I have been a CNA for 5 years. i am also a nursing student (BSN/RN) on my last quarter. i work as a registry CNA right now, so i see a lot of different nurses and units etc.
I was on an ICU unit with a elderly female pt who was there for encephalopathy after trauma to the head. she fell outside a liquor store. she has history of alcohol abuse but she denies recent consumption. the liquor store owner states she regularly buys alcohol. she takes anxiolytics at home for anxiety. shes also on SSRI antidepressants. she has a history of chronic lower back pain, neck pain, and states she has pain all over.
I was called in to sit with the patient. when i came she was really agitated and anxious and kept trying to get out of bed. she is A/O X4. shes been there for 5 days now. she continuously asked for her pain and anxiety meds. she had, tylenol q4hr prn (mild to moderate pain 1-6) norco q4hr prn (sever pian 7-10), lorazepam q2hr agitation (on a scale CIWA scale 0.5-2g).
she knows her meds but doesnt know what times theyre suppposed to be given. she asked the nurse but the nurse refused to give her the times because she thought the patient was addicted and drug seeking. the nurse would say "thats all you care about is your painkillers to get off. you dont ask about anything else".
i was sitting with her the whole time and she was shaking and visible anxious the whole time. the nurse would refuse to give her lorazepam or pain meds until she was literally ready to get out of bed.
based on her CIWA she was suppsoed to get at least 0.5 to 1g q2hr however she only gave it twice the whole shift. at the beginning and at the end.
the mobile xray came. from her xrays i saw she had plates pins and other surgical metals in her neck. so that explains the neck pain.
the nurses excuse for withholding the pt meds was that her blood pressure was too low and her respirations were too low. her blood pressure and respiration would naturally lower when she fell asleep but shot up to normal when she was awake. so the pt is anxious so is constantly looking at the clock, so i advised her to relax and try to sleep so that the time passes faster. now, the nurse comes in to assess the patient but every time she would come, the patient was napping. the nurse would write down pt's v/s and leave. then the pt would wake up and ask for her meds and anxiolytics. the nurse would come in and say that her v/s are too low even though they arent when shes awake. so this goes on for the whole shift. i told the nurse that shes axious and in pain but the nurse just shrugs it off and says shes an alcoholic, all she wants to do is get high.
this RN was floating from another unit to the ICU. shes from a medsurg floor.
in my head this is not ethical practice. is it? pain and anxiety are subjective. sometimes objective data can help us assess a patient's pain or anxiety but the patient's word should be taken as truth when it comes to pain or other subjective data. or at least thats what our nursing school teaches us. im always learning so please do provide constructive criticism thanks!
While you should understand the HIPAA violation by now, you will understand better once you're working as a nurse. It sounds like your heart is in the right place. Take it as a lesson on how NOT to be as a nurse...use therapeutic communication with patients. That patient was withdrawing. Withdrawals...even while being given small amounts of your meds, are HORRIBLE. Of course this patient was anxious.
I have personally been there...withdrawing from benzos. It wasn't my fault my body became tolerant to the drug. It's extremely addictive and my doctor had me on them for 10 years. Then he retired and I was left with an obnoxiously high tolerance and no meds. Acute severe withdrawals that has now left me 4 months later with bad symptoms. Then you're treated like a junkie by medical professionals. I didn't take the drug to get high. Once I had a tolerance, I took it to feel normal. To not experience withdrawal.
That being said, I too violated HIPAA as a sitter. So I don't mean to sound like the ethics angel. I remember when my patients started getting either very anxious or combative and not responding well to therapeutic communication, I would look in the MAR to see when they could get their next dose of Ativan and notify the nurse of the patient's behavior. I know better now. I have read posts on this site of nurses being caught and fired. I got lucky.
Quick story. I was sitting for a pt who was getting very very agitated. The nurse walked in with an IV push med. I asked her what he was getting. She said "What he's supposed to be getting." As rude as she said it (I wouldn't be that rude) she was right. I had no business knowing what med he was on unless it affected my care. Come to think of it she should have said that it's a medicine that might make him more of a fall risk so be careful walking him to the bathroom. That's all I legally had the right to know.
I have been a CNA for 5 years. i am also a nursing student (BSN/RN) on my last quarter. i work as a registry CNA right now, so i see a lot of different nurses and units etc.
I was on an ICU unit with a elderly female pt who was there for encephalopathy after trauma to the head. she fell outside a liquor store. she has history of alcohol abuse but she denies recent consumption. the liquor store owner states she regularly buys alcohol. she takes anxiolytics at home for anxiety. shes also on SSRI antidepressants. she has a history of chronic lower back pain, neck pain, and states she has pain all over.
