Clinical Judgement Call...Not sure if I did the right thing

Nurses General Nursing

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Today I had to transfer a patient back to the hospital and I'm not sure I did the right thing in advocating for the transfer...perhaps I still have new grad informationitis from studying so much to pass NCLEX. A brief HIPPA safe (I hope) background:

D arrived yesterday with a history of Afib, Heart valve replacement, and a Non STEMI MI during this latest hospitalization. In addition her Troponin levels were still critical and her PT/INR levels were no longer in therapeutic range. Early this morning the night nurse called the doctor because the patient was diaphoretic and her vitals were all elevated. In addition the patient c/o reflux and epigastric pain. The doctor ordered reflux medication which was given with a very small amount of relief.

I took over at 0630am. The patient continued to complain of epigastric pain increasing from a 5 at 0800 with morning meds (including Carafate) to a 10 at 1200pm after the second dose of Carafate which had not worked. Vitals were elevated (BP 137/87 when it is normally 100/60, HR 92-normally around 60, O2-93 on 2L NC-it was 97, and her MAP was 112). I called the doctor again because I felt those levels were serious and the patient showed distress. The doctor ordered the patient to be transported to the hospital for evaluation.

My questioning of my decision comes from the administrators wondering why I even called the doctor for what was in their minds "just reflux" because according to their paperwork the MI was in the distant past though when I admitted the patient last night the hospital said it was what she was being treated for and her Troponin was critically high.

Was I right to think because women often present with epigastric pain and "bad reflux" that evaluation was a safer option than assuming the patient was okay and it would go away with enough antacid?

allnurses Guide

NurseCard, ADN

2,847 Posts

Specializes in Med/Surge, Psych, LTC, Home Health.

You are always better off sending the patient/resident out to the hospital when

it seriously looks like something is wrong.

Did the hospital keep her this time or send her back?

AvaRose

191 Posts

We sent her at 1330 and as of 1830 she was still at the hospital with no report called in to transfer her back. I don't know if the ED was that backed up that even a potential MI would sit there that long or if they admitted her for further evaluation, but I'm guessing further testing is being done. The doctor wanted to be called before we even thought about accepting her back at our facility.

cleback

1,381 Posts

With 10/10 pain I would have advised a trip to the ER too. That goes beyond reflux in my opinion.

Cowboyardee

472 Posts

10/10 epigastric pain, diaphoresis, recent hx of MI...You definitely have to at least send them somewhere that can check an EKG. Your judgment was fine.

Specializes in Critical Care, Education.

You did the right thing. Never let an administrator second-guess your professional judgement.

CoffeeRTC, BSN, RN

3,734 Posts

Nope! Long time LTC nurse and I would have done the same. You gave a prn and carafate and they were still complaining of pain, diaphoretic, abnormal labs....Yep. As long as you document what you assessed and the interventions you tried and the calls to the doctor, it should be fine.

Specializes in SICU, trauma, neuro.

You absolutely made the right decision, and apparently the MD agreed with you. I highly doubt it was "just reflux" with no relief from the reflux meds, and with that variation in VS. Would they rather you have assumed it was reflux, only to have the poor woman die in agony from an often treatable cause?

Some people...

AvaRose

191 Posts

Thank you for the replies. I don't know about the admin there. I understand that Medicare only pays so much per day for the patients but sometimes outside tests are needed so they shouldn't be quite so quick to dismiss the need to further evaluate patients. The main reason I was worried was that right as they were transporting her the paramedics took her vital signs and they were back to her normal range, but everyone but admin was still encouraging her to go get checked. Funny that we ended up with 6 firefighters and 2 paramedics to transport her when we had called a transport company for a immediate pick-up no lights and sirens but say the words "chest pain" and you get everyone stat. I'm off this weekend but we'll see if she returned or not when I work again on Tuesday.

AceOfHearts<3

916 Posts

Specializes in Critical care.

I think you did the right thing too. I think any patient- male or female- should be further evaluated for this. It's also important to rememebr that females also don't always prevent with the stereotypical s/s of an MI.

Out of curiosty- was any nitro given by the facility or EMS?

NO you were not right. The patient had a recent MI, now presenting with pain, diaphoresis and vital sign changes.

You cannot assume this is reflux! You needed to perform a stat EKG and administer nitro SL. Of course the doctor needed to be notified, but just because the doctor and the night nurse THOUGHT it could be reflux, YOU need to start ruling out cardiac causes FIRST.

ComeTogether, LPN

1 Article; 2,178 Posts

Specializes in Transitional Nursing.

Tell the admin to show you their nursing degrees, and you'll talk.

My admin does this too. Asks us to dip residents urine if they even have a hangnail, because you know, everything is because of a UTI. (eye roll)

Good job sticking to your guns. Don't give it another thought.

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