NURSING JUDGEMENT.

Specialties Geriatric

Published

The other night I went to work (3-11) shift. I got report from dayshift nurse. I asked about a specific resident who had been on antibiotics for a UTI for a few weeks now, was told that she was OK, had pain pill earlier that morn. Just as we were finished our narc count and came out of the med room. The residents son comes up to us and tells us his mother is c/o a headache and would like something for pain. But he says he would rather she have Tyl rather than narc, because she seems to be very loopy from the narc.As he was telling me this, I thought I gave her narc pain pill the night before and she didn't act loopy, (she is normally a very alert and oriented person).

The dayshift nurse leaves, I take my little lady her tylenol. She is acting very unlike herself, very lethargic, confused and disoriented. I get vs and her bp was 90/40 HR 80 RR 30 and SPO2 86%, I start her on 02@2L/NC and call the Dr. Was not able to speak to Dr, but spoke with Dr's nurse told them what was goin on with her, nurse said he would relay the message to the doc and have him call me back, her 02 only came up to 90%. I was really uncomfortable with her condition, so I just went ahead and sent her out the hosp w/o waiting for the dr to call me back. She was admitted to ICU with hypotension and sepsis.

The admin called me later that evening and asked me what had gone on with her, and I told him, he asked" which dr. sent her out ?"I told him "I sent her out", he then said to me, "You sent her out ? So you used your nursing judgement and sent her to the hosp ??" I replied "Yes I did. I was not comfortable with her condition and felt that she needed to go to the hosp and she was admitted to ICU." And then he said I did a" good job." I felt good about sending her out b/c I knew it was what needed to be done, but I also felt bad that the dayshift nurse didn't do it earlier.

I was off the next day and when I went back to work another nurse said the dayshift nurse made a comment about the resident going to the hosp and how she must have had a change in condition rather quickly after she left. (mind you I started my shift at 3pm, I had that resident out of the facility and on her way to the hosp by 4:30). i guess she got a call from the hosp inquiring about this resident and the dayshift nurse was overheard saying "I don't know why they put her in ICU, I didn't think that would have been necissary, cause she wasn't like that one my shift." or something to that effect. Really trying to cover her ass. She never said anything to me during report about her until I asked if the hosp had called, and they said she was doing a hundred percent better. Really kinda made me feel good about my decision to send her out.

Since I am still new and inexperienced. I dont' think the vetern nurse I followed very pleased about it. I didn't get a good thing you caught that, or good job, or anything else from her. I got kudos from the RN super, another nurse (who doesn't even work LTC as she works the Rehab part) and another nurse plus the Admin. Not that I want the dayshift nurse to praise me or give me kudos, would have just been nice if she would have acknowledged me for it.

Anyway, I was pretty proud of myself. It really boosted my confidence as a nurse.

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Specializes in Wound Care, LTC, Sub-Acute, Vents.

Good job. It's nice when you make correct nursing judgements, right? I called 911 myself in the past and sent out patients and getting the orders after the fact.

I would just like to make some suggestions when this happens again in the future so you can add extra nursing interventions in this situation and chart it as well. Next time, you can use a non-rebreather mask instead so you can give more concentrated oxygen to the patient and see if this brings up the oxygen saturation (make sure patient has no dx of COPD before you crank up the oxygen). You can also put patient in high fowler's position and see if this will bring up the oxygen saturation. Lastly, you can elevate the legs and see if this will bring up the the blood pressure. You probably did these already and just didn't include them in your post.

I usually do the above interventions in your scenario before calling the doctor and tell the MD if they were effective or not. I then chart everything.

Again, good job and be proud. You probably saved this patient's life.