I was called in to sit with the patient. when i came she was really agitated and anxious and kept trying to get out of bed. she is A/O X4. shes been there for 5 days now. she continuously asked for her pain and anxiety meds. she had, tylenol q4hr prn (mild to moderate pain 1-6) norco q4hr prn (sever pian 7-10), lorazepam q2hr agitation (on a scale CIWA scale 0.5-2g).
she knows her meds but doesnt know what times theyre suppposed to be given. she asked the nurse but the nurse refused to give her the times because she thought the patient was addicted and drug seeking. the nurse would say "thats all you care about is your painkillers to get off. you dont ask about anything else".
i was sitting with her the whole time and she was shaking and visible anxious the whole time. the nurse would refuse to give her lorazepam or pain meds until she was literally ready to get out of bed.
based on her CIWA she was suppsoed to get at least 0.5 to 1g q2hr however she only gave it twice the whole shift. at the beginning and at the end.
the mobile xray came. from her xrays i saw she had plates pins and other surgical metals in her neck. so that explains the neck pain.
the nurses excuse for withholding the pt meds was that her blood pressure was too low and her respirations were too low. her blood pressure and respiration would naturally lower when she fell asleep but shot up to normal when she was awake. so the pt is anxious so is constantly looking at the clock, so i advised her to relax and try to sleep so that the time passes faster. now, the nurse comes in to assess the patient but every time she would come, the patient was napping. the nurse would write down pt's v/s and leave. then the pt would wake up and ask for her meds and anxiolytics. the nurse would come in and say that her v/s are too low even though they arent when shes awake. so this goes on for the whole shift. i told the nurse that shes axious and in pain but the nurse just shrugs it off and says shes an alcoholic, all she wants to do is get high.
this RN was floating from another unit to the ICU. shes from a medsurg floor.
in my head this is not ethical practice. is it? pain and anxiety are subjective. sometimes objective data can help us assess a patient's pain or anxiety but the patient's word should be taken as truth when it comes to pain or other subjective data. or at least thats what our nursing school teaches us. im always learning so please do provide constructive criticism thanks!
Thank you for any feedback!
You have excellent observational skills. In this case as a seasoned nurse... I would have further assessed the patient and medicated them appropriately. However, as a CNA in this scenario you are limited in your actions.
In the future.. if you feel your patient is not getting the care they need... you certainly can go to a charge nurse with your concerns..even up to nursing supervision if needed.
how am i violating HIPAA? i am assigned to that patient. i am not looking at any other patients. she asked me if she had her anti anxiety ordered because she takes them at home. i checked (need to know basis) i m sure checking my patients mar more unethical than what the nurse did... (sarcasm). the patient also asked me why she was at the hospital, so i checked the H&P.
i am not using any patient identifiers. we only know that shes a female. so how is that a hipaa violation? so are all case studies hipaa violations too?
based on 2018 hipaa, thats not a violation.
I can understand why you feel that you are not violating HIPAA, and as registry CNA you may not have been trained on this information because you are not directly employed by the facility. In my nursing program we need to look at the MAR and H/P in order to complete the requirements for our clinical paperwork. This is permitted in clinical because we are logged in as nursing students under the EHR and are providing nursing care to our patient(s) and charting on them.
I was a float pool CNA at my former hospital (I was a sitter many many times). As a CNA at that facility we didn't have access to the MAR or nursing orders. Looking at the MAR and going through the patient's history is the responsibility of the nurse. As the sitter your responsibility is to communicate the patient's needs with the nurse. I am now a PCA at another hospital and in my orientation is was stressed that PCA's are not to look through the MAR, notes, H/P, or anything in the chart that doesn't have to do with the direct care that you have provided to that patient. Doing so is considered "snooping" (exact words used by the facility) and your account can and will be flagged and could lead to termination for HIPAA violation. We can even get in trouble for being in a chart for too long, and it is stressed that we shouldn't have more than one chart open at once. Basically get in, get out, chart vitals, I/Os, etc. and log out of the chart immediately.
You have to stay within your scope as the CNA/Sitter, as hard as that may be now that you are a nursing student and are able to start seeing the bigger picture. Stay humble, and advocate for your patient as much as you can, but do it within your scope and communicate with the nurse rather than "snooping" through the chart.
Sounds like the float nurse was full of judgement and never took time to assess and understand this patient. Really unfortunate--the patient was so anxious and in pain. You'll be a great advocate willthemurse!!!
OP, it's not that I don't believe what you think you saw or didn't see, or that RN wasn't a big meany, but I have to defer to the RN's license and experience against a nursing student/experienced CNA's judgement even after hearing your side of the story and without being there or knowing either of you. And you were absolutely out of your scope trying to find answers in the chart for the patient and apparently attempting to assess the patient. Frankly, if I were the nurse, it would have really ticked me off that the CNA was second guessing me.
Let me plant some seeds for you as a little thought experiment:
-Why were you there? Why did this patient need a sitter? What was your job?
-You say your pt was A+Ox4 but "kept trying to get out of bed?" what's that about?
-Is it possible that this chronic alcoholic has been to this unit before?
-Is it possible that this nurse knows this patient?
-Is it possible that the RN was weighing effects of withdrawl, the head injury, confusion, ICU delirium, encephalopathy and pain management considering the low vitals to find the best solution?
