Vent thread... when to send a pt out - page 2
I've been at an LTC facility for 3 months now. One thing is clear at my facility: take caution before sending residents out to the hospital. I was always taught as far as LTC goes, especially as a... Read More
Nov 28, '12Quote from ktwlpnThis was in reference to the 101 lady who was kept comfortable at the facility not the OP (as indicated by my quotes of the previous post.) DNH means do not hospitalize and palliative patients will often, but not always, have this order.DNH does not mean do not treat.
The nurse acted appropriatly IMHO-she reported her findings to the physician and he gave the order to send her out.
Nov 28, '12You did a fantanstic Job! I've worked LTC and ICU and I would have done the same thing. Any change in mental status that is not baseline and has a new onset audits a trip to the ED IMO.
PCU will be great for you!
Nov 28, '12My old DON used to blame me for sending residents out for "no reason" I'd always send them out when in doubt. Sometimes they would come back right away and sometimes they'll be admitted to ICU or the floor. However, can never be too cautious.
Nov 28, '12Just want to say that you rocked that one! I wouldn't administer neb tx without an order, especially if there was no reason to.
Nov 28, '12I get sass from our ED all the time. They see an old person at the jumping off point who's having old-person problems and think it's a waste of their time and skills. Not saying it's all EDs, just the one we use. I think they're super burned out on drug seekers and people using the ED for primary care, that unless you're spurting blood from some hole in your body, they'll roll their eyes and point to the waiting room. I've had nurse-friends who worked in the ED say as much.
Anyway, you did fine. Pay lip service to your DON. Her job is to watch the bottom line. "Yes, DON, I'll remember that for next time. But this is the reason why blah blah blah. I didn't want their family to call the state on us!" Mention "The State" and your DON will be quiet. Same with giving meds without orders. Mention that it's illegal. What's she going to say? "So, I know it's illegal, do it anyway?" Probably not. If she does, RUN.
Nov 29, '12Quote from pppp87Huh?? On AN there are all sorts of things for which nurses think they can lose their license. Well, practicing medicine without a medical license is something for which you can actually lose your license. Chart your attempts to try to contact the doctor--be specific: when you called, how you tried to reach him/her (answering service, , etc.). But don't just give a med and look for an order later. If it is a bad outcome, there is a good chance the doctor and your DON will hang you out in the wind.my don actually encourages us to give meds without an md order. she criticized a new nurse, asking her what she would do in an emergency if she wasn't able to get an md. her expectations are that we act first and get an md order later.
Nov 29, '12Another OH SO FAMILIAR vent. You did YOUR best, you went to another "more experienced nurse" for an opinion, then advocated for your patient. You did exactly what was right for the situation. I have been a LTC RN for going on 7 years now. We nurses who see these patients and interact with them WAY MORE than any hospital nurse; sometimes we must stand our ground!! You will learn as you go. You will develope a keen instinct. Before you know it you will know without a shadow of doubt. Just when to use your nursing "judgement", assessment and clinical skills in order to be able to stablize your patient and when HOLY CRAP Ms. Debbie D. Patient is a code status CPR, call the ambulance stat! For the most part, I am sure the DON does not mean anything personaly towards you. She is just doing her job. Heads in the beds = job security. Also the longer you work there the more Admin. will trust you. There are ALOT of nurses who seem to loose their head and want to send, send, SEND 'em out before trying other options first (in appropeiate situations). I have been in your shoes, seems like yesterday. You are gonna be just fine. Just don't take it personal! Of course your DON wants what is best for your patient, but is also heavily involved with the business end of the facility too. Best of luck to you always
Nov 29, '12Yep Mappers!! With the hospitals keeping patient's for less and less time. They come to us with a very high acuity alot of the time. I mean a procedure that used to land a patient in the hospital for let's say a week. Now they are being discharged from the hospital in 2-3 days. Too sick to go home we get them **shakes head**
Nov 29, '12Quote from psu_213Yep.. I haven't given anything to date without an order here but it is what is expected in an emergency here, especially at night when the doctor is almost always not readily available. During the day, IV's have been started, D5, fluids, neb's etc have been given w/o an order. We should really have a Dr oncall here..Huh?? On AN there are all sorts of things for which nurses think they can lose their license. Well, practicing medicine without a medical license is something for which you can actually lose your license. Chart your attempts to try to contact the doctor--be specific: when you called, how you tried to reach him/her (answering service,, etc.). But don't just give a med and look for an order later. If it is a bad outcome, there is a good chance the doctor and your DON will hang you out in the wind.
Nov 29, '12Quote from psu_213ALWAYS call the receiving facility when you send a patient ANYWHERE. (in any setting...this includes ER nurses sending patients back)did you call ahead to give report to the ER? I realize that it sounds like this person was somewhat familiar to this ER, but it is always helpful to hear the the facility when they send a resident in--why are they coming? How are they different from their baseline? What interventions did you perform before they left? Etc. As I said, if you did not call it does not excuse the ER nurse, but, speaking from experience, it can be helpful to get that call.
I am an old ER nurse, and it chapped my hide when I didn't get a call when patients came from any another medical facility.
I teach nursing, and hammer this point home to my students. It's just plain rude not to call, and bad outcomes will happen when we don't share clinical (and any other pertinent) info.
A lack of communication is the worst thing we can do for our patients!
And send as much paperwork as you think is appropriate (H&P, MAR, nurses' notes, face sheet)
And seeing that your pt ended up in the ICU, you made the correct call to send, period.Last edit by hogan4736 on Nov 29, '12
Nov 29, '12Ah, yes, albuterol is right for urosepsis, the old treat urosepsis via the lungs approach. Why not?
I think you should quietly, anonymously report the DON to the powers that be. She sounds realistic but dangerous. Does she have a longstanding relationship with the evasive, elusive, rarely available doctor, who then writes whatever orders are necessary to cover what's already been done?
She is practicing medicine without a license, she is implicitly diagnosing, she is wanting her staff to do likewise - all so the doctor can sleep through the night or keep seeing patients at the office or keep bringing his business to this nursing home. Maybe it's the facility owner who doesn't want to pay for a doctor who is willing to work. What a damned mess! And it's not uncommon.
Whatever the reason, do not get into this very bad habit of practicing outside of the law. You worked hard for your license and you will lose it if you do what this DON wants you to do. And no one, not the doctor, not the owner, not the DON, no one will back you up if anything goes wrong.
Be sure to document explicitly when you call a doctor - write the phone # you used in the chart. Write what you did when you couldn't reach the doc.
How much trouble are you in for sending someone out without an order?
The ER nurse is a real trip! Never mind her, but do call and give report in the future.
Nov 29, '12You did great and you did your best. Sometimes we think we should do more but the mere fact that you act quickly is something to be proud about.