Vent thread... when to send a pt outRegister Today!
- by pppp87 Nov 27, '12I'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 newer nurse, "when in doubt, send them out." At my facility, the DON seems to be overly concerned with the # of Medicare patients and how it affects the total reimbursement from Medicare, i.e. $$$, folks.
Anywho, I had a 65 yo resident with hx of cva, afib, dvt, esrd and hypertension. Due to the cva, she has dysphasia and can't communicate well. It's apparent to everyone that she's "with it" and understand's what's going on around her but her speech is distorted. She's usually always "talking" though. This morning at 0500, in the middle of my medpass, the CNA's grab me and tell me she's lethargic and not responding as usual. I go in and sure enough she's very lethargic and not responding verbally at all. She's able to follow my commands and squeeze my hands, but very weakly. She couldn't lift her arms at all. Her eyes occasionally rolled in the back of her head and she couldn't keep them open for long. She had a fixed stare at times, so I thought maybe she was having a cva. Her skin was cold. Her bp was 139/77, when her SBP is usually 80-100. Her o2 sat was 82%. I put her on 2L. Her bs was 114, no hx of DM. After I put her on 2l, I wasn't able to get a pulse ox reading.
I grabbed the other nurse who was working and has years of experience and she agreed that she didn't look well.
I sent her out and 20 mins later the ER Nurse calls me with an attitude saying she's treated this patient 3x before and this is her baseline. I calmly told her she's been a patient of mine for 3 months and this is definitely not her baseline. The woman argued with me that because of her hx of cva she is completely nonverbal and doesn't speak. I explained to her she does speak, although incomprehensibly...
The patient was admitted for urosepsis.
My DON said I did a good job assessing, but why didn't I think of giving her a nebulizer treatment? To my knowledge, the resident has never had respiratory issues. She basically told me I should've done more to try and keep the resident there because it looks bad when the hospital is audited by Medicare for readmissions.
I just leave work sometimes feeling horrible. I try to put my patients first and care for them as I would my family. I don't have all the insight and years of critical care experience that my DON has. If that was my grandmother lying in the bed, I would definitely call 911 after doing all I knew to do and still feeling something wasn't right. We're not even able to call the doctor at night, we text him. And it usually takes him eons to respond back. The DON almost expects perfection. If something would have happened to the resident, I would've been blamed. Can't win for trying at this place! I managed to get all of my paperwork done, call the family, finish my med pass, medicate a seizing patient and deal with some low blood sugars and all she could point out were the things I missed this morning!!
Ugh :/ Just venting...
- Nov 27, '12 by missnurse01darling you did awesome! I could never work LTC and am amazed at those that do.
as she was admitted for urosepsis, I don't see how a neb tx would have helped her...I mean was she wheezing? have an resp hx that would point to that way? You did the right thing, don't worry.
hugs and chin up
- Nov 27, '12 by psu_213It sounds like you did a great job...
A few points that come to mind:
1. The nebulizer tx? Uh, no. Just because someone has a low pulse ox., this does not mean they need or will benefit from a breathing tx. If on auscultation they have wheezes, then a breathing tx. can help. Don't tell your DON this, but a tx. sounds like a waste of time here. Also, you can't give one without a doctor's order and it would be a waste of time to wait for the doctor to call back when the resident has other issues.
2. The ER nurse had no reason to be such a snot. I'm not defending her attitude or how she treated you; however, 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.
3. Keep taking those blood sugars! Even with "no history" of DM, I've seen blood sugars all over the place. I know you took it, which is great. And don't think that they cannot be hypoglycemic even if they are not diabetic.
- Nov 28, '12 by pppp87@missnurse01 thank you for your comment! my don was acting as if i was sending her out for resp distress. I never stated to the NP, DON or EMS that she was in distress. But a sat of 82% clearly just isn't right. thank you for your kind words and comment... @psu_213 thank you for your comment. 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. being a newer nurse, i don't have the experience to do so. nor, would i, since to me its unethical. we have an md for a reason... thank you for your advice about calling in report to the er. I've never seen it done here actually but I would love to give the ER report because I'm sometimes worried that EMS won't relay everything to them..
- Nov 28, '12 by pppp87The evening charge called the hospital this evening and found out the pt was admitted to the ICU. My DON is still brushing it off and saying that everyone here probably has urosepsis and that's something that could be treated here... I was offered a job at a PCU in a teaching facility so hopefully I can move on and get a better nursing foundation there...
- Nov 28, '12 by Kittypower123As a nurse in LTC I would have approached the situation exactly the same way. After assessing, I'd call the MD to notify of the situation and get an order for transport to ER and O2 in the interim. The DON may not be happy about sending someone out, but if it's in the best interest of the resident that is what you have to do. I have been able to keep someone in the facility when a medical situation arose, but it was not urosepsis. Sepsis is very dangerous and patients need more than what we in the LTC can provide. Frankly, I'd rather have my employer unhappy than the BON.
- Nov 28, '12 by CapeCodMermaidWhat can the hospital provide for sepsis that we can not? IV antibiotics? We can do those. Supplemental O2? Yes...that we can do.
Clearly every situation is different. We had a nurse want to send a resident to the hospital today because it took her a few minutes to respond. The woman is 101 and has stated on more than one occassion, she is ready to die. What would be the point of sending her to die with strangers? We gave her a liter of fluid because the MD insisted and kept her in the facility...her HOME for the last 4 years where everyone knows and cares about her. When I left tonight, she was comfortable in her bed.
- Nov 28, '12 by mappersQuote from CapeCodMermaidConsidering the patient ended up in the unit, I'd say that LTC could not manage this situation. Sepsis can turn bad very quickly. LTC cannot administer bi-pap or tube a patient, cannot do ABGs in a timely manor, cannot