-You state that the pt was sleeping when the nurse came to assess and the patient's vitals were low, but normal while awake. Is it possible that the vitals could be lower after receiving medications? Do you think that maybe this could have played a part in any decision making?
-What kind of experience do you have with interventions for chronic patients who normally self medicate with alcohol?
-How many times have you used a CIWA scoring tool in a real world situation?
-Do you know if this nurse wasn't already having an internal dialog about this patients needs?
-Do you know if this nurse had conferred with other nurses, the patients provider or team about other intervention?
-Do you know if this patient had any behavioral care plan in place?
-Do you know that the MAR was actually current or had maybe a provider talked with the nurse about intervention, but maybe forgot to update an order?
What I'm trying to get at is that there was a lot more going on than you can see from your bedside seat watching that patient.
I can understand why you feel that you are not violating HIPAA, and as registry CNA you may not have been trained on this information because you are not directly employed by the facility. In my nursing program we need to look at the MAR and H/P in order to complete the requirements for our clinical paperwork. This is permitted in clinical because we are logged in as nursing students under the EHR and are providing nursing care to our patient(s) and charting on them.
I was a float pool CNA at my former hospital (I was a sitter many many times). As a CNA at that facility we didn't have access to the MAR or nursing orders. Looking at the MAR and going through the patient's history is the responsibility of the nurse. As the sitter your responsibility is to communicate the patient's needs with the nurse. I am now a PCA at another hospital and in my orientation is was stressed that PCA's are not to look through the MAR, notes, H/P, or anything in the chart that doesn't have to do with the direct care that you have provided to that patient. Doing so is considered "snooping" (exact words used by the facility) and your account can and will be flagged and could lead to termination for HIPAA violation. We can even get in trouble for being in a chart for too long, and it is stressed that we shouldn't have more than one chart open at once. Basically get in, get out, chart vitals, I/Os, etc. and log out of the chart immediately.
You have to stay within your scope as the CNA/Sitter, as hard as that may be now that you are a nursing student and are able to start seeing the bigger picture. Stay humble, and advocate for your patient as much as you can, but do it within your scope and communicate with the nurse rather than "snooping" through the chart.
Thank you for a civil response. A lot of the nurses on here are fast to eat their young. how disappointing. Now I understand where I went wrong. again thank you
Thank you for a civil response. A lot of the nurses on here are fast to eat their young. how disappointing. Now I understand where I went wrong. again thank you
WILLTHEMURSE, I read through this thread. No one on here was guilty of NETY. You got some really good feedback.
It feels awkward and icky when we make a mistake -- at least for me it does. And some here who responded to you, if they came off as harsh -- I think it's only b/c they are all too aware of how much hot water a HIPAA violation can get you into.
Bottom line, getting into the patient's chart the way you did was a mistake -- you didn't know better and now you do.
Also, you are a student -- soon to be baby nurse. It's an exciting time and you have learned so much ( I was impressed with your assessment of the situation -- while you may not have been privy to all the details, you are obviously curious and sincere in your patient advocacy). But when working in the CNA/sitter capacity, keep your head down -- give great CNA care. And after you graduate and begin to grow as a nurse stay humble and teachable.
Assign positive intent to those older nurses who speak into your practice, get connected with a nursing mentor -- someone who you can bounce ideas off of and who can help you navigate nursing culture. Much of what a youngin' calls NETY isn't really NETY -- which makes it harder to deal with/take seriously true lateral violence (which is a thing and is intolerable).
Orion81RN
962 Posts
Ok, long post.....
While you should understand the HIPAA violation by now, you will understand better once you're working as a nurse. It sounds like your heart is in the right place. Take it as a lesson on how NOT to be as a nurse...use therapeutic communication with patients. That patient was withdrawing. Withdrawals...even while being given small amounts of your meds, are HORRIBLE. Of course this patient was anxious.
I have personally been there...withdrawing from benzos. It wasn't my fault my body became tolerant to the drug. It's extremely addictive and my doctor had me on them for 10 years. Then he retired and I was left with an obnoxiously high tolerance and no meds. Acute severe withdrawals that has now left me 4 months later with bad symptoms. Then you're treated like a junkie by medical professionals. I didn't take the drug to get high. Once I had a tolerance, I took it to feel normal. To not experience withdrawal.
That being said, I too violated HIPAA as a sitter. So I don't mean to sound like the ethics angel. I remember when my patients started getting either very anxious or combative and not responding well to therapeutic communication, I would look in the MAR to see when they could get their next dose of Ativan and notify the nurse of the patient's behavior. I know better now. I have read posts on this site of nurses being caught and fired. I got lucky.
Quick story. I was sitting for a pt who was getting very very agitated. The nurse walked in with an IV push med. I asked her what he was getting. She said "What he's supposed to be getting." As rude as she said it (I wouldn't be that rude) she was right. I had no business knowing what med he was on unless it affected my care. Come to think of it she should have said that it's a medicine that might make him more of a fall risk so be careful walking him to the bathroom. That's all I legally had the right to know.