so what DO you do?

Nurses General Nursing

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Hi everyone! Just needed some advice from some more experienced nurses. I graduated last December, worked in subacute for 5 months and now currently at a hospital med/surg tele unit. There are several scenarios that really freak me out and make me draw a blank when it comes to what to actually do for the patient, so any input from others would be greatly appreciated!

I had a patient who came in for a P.E., was started on heparin drip. She was fine all night but then complained of a new onset of chest pain, so being the new nurse that I am, I freaked out. I grabbed a set of vitals (they were stable), she had on 02, i did a stat EKG and I called her primary Dr. The primary Dr. told me to call the hospitalist, so I call the hospitalist and it took him a while to get back to me. It just doesnt make sense to me, you would think someone having chest pain that you'd need immediate action and I felt like no one was around to help at the moment. I stayed with the patient and the hospitalist finally called back after 10 minutes and told me "well if she came in with a P.E. of course shes going to have chest pain" but i told him it was a new onset. So he just told me to do the EKG, give her pain meds and that was it. Btw our facility doesnt have standing orders for NTG.

Was this situation handled correctly? The scenario just left me very unsettled for the next time I have a patient with chest pain.

Next what do you do for someone who is hypoxic? Put 02 on them, sit them up, lung sounds,.. nonrebreather?

I just feel as a new grad all my knowledge goes out of the window!

Thanks very much :)

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Specializes in Med/Surg/ICU/Stepdown.

I think what you did was absolutely appropriate given the scenario. You assessed the patient and you notified the prescriber of the findings.

Simply coming in for a PE doesn't mean that the patient will appear symptomatic. I have had several patients admitted from the ER for unrelated symptoms and the PE is found incidentally on a CXR. You noted this is NEW onset chest pain, not that the patient had been experiencing it prior, or even at baseline. Regardless, does your facility have a rapid response team? You mention that the hospitalist's delay in returning your page made you unsettled due to the patient's symptoms; if you had a rapid response team, they're your back up. Concern for the patient alone is reason for calling a rapid response, but in light of your assessment, and the fact that you need hospitalist orders to proceed, calling a rapid response is more than appropriate.

The only piece of advice I'd offer to you in the future is to make sure you're assessing the patient and not just looking at their symptoms. The patient complained of chest pain and is in for a PE, but that doesn't exclude the possibility of other conditions causing the symptom. You need a more detailed assessment. What does it feel like? Is anything making it better/worse? Where EXACTLY is the location? What are the vitals? What is the EKG reading? Further assessment information allows you to delineate whether the chest pain is urgent and related to the PE, or if it is something simple ... like GERD. And these skills will come with time.

For your last question, if a patient is hypoxic, they need oxygen. It sounds silly, but it's simple, and true. Look at their O2 saturation and then consider their baseline/what their normal O2 needs are. You may have a COPD patient who typically hangs out at an SpO2 of 88% all of the time. That's going to be different from your young, heathy patient who always runs at an SpO2 of 95% and feels off if her O2 saturation drops any lower. Aim for a goal saturation of > 92%. Usually a NRB is the best way to achieve that. And this is also where a rapid response team comes in handy because you're going to need to get to the root of the problem and that's going to require further testing.

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Your initial nursing response was correct. I am not clear on your follow through. Know who to notify first in any scenario, consider a rapid response or when you call, feel free to say "this patient needs to be seen." Know what other nurse is on duty that you can trust to assist with your plan.

Who interpreted the EKG? Did the hospitalist evaluate at the bedside? Was the patient hypoxic?

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Specializes in SICU, trauma, neuro.

Calling a rapid response is a great way to get immediate attention -- which I would want given the new onset of chest pain. The pt could have thrown a 2nd preexisting clot (which heparin won't lyse), or he could be having an MI (just because he was admitted for one dx does not make him immune from developing another dx.) Or it could be GERD or anxiety, but is that an assumption you want to make?

For hypoxia, first look at the *pt* -- not just the SpO2 meter. A simple oximeter won't show the pleth (oximetry waveform). If the pt's finger is cold, he's moving around, if the probe is loose, etc, a 75% may not even be accurate. If he looks hypoxic and you believe the number, absolutely throw a nonrebreather on, and call a rapid response. If the nonrebreather is not cutting it (e.g. if the pt is not making sufficient respiratory effort), hook up the ambu bag to your O2 flow meter and start bagging. Of course, if you have an RRT there, they can help or get something like a BiPAP/CPAP which would be a step up from the nonrebreather and might be sufficient. But if you have to resport to bagging and the cause isn't immediately reversible (e.g. pt overnarcotized -- give Narcan, and they wake up swinging), the pt probably needs to be intubated...so you'd want the rapid response team there asap.

Also get your charge nurse involved. He/she will generally have the experience needed to 1) know what to do and 2) increased assertiveness and clout that may be needed for dealing with inappropriately unconcerned hospitalists.

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We do have a rapid response team but i didnt think it would have been necessary for them to come because the vital signs and everything were stable. I just got nervous because im not sure if its possible to get another PE while on a heparin drip so I was scared that she was maybe having another one. I was also asking my fellow nurses as well on what to do but they told me to keep ringing the hospitalist because he tends to not answer back right away so i paged him numerous times in a row which he was angry because it wasnt a RRT situation

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Specializes in Med/Surg/ICU/Stepdown.
We do have a rapid response team but i didnt think it would have been necessary for them to come because the vital signs and everything were stable. I just got nervous because im not sure if its possible to get another PE while on a heparin drip so I was scared that she was maybe having another one. I was also asking my fellow nurses as well on what to do but they told me to keep ringing the hospitalist because he tends to not answer back right away so i paged him numerous times in a row which he was angry because it wasnt a RRT situation

In the future, you don't need "unstable" vital signs to justify calling an RRT.

I had a patient who only presented with AMS. I knew it wasn't his baseline, but I couldn't pinpoint what was going on. His vitals were stable and he was responding to questions appropriately, but he wasn't himself. I called an RRT for "RN concern." Turns out he was having a cholinergic crisis. It's a good thing I did call. Always trust your gut.

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Specializes in Emergency/Trauma/LDRP/Ortho ASC.

Next time call RR or insist that pt be physically seen by the MD. If he refuses call the house sup or go up the chain per policy. It sounds like you did right...did he at least eyeball her rhythm? The point of RR is to prevent deterioration in pt condition so they really don't need to be acutely unstable for you to call. I respond to RRs as an ED nurse and I'd always rather come up and check it out even if it's just because you "had a feeling" than futilely work their asystolic code blue an hour from now.

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