Would you have opened this case?

Isabelle49 · Mar 4, 2011

I had an admission today on a 2 year old little girl who had an abscess on her labia (suspected spider bite). She was in for an I&D by the surgeon yesterday and sent home the same day. Today, I was sent in to open, and pack her abscess with Iodoform (I took out approx 2" from the wound). The whole procedure was so traumatic to the little girl that I didn't feel comfortable completing the admission. She had to be forceably held down by her Dad and Uncle while I tried to pack this 0.2 cm opening with 1/4" gauze. I stopped the procedure, called my supervisor, and was told, or should I say "ordered" to open up the case and pack the wound. Not feeling comfortable, I called the Pediatrician who agreed that the toddler should have been admitted to the floor after the surgery. She told me to call the surgeon and see if he would do a direct admit, which I did. Although I couldn't speak with him directly, his secretary called back and told the Dad to bring his daughter to the surgeons office this afternoon. I (emotionally drained) went back to my office, and stood by my conviction that I was not comfortable opening this case, and was told that "sometimes in home health we have to do things we aren't comfortable doing". At this point, I pretty much stormed out saying, "well fire me because I'm not going to do that kind of nursing". Now I've been a nurse for about 8 years, but only 8 months in home health, but no matter what the field, I'll advocate for my patient to the very end if I feel strongly enough. In my heart I know I did the right thing (maybe not telling my sv to fire me...lol), but I could really use some support from felllow nurses, or some constructive advice if you think I was wrong.
As an added note, the little girl was refusing the oral abx, and as in many home health cases, not a very clean environment. The Pediatrician suspected a staph infection and there is also a 4 month old baby at home too. The whole picture just made me feel she was better off in the hospital with IV abx where she could get ATC care.

I may have refused this case from the outset. Agree, this baby should have been in a hospital. I don't know if the surgeon ordered anything appropriate for pain, but I cannot imagine the pain of packing the labia that had been abscessed, I&D's and would have been ACUTELY inflammed and painful. It is completely inappropriate to expect any patient to endure acute severe pain in the home when other measures can be taken. I don't know how you did it - I know I couldn't and I was NICU/Peds/Pediatrics for 12+ years. Stupid surgeon - somebody needs to I&D his scrotum and pack it a few times - maybe that will teach him something. The surgeon may not know what pain feels like.

Capco56 · Mar 4, 2011

LOL!!!!!! Thank you, Isabelle! You gave me a great laugh to an otherwise very emotional day. :yeah:

I did end up aborting the packing. I just could not make this little girl endure it, and I truly hope he ended up admitting her. Thanks for your input (and humor)....much appreciated!

Isabelle49 · Mar 5, 2011

LOL!!!!!! Thank you, Isabelle! You gave me a great laugh to an otherwise very emotional day.
I did end up aborting the packing. I just could not make this little girl endure it, and I truly hope he ended up admitting her. Thanks for your input (and humor)....much appreciated!

Capco56, Kudos to you for being a Patient Advocate, especially to a little one who cannot voice their opinion or defend themselves.

systoly · Mar 9, 2011

Thank you for showing everyone that there are strong, dedicated nurses in home health. Your decision was based on facts and evidence, what medical evidence did your supervisor provide to explain how opening the case would produce the best outcome for the patient? You are a blessing to your patients AND to your supervisor, who foolishly fails to recognize this.

Capco56 · Mar 9, 2011

Thank you, systoly and Isabelle, too. It feels good to hear support from fellow nurses, and, although I never doubted my decision, your encouraging words make this whole ordeal more tolerable. To update you on the sad situation, the doc did not admit the little girl, but sent her home that same night. Another nurse went out the following day, opened the case, packed the wound, and wrote in her note the effect on the child was "traumatic" and the wound packing produced "bloody drainage". As for me, I was reprimanded, not for going against orders, but for my "rude behavior" toward my supervisor. I have 3 (scheduled) days off, so I'm writing my response tomorrow to attached to my written "verbal warning". I have to mention that this supervisor is not my regular one who was out that day. I talked with her yesterday and she was very sympathetic not only to me but to the child as well. There are just some people who call themselves nurses who have no business being one. (Docs too) Just my opinion. So I can only hope the child is going to be okay. I saw that the wound was MRSA positive, so I worry about the 4 month old at home. Also saw today that she was already d/c'd from our services. I fear the bottom line for all this was the lack of insurance that this family has. Such a shame that the innocent ones have to suffer from it all. (sigh)

BrookeeLou_RN · Mar 10, 2011

Have over 20 yrs HH exp and no I would not have opened the OP case.. You were excellent patient advocate and I agree completely. I have had supervisors threaten me to open cases..one patient said he was driving to go fishing and if I wanted to open case I could join him on his boat...Supervisor even made me call referring physician about lack of home bound status and DR screamed at me stating" I said he gets home care." I still refused, agency covered their backside and sent their most experienced nurse the next day who was so angry at the waste of her time and she agreed with my assessment. In this case I was patient advocate of patients right to NOT receive unwanted services.

You are a great nurse.. stand by your gut and conviction.

systoly · Mar 10, 2011

You know the supervisor was actually spot on. Sometimes in nursing we have to do things that aren't comfortable, gain us disfavor or negatively impact our career in the short run. But I don't think anybody can put a price on being able to go to sleep knowing you did the right thing and looking in the mirror with your head held high when you get up.

Capco56 · Mar 10, 2011

You know the supervisor was actually spot on. Sometimes in nursing we have to do things that aren't comfortable, gain us disfavor or negatively impact our career in the short run. But I don't think anybody can put a price on being able to go to sleep knowing you did the right thing and looking in the mirror with your head held high when you get up.

Understand, and agreeable. I can understand firmly holding a child down to put in an IV or give an injection. Heck, I would have even been okay, not comfortable, but okay if this wound was on her foot. But as I said to my (sympathetic) supervisor; If this was an 80 year old woman being forcibly held down by two grown men while I poked and prodded at her private area, would that be considered acceptable? I think not. In fact, that just might be considered elder abuse. So why do we feel it is okay to do this to a helpless child? So, yes I can hold my head up high when I look in the mirror. The restful nights have yet to come, though.

systoly · Mar 10, 2011

NOOO not ok. My bad. Failed attempt at sarcasm. The supervisor was wrong. I meant her statement was correct in the sense that you did what was uncomfortable and unfavorable for you in order to protect the patient. You chose not to take the easy way out, but rather put the patient's well being befor your own. Sorry for causing a misunderstanding. I have the highest respect for what you did.

Capco56 · Mar 10, 2011

LOL....Ok, we definitely got our wires crossed. :bugeyes: I got the drift of it now...lol

Capco56 · Mar 10, 2011

P.S. Thank you for the compliment :)