Did I did not do enough?

[Depressnewgrad]

I worked in nursing home in sub acute unit . I have patient that was c/o a lot of pain on left leg . Pt has left hip replacement and on rehab for that . I noted patient was medicated with pain medicine at 9pm and that she was still on a lot of pain at 11pm . I worked 11-7 shift . So I went assessed patient , neurovascular check complete . Left hip surgical site was fine but noted increased swelling on left leg , faint pulse , and from knee down the extremity feel cool to touch , she's able to wiggle toes and denies numbness , movement was limited on that leg . Vitals was checked as expected HR and Bp was elevated . I called the doc and told him about my findings and that even though pt is medicated for pain medicine oxy and hydomorphone alternately per order she only have minimal relief and that I'm concern about it . Doc did not order X-ray . He just basically told me that he will see patient early on am . I also notified him about the vitals . No reported recent fall . So all throughout the night I just medicated pt with pain medications , reposition her , applied ice for comfort . In the am they did X-ray and found out it has dislocated hip . Patient was sent out to hospital . The problem now pt states that When CNA put her to bed she heard something puff out . She didn't not mention this to me . My question .. did I didn't do enough? I asked pt if she want to go to hospital she refused . So I'm not sure what else could I have done aside from notifying the doc and medicating her ? Now my facility want me to write a written statement about the incident . So I'm going to write exactly this .

[canoehead, BSN, RN]

Nursemike,

One leg is visibly shorter than the other, by 2-3 inches. No tape measure required. And external rotation of the hip, where the patient cannot tolerate repositioning indicates a likely hip fracture

[Depressnewgrad, ADN]

Thank you! I actually charted it that I did not noted any signs of deformity during my assessment , no shortening , internal rotation . Also, I did called one of the senior nurses (LPN) who have longer experience than mine she's been an LPN for a long time and we both did not noted any other abnormalities aside from the significant findings that I mentioned above . I still feel though that I did not do enough . I should have been a better advocate to my patient by calling the physician second time . This will be a learning experience:(

[hppygr8ful, ASN, RN, EMT-I]

Based on the information you provided It appears you did all you could. One thing you didn't mention is if the leg in question was externally rotated which might have indicated a dislocation or even spontaneous fracture, The only other thing I might have suspected was a clot but without an ultra sound it would be hard to tell. In my experience and it does depend on the relationship you have with the physician is that sometimes you have to lead the doctor where you want them to go. I have done dressing changes where a wound looks really ugly and while changing the dressing I collected a culture. When I called the physician I said "The wound has quite a bit of purulent drainage and I took the liberty of collecting a culture. Would you like me to send that to the lab? The Doctor answered in the affirmative and turned out there was MRSA in the wound. We were able to start treatment right away. I don't think you have anything to worry about.

Hppy

[nursemike, ASN, RN]

That much? Wow. Thanks. (I was responding to canoehead)