When do you worry??? New RN ???'s

  1. New Nurse question:

    I have been told I will learn the nuances, like when to worry. What to do if, etc... but I don't think my patients can wait, so I tend to over worry right now.

    So, dumb question. If pts are fairly new ED admits and they develop high(er) bps, high(er) temps etc, what do you do BEFORE you panic and call the doc.

    For instance, hypothetically but ususal case:
    older lady with COPD comes in for gallstones, NPO, fluids running about 100 hr., UA clear. Over next six hrs she pees only 225 cc,concentrated (foley), temp 37.9, hr 101, bp 150/100. Im thinking dehydration, she is COPD already distressed resp (on home o2) so dont want to fluid overload her either.

    Some nurses tell me,dont worry thats not unusual with pain (hard to elicit pain scale as she has dementia) and her bp is high not low. Others freak because her output is low and want to call doc and get bolus order, others I have heard say wait and see, doc will be in in the morning. She has course crackles and is on home o2 and RT is treating her every 3-4 hours.

    I have lots of pts who suddenly their BP will go up but they may be in pain or agitated stroke or dementia pts. Every hemodynamic change sets off alarms in me, but I want to get better at knowing when to worry.

    Any suggestions guys?? I cant just slap an aspirin/tylenol in em and call in the morning....

    Still learning
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  2. 9 Comments

  3. by   Tweety
    You are already thinking like a critical thinking nurse and this is good.

    Sometimes the old jaded nurses who don't panic miss things with their casual attitude. Their patient crashes and you always hear "they were fine a minute ago, I was just in here.........". It's your patient, your new license so continue to think like this.

    However, you do develop over time a sixth sense that something just isn't right.

    She probably is indeed dehydrated but the rales may indicate that she's holding on to some of her fluid. How long has the 100 cc/hr been running? The 225 cc in six hours is 30 cc/hr, which is my minimum level of comfort, so I wouldn't panic just yet.

    The BP is above my comfort level, but it could indeed be pain, so a thorough pain assessment using nonverbal cues, such as guarding, grimaces, pain to palpation, etc.

    The respiratory distress bothers me as well. I'm sure this distress is not her baseline. Is there documentation that the MD is aware of this. Was she like this in the ER and just hasn't gotten any better?

    I guess besides the hemodynamic changes, and change of any sort is signicant, what I would look at is the patients presentation. How has that changed? What was the urine output in the ER when they put the foley in. What did her lungs sounds like in the ER. What was her BP in the ER. What's her BUN/CR - which would be the telltale of dehydration vs. overload. What was her baseline CXR, are the rales a pleural effusion/pneumonia? If nothing really has changed since then, perhaps she just needs continued treatment as ordered and a watchful eye.

    If her lungs were clear, if her BP was lower, etc etc. then a prudent call to the MD is in order to maybe order a chest xray, etc. because the patient is experiencing a change in condition the MD might not be aware of.
    Last edit by Tweety on Oct 4, '06
  4. by   ArizonaMark
    As a new LPN working toward my RN, I appreciate this question and the comprehensive response from Tweety. I too am in med/surge and worry endlessly over my pts.
    Last week I assumed care of a pt. who was "stable" all day according to report. Upon entering the room and taking her initial vitals (which I personally always take), I found my "stable" pt. with a 103.3 temp. and b/p systolic over 200.
    Day shift nurse casually states, " Oh, she's just spiking a temp. again." Yeah, right ! I dumped two Tylenol in my pt., put some cold washcloths on her feverish forehead, and I CALLED THE DR. !
    Other than the reporting-off nurse, all the other nurses on the floor were supportive of my decision. Dr. ordered a B/p lowering med. stat, and to have the pt. placed back on antibiotics as he thought she had resolved her infectious process.
    My young (nurse experience) rule is, if in doubt call the Dr.!
    Mark :roll :roll (my life, LOL)
  5. by   Tweety
    Mark, that is a very good rule........when in doubt, make the call.

    Changes in condition are always worth reporting.

    However, sometimes we old nurses don't panic and get excited, like we used to as a new grad, because we've seen and done so many things. I don't mean to imply we don't have critical thinking skills and just blow things off. It's just that we don't get excited, we stay calm and process it as the information in a rational manner that doesn't include freaking out.
  6. by   augigi
    I'd need more info about the patient to make an educated guess, but ALWAYS trust your gut. If you think "something is not right" - go with that. Every time I have ignored that voice within, I've regretted it badly.

    In this case, I'd want to know what the chest XRay looks like, and what her albumin is. Looks like she is relatively dehydrated (vascular space), which may have made her peripheries squeeze up to cause the hypertension and poor urine output. On the other hand, she sounds wet in the lungs, so I'd wonder why her fluid is shifting to the tissues, and suspect her albumin may be low and causing this fluid shift. On the other hand, she may normally be hypertensive, and she just has a chest infection.

    In summary, if you aren't sure, call a supervisor or doc. You will never get in trouble for worrying "too much" - as long as you can provide a valid rationale for your concerns.
  7. by   Fairlythere
    Thanks Tweety, I guess the breakdown and finding more information is the key. ED reported she was here for gallstones, conservative treatment, sweet lady, given pain meds, labs looked "okay", etc. I think its a case of our treatments (adding iv fluids, etc) making things that were hidden pop up (exacerbation of COPD,etc) and on night shift I have to dig harder and deeper. I definately will continue to question my gut instincts. I just get frustrated at times when I ask the NTL stuff and I feel like they blow it off or think I am overreacting. But I will keep asking...
  8. by   Jennerizer
    You'll learn with experience. I know when I first started, I panicked any time a patient would report chest pain. I automatically assumed they were on the verge of a heart attack. The hospital where I work - we are free to call the doctor without having to run it by the clinical leader or charge nurse. I usually will involve the clinical leader to get her opinion, but if mine differs or I don't feel good about the advice, I make the call to the doctor.

    At another hospital I used to work at, we would need the supervisor's permission to call a doctor past 11 pm. I had a 27 yr old patient with a BP of 172/110 & they would not allow me to call the doctor because "We don't call that doctor at night." It made me feel so uneasy & I knew if anything happened to the patient, I would hold all the blame because ultimately it is my license & I am the one caring for him/her - I quit that place after 6 weeks. Trust your gut feeling every time. You may annoy a doctor here & there, but I feel it's better to do all that you can rather than not enough.
  9. by   cardiacRN2006
    This happens to me all the time. I'm noticing the trends in my VS or OU(since I do them Q1hr), and thank God we have hospitalists who hang out in ICU because I don't have to go back and forth on whether to call them or not. But, my preceptor tells me that the VS are fine, to not get worried over them. When the Dr is reviewing my chart, I will casually mention, "his diastolic BP has crept up and is now over 105". Do the drs care? No, I got an order for a BP med to give if SBP is >160. Gee, thanks.

    So, Why doesn't anyone care about elevated VS?
    I'm fearful that I won't worry about things like this anymore because my preceptor tells me not to, and then when I'm on my own I will miss something.
  10. by   idt
    I am not a new RN, but new to the country. When I first started on the ward here, I used to worry about lawsuits. Always on my toes, making sure I covered everything.

    Then, I found out that there is something out there that covers trial defense for work-related criminal charges (bad things do happen to good people....... hopefully never in our case). Anyway, I got the plan & now, I feel like I can do my job without worrying too much about everything. It's a real load off my mind.
  11. by   Fairlythere
    Exactly! I guess if the docs are aware, I wouldnt be AS concerned. Its frustrating

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