dilauded PCA wouldn't have met our protocol for removal, but I have no idea the protocol for your facility.

Hope he's on the mend soon, it's never fun being the patient.

[imintrouble, BSN, RN]

I almost always take the nurse's side over family member complaints. I always try to find an excuse or reason for questionable care.

I've tried to explain the OPs complaints, and absolve the nurses caring for him of any guilt. But I can't.

I'm not sure how I'd handle a formal complaint, but I'm positive I'd make one. Press Gainey is not the way. Care as bad as what the OPs husband received requires face to face interaction. I'd go directly to the CNE. Not the charge nurse, not the unit manager, and not the floor director.

To Been there done that, I'm sorry about your Dad. The what ifs are so hard to live with. Your statement about hospitals being dangerous places is spot on. It always amazes me that people fight like heck to get admitted.

We are a lucky family in that we're healthy enough that none of us require hospitaization. But when it does happen, there's a chair with my name on it beside my family member's bed. Not to critique, but to protect.