Lovenox and a bleed? grrr

[Imuneek2002]

I had a patient yesturday that had a stroke, a hip fracture and a small bleed behind her eye. The doctor had come by and written orders for no anticoagulants so I clarified a few other things with the order and said so we are holding the lovenox for now. And she said no, no we don't want to do that because she has a hip fracture and the risk of a DVT is high so lets give it to her and I said even though she has the bleed and the doctor said it was a very, very small bleed and the risk of a DVT was higher... ok so I did what the doctor ordered. And nights said I never would have done now because I would have been afraid to get sued. Now I feel just wonderful... I guess I should have asked another nurse or doctor before giving the shot.

[AprilRNhere]

Did you document that you told the dr about the bleed and it was still recommended...what was said etc..?

I'm new..and would have given it anyway...and then charted every word said.

[Imuneek2002]

I charted it as an order that it was ok to give per the doctor. I should have charted a progress note now that I think about it. It wasn't a big deal to the doctor so I wrote the order and went about my work because I was super busy of course. I didn't think it was a big deal until the night nurse said something. I should have gone back and charted some more. I guess I better chalk this one up as a learning experience and never let it happen again right?

[AprilRNhere]

Yes- learn from it.

I know I learned my charting lesson first week off orientation...when my R/O pt who denied pain all night told the am nurse she'd had chest pain ALL NIGHT! I almost had a heart attack myself!

[zamboni]

I charted it as an order that it was ok to give per the doctor. I should have charted a progress note now that I think about it. It wasn't a big deal to the doctor so I wrote the order and went about my work because I was super busy of course. I didn't think it was a big deal until the night nurse said something. I should have gone back and charted some more. I guess I better chalk this one up as a learning experience and never let it happen again right?

And If the doc had told you to hold the med, it's possible that the following shift would have filled your head with visions of courtrooms when the patient develops a DVT.

There will always be situations where two risks have to weighed against each other. Sometimes, it may be clear which problem is a priority, but often times it will be a crap-shoot. (I have also seen nurses use "You might get sued" as their only rationale when questioning something, and I learned long ago to take it with two or three grains of salt...) There will be many times when a treatment is chosen as the lesser of two evils, and all you have to do is document.

I don't know anything about your patient. But you did right initially questioning and bring the bleed to attention. I don't think you can say you'll never let it happen again, because each patient will be different. All you can do is document, and you admit that yours may have been a little lax. Focus on that, and utilizing your resources more and you'll be fine.

[sharlynn]

Yes- learn from it.

I know I learned my charting lesson first week off orientation...when my R/O pt who denied pain all night told the am nurse she'd had chest pain ALL NIGHT! I almost had a heart attack myself!

Don't you just hate it when that happens! That or I didn't sleep a wink all night.

[seanpdent, ADN, BSN, MSN, APRN, NP]

I charted it as an order that it was ok to give per the doctor. I should have charted a progress note now that I think about it.

I would agree. No matter what the discrepancy, if you chart it as such you are at least covered in a court of law that you within your practice guidelines.

But also remember it is perfectly within your rights to refuse to administer a med if you you feel it will harm a patient. A doctor would simply have to get another nurse to adminster the med, or the MD themself would administer the med. So it's a double edge sword, simply saying 'I did what the doctor told me', does not hold up in court.

Just food for thought.

You should be proud that you were thinking of your patient's safety, even with your hectic busy day. Staying focuses is was good nurses are made of.

:wink2:

[oramar]

I have seen doctors do exactly what this doctor did a thousand times. They usually order the blood thinner under the circumstances you describe. Cloting is the greater risk.

[lorilou22RN]

The pt had a hip fx, and a stroke (embolic I presume?). She/he fell, due to the stroke, fx the hip, and suffered a small bleed behind the eye, correct...? Definately as a new nurse question the doc about the rationale, you do need to understand. But as long as the stroke was embolic vs. hemmorhagic, lovenox dosing therapeutically is appropriate (was it therapeutic dosing or prophylactic?) This pt needs anticoagulation, they could get a DVT due to hip fx, or perhaps already has one and that is why they stroked in the first place.

As one of the prior posts stated sometimes the docs have to pick the lesser of 2 evils when determining care. Just chart appropriately to CYA, and move on.

[husker_rn, RN]

I would have brought it to the physician's attention too, but made sure I documented it well. Sometimes I've felt like I'm writing a book but it has covered my a** on several occasions. CYA....CYA....CYA

[suanna]

You did a fine job. The only documentation I would have made is that I reviewed/verified current orders with "Dr. XXX" in my nurses notes. If you write the order "give lovenox as ordered" its redundant-you already have an order of lovenox. I doc shouldn't have to give an order two or three times to get it done. Also, if the patient did have a bleed, most likely completely unrelated to a little lovenox,you don't want to call special, unnecessary attention to the lovenox order. That just puts a red flag up for any attorney that might be looking for someone to blame. You were absolutely right in clairifying the docs intention for lovenox. Monday morning quarterbacking is a favorite hobby in our profession as well as a great way to make other nurses nuts!

[jjjoy, LPN]

Monday morning quarterbacking is a favorite hobby in our profession as well as a great way to make other nurses nuts!

:smiley_ab:doh::lol_hitti:chair::deadhorse