The Ointment and the Oxygen: Two Requests You Cannot Fill
Mrs. Kowalski's daughter stops you in the hallway and presses a tube of ointment into your hand: "The nurse used this on Mom's bottom last week and it worked. She's red again - can you just put some on before you leave? Nobody's come." Ten minutes later Mrs. Kowalski, who is on 2 L/min oxygen by nasal cannula, says she feels short of breath and asks you to "turn it up to 4 like they did at the hospital." The nurse is at lunch and the charge nurse is covering another unit.
1. How do you respond to the daughter about the ointment?
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You cannot take an order from a family member, no matter how reasonable the request or how familiar the product. Application of a medicated ointment to broken or reddened skin is a nursing task; even where a facility allows aides to apply barrier cream, it must be on the care plan, from the nurse, for that resident.
Say it plainly and without blame: "I can't apply anything the nurse hasn't ordered, but I will look at her skin right now and get this to the nurse the moment she's back."
Then actually do it:
- Look at the area during your next check and describe it (location, size, color, whether the skin is intact or open).
- Keep the resident clean and dry - that is within your role and is the real treatment.
- Hand the request and the tube to the nurse, including the daughter's name and what she reported.
Do not promise the cream will be used, and do not promise it won't. Report the fact; the nurse decides.
2. The resident is short of breath and asks you to increase her oxygen. What do you do, in order?
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Oxygen flow is a medication order. You do not change it - not to 4, not to 3, not "just a little."
In order:
- Stay with her. Do not leave a short-of-breath resident alone.
- Check the equipment before you assume she needs more: is the cannula in her nose, is the tubing kinked, under her arm, or disconnected, is the humidifier empty, is the cylinder or flowmeter reading what it should be? A displaced cannula looks exactly like worsening breathing.
- Position her upright and coach slow breathing; loosen tight clothing.
- Take a set of vitals - respirations, effort, color, pulse - so your report has numbers.
- Call for the nurse or charge nurse immediately using the call system or have a coworker page. If she is struggling to speak, blue around the lips, or unresponsive, call for help and emergency response rather than hunting for the nurse.
Never silence the alarm or leave the flow where you think it should be.
3. What is documented for each of these two events, and what is not?
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Ointment request - document: the daughter's request at the time it occurred, that you inspected the skin, and the objective description ("reddened area, left buttock, approximately 3 cm, skin intact"), that you reported it to the nurse at the time of report, and the care you gave.
Do not document an opinion about the daughter, and do not write that you "applied cream" if you did not.
Breathing episode - document: time, what she said, what you observed (respirations per minute, effort, color), that you checked the cannula and tubing, that you repositioned her, the vitals you took, and the exact time you notified the nurse and who came.
Do not document "oxygen increased" (you did not do it), do not chart a guess at why she was short of breath, and do not chart before you act. If you gave a verbal report, note that it was given and to whom - a verbal report that is not recorded is the one that gets forgotten.