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thank you for the suggestions, I really did not think of the non rebreather mask, I knew she needed O2 and the NC was what I had that was handy, I did raise her HOB and feet. As much as I enjoy working with my residents. This particular LTC facility worries me. Things like this get over looked ALOT. There was an instance the other night where the CNA's found a resident had passed away, but had most likely passed away towards the beginning of the shift, b/c when they found him, rigor mortis had already set in. NOW THAT's SCARY !! I know a lot of it has to do with us working short staffed, the nurse to resident ratio, and that they have been admitting residents who are more acute care than LTC or Rehab. They have admitted residents on Hospice Care, one night I had 2 hospice care residents along with my reg 24 residents. Last night I sent a resident out to the hosp at shift changed, the night nurse had just got there and the CNA's were doing there rounds and got us b/c one of the new residents had loose, bloody mucusy stools. So the night nurse and I both decided to call the doc and get order to send him out to hosp. This resident was admitted with a hx of cirrhosis and had a bilary drain, foley cath. and massive amts of pain pills, I had never seen an Oxycontin 15mg tab. until now. and this guy is not a big guy.

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Specializes in SICU.

You're doing the job of a good nurse. Way to go!

The most important thing is to be attentive. You could have just gave the pain pills since the patient was "in pain". Really she was in pain because she was so dehydrated and couldn't breath. You caught it. Keep it up.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

You did a great job! well done.

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Good for you!

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Specializes in Clinical Research, Outpt Women's Health.

Good catch. I will say though that fragile elderly can turn on a dime so perhaps the day nurse did not see the same presentation you did..........................

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To echo CrunchRN and maybe make you feel a little better toward your coworker, I've had a pt act totally normal at the beginning of my shift and showing clear signs of sepsis by the end. It's entirely possible that nurse didn't see anything out of the ordinary. But you did and you did the right thing!

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Sounds Like you work at a facility just like mine. Twice now in the past few months I have came across a resident who had passed and rigor mortis had set in. It is the total lack of competent CNA's. We are working so short staffed it is not funny. I have right now 37 residents as does my other nurse. I have total dementia patients along with Pain pill seekers, and very Demanding families. I totally depend on my CNA's to be my eyes and ears when I'm busy. But my facility is more worried about the money issue rather than the safety of their residents and staff.

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We just learned about shock, among it septic shock.

It's an extremely slippery slope once you get into the late phase of progressive stage.

Good job, chances are you saved that patients life.

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Sounds Like you work at a facility just like mine. Twice now in the past few months I have came across a resident who had passed and rigor mortis had set in. It is the total lack of competent CNA's. We are working so short staffed it is not funny. I have right now 37 residents as does my other nurse. I have total dementia patients along with Pain pill seekers, and very Demanding families. I totally depend on my CNA's to be my eyes and ears when I'm busy. But my facility is more worried about the money issue rather than the safety of their residents and staff.

I have educated angry CNA's on this forum and will educate angry nurses as well.

If you're ''so short staffed it's not funny'' , how can you deem your CNA's incompetent? what is their Pt ratio?

They have nearly just as many patients as you, and probably have more involved tasks (have you ever showered and dressed a contracted patient? - it's time consuming. Now lets say theres 4 Pts like this. Think about it)

Now I know that you probably have to give meds for 20 patients, change bunch of stage 3 / 4 dressings, but the CNA's do the lower level care that is just as involved and time consuming.

Just as you were too busy to notice a freshly deceased Resident, they were too busy as well.

Edit-

Now if they are busy hanging around the nurses station on their phones, calling they's baby daddy and eating bon bons then yes, they're in the wrong.

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Obviously you do not read my post close enough. I currently have 37 residents. That is roughly 10 meds a piece. I also do have wound dressings on my shift. My Aides on the other hand have around 10 residents each. And Your "edit" Is what I'm talking about. I am constantly looking for these girls. They are either in break room with their "buddies", or on their cell phones. They hide in residents rooms. And when I say Incompetent...I Mean it!. Please don't assume I'm angry! I'm not I'm ******! This is my passion and my job! I can't afford to lose my licence because my Aides would rather talk on their cell phones than take care of these wonderful people. And before You say it, yes us Nurses have complained till we are blue in the face. But we get no back up for the"higher" up people. We are told to Quit picking on them. Or to write them up (which we do). But that gets us nowhere. In fact that usually makes things worse. Then they gang up together and make the environment worse. I love my job. I love my residents. But sometimes it is very hard to do my job safely without the right staff. And just to add..I do have a few wonderful Aides that I work with. Just not enough.

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