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When not to be a team player

I work in a long-term-care (LTC) facility. Recently one of my patients was scheduled for a bone scan at the hospital. Before he left, a nurse manager from the hospital called to ask me to fax her a signed and witnessed consent form for the procedure. I said (politely) that obtaining the patient's consent isn't my responsibility and refused her request. In the end, the patient gave consent at the hospital and the procedure proceeded as scheduled-but not before the nurse manager accused me of not being a "team player" for refusing to send along "routine paperwork." (The hospital and LTC facility are owned by the same corporation.) Was I out of line?-F.L., N.C.

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Not at all. Informed consent is not a meaningless formality as your colleague implied-it is a process that includes informing the patient about the procedure, including its benefits, risks, and alternatives, and answering the patient's questions. Obtaining informed consent is the responsibility of the provider performing the procedure and cannot be delegated to anyone else, including a nurse (although a nurse may sign the consent form as a witness to the patient's signature).


Assuming the patient is a competent adult, he or she may sign the form at the time of the procedure, as was the case here, but the provider should have already discussed the test with the patient, including why it is indicated and what it entails. If the patient is not competent, the provider needs to contact whoever has the authority to make medical decisions for the patient.



Puzzled about PPD

As an RN working in an adult day-care center, I sometimes administer and read purified protein derivative (PPD) tuberculin skin tests (TSTs). I do this without an order from a physician or advance practice nurse. Is that within my scope of practice?-N.S., PA.


Our infection prevention consultant says that this is a common question with no universally applicable answer because legal variations exist from the state level all the way down to the facility level. In some states, regulations may require certain facility types, such as LTC facilities, to routinely screen patients for tuberculosis. RNs in these facilities may be authorized to perform these functions under a non-patient-specific standing order, which does not require a physician's or NP's direct involvement with the individual patient. In some jurisdictions, the state department of health certifies nurses and pharmacists to administer and interpret PPD TSTs and waives the need for an order if the practitioner is certified.


In short, this is generally considered to be within an RN's scope of practice if he or she is properly prepared and authorized by the employer under state laws and public health regulations. Find out your facility's policy and procedure and confirm that PPD TSTs are included in standing orders.


In addition, as with any procedure involving medication, you are responsible for knowing how to administer PPD safely and correctly. This includes knowing how to assess patients for possible contraindications to the test, such as a clear history of treatment for tuberculosis, and interpreting test results accurately. If you do not feel competent to administer the test or to read the results, discuss the issue with your manager and request more training.



Keep child safety seats in the car

My patient, who just gave birth, says her pediatrician warned her to use the car safety seat (CSS) only when transporting the infant in the car, not for routine napping at home. If the seat is properly designed for infant safety, what's the rationale?-L.L., TEX.


Because several hundred infants die each year in sitting devices such as CSSs and strollers, the American Academy of Pediatrics discourages routine sleeping in sitting devices. In one retrospective review of 47 infant deaths occurring in sitting or carrying devices such as CSSs, bouncers, strollers and slings, all but one death resulted from asphyxiation, either strangulation by straps or positional asphyxiation.1


A recent study reinforces these findings. Researchers analyzed 11,779 infant sleep-related deaths reported in 2004-2014 National Center for Fatality Review and Prevention data. The main outcome was sleep location (sitting device versus not). They found that 348 deaths (3%) occurred in sitting devices. About 63% of these were in CSSs, which were used as directed in fewer than 10% of cases. More than half of deaths in CSSs were at the child's home.


Compared with other deaths, deaths in sitting devices were more likely to occur when the child was under the supervision of a child-care provider or babysitter than a parent. The researchers concluded that "using CSSs for sleep in nontraveling contexts may pose a risk to the infant."2




1. Batra EK, Midgett JD, Moon RY. Hazards associated with sitting and carrying devices for children two years and younger. J Pediatr. 2015;167(1):183-187. [Context Link]


2. Liaw P, Moon RY, Han A, Colvin JD. Infant deaths in sitting devices. Pediatrics. [e-pub May 20, 2019]. [Context Link]