Need Dialysis RN feedback

Trauma Columnist · Aug 7, 2011

Is it policy that you notify an MD when a pt is hypertensive?

I know I work with a very large neph practice and I agree with you: I have some very noncompliant its who are ALWAYS hypertensive because of not adhering to their meds as evidenced by good control when they are in the hospital!

I would ask if you have a written policy on this? Was there something weird about this instance?

renal123 · Aug 7, 2011

Thanks for responding. I did find their policy online - says call doc before treatment unless this is typical for patient. Then says call doc if no decrease in B/P in 1 hour. Then post B/P call doc if high unless this is typical for patient. It was a busy nite and the guy went AMA so he wasn't there long. I was in management with Gambro for 12 years and I wouldn't have given up on a nurse - especially when this was an isolated and uncharacteristic episode.

Trauma Columnist · Aug 8, 2011

Me either. Have seen far worse actions. I would push the appeal process if it comes to termination. What did the doc say/want done?

renal123 · Aug 8, 2011

He just told the nurse manager "to deal with it" and doesn't even know what nurse was involved. Out of the 1000 things I did that day this was not perfect. Instead of trying to smooth things over with the doc she called corporate.

Trauma Columnist · Aug 9, 2011

Gee whiz.

I'm an APN and if I was called every single time a pt was hypertensive, I'd literally be on the phone all day.

If this is the norm for this pt, I just don't see the necessity of notifying the MD every single time.

AsatruRN · Aug 11, 2011

Wow...that was the norm when I worked in dialysis. Basically if the b/p was over a certain amount pre treatment we had to give PRN, and hold HD until b/p came down into range. During treatment same thing - it should trend down and we can give PRNs. Still high post treatment they're supposed to stay unless MD says it's OK to be discharged.

As far as your AMA patient - if you called the doctor and left a message that is proof on your end that you attempted to contact the MD. Then the patient goes AMA...at that point I suspect the patient has to sign a form for AMA and you have to do some documentation of your own. You know - patient is encouraged to stay, high b/p, asymptomatic, left anyway. Were you supposed to continue calling the MD about this one patient for the rest of the night?

The policy is not very specific. From what it says however - you are required to call unless "It's typical for the patient." From what you are telling me you followed policy. The hypertension is typical for the patient.

Your nurse manager seems like she is jumping the gun for calling corporate. If I may ask is there bad blood between you guys? Incidents such as what you described happen all day every day for a Chronic HD unit. The doctor was probably angry with the patient because the MD has probably tried and tried until blue in the face to get this patient to comply - and is taking it out on the nurses. Did the doctor give a specific order to notify him or her about this patient's hypertension with specific parameters? I'm guessing not. We cannot keep the patients there against their will. The patient left AMA.

Furthermore if no harm came to the patient it would be really hard to prove anything with their investigation. If the investigation concludes and you still work at that clinic I suggest you work with the regional management, your (evil) nurse manager, and the (evil) doctors to provide a unit based guideline or protocol so this doesn't happen again to you. A protocol with actual numbers. And next time page the silly MD like, every 5 minutes until he or she calls back

If this fails you could get a job in any of the other thousands of outpatient HD clinics in half a second.

renal123 · Aug 11, 2011

Well, I did get fired. The investigation said I went over and above protocol for fluid removal and doc denied I tried to call him. So doing extra for this fluid-overloaded patient cost me a job. They said I went beyond my scope of practice for an RN and violated the nurse practice act. So I think I have had my fill of outpatient HD and thinking of returning to hospital based. I miss my 3 12hour shifts anyway. I have experience in several areas so I'll hopefully find something quick. I just thought it would be a decent job while I'm in school. I'm hopefully starting NP program in January. Thanks!

Trauma Columnist · Aug 11, 2011

That's awful. I can tell you, from my experience, that having mid-levels as the go-between for the nurses and docs, we've eliminated much of these problems.

In our practice, the nurses feel very comfortable calling me (and my 3 other mid-level co-workers) for any and all advice. We are very approachable and have no problems just talking out a situation.

Maybe a dialysis unit that uses this model would be a better fit?

At any rate, I wish you the best. Take care and let us know how things work out.

3cdn1usa · Aug 14, 2011

Renal123,

OMG!!!! like you guys said before, this happens everyday in pretty much every unit!! We can't help those that don't want to be helped. I can't believe you were fired for this. I am sure there are progress notes on their non-compliance. Did you make a detailed pre assessment note and noted that you called the MD? Hope so, then file a wrongful dismissal. Sure is frustrating...I don't even know you and I am upset about this! Holy Ham Sandwiches!

550Qb · Aug 14, 2011

How much did you challenge the EDW? We're only allowed to take 1 additional kg without a doctor's order.

renal123 · Aug 14, 2011

Unfortunately Florida is an "at will employment" state. You can get fired for any reason at any time. But I have a bunch of interviews next week and who knows - I may find the perfect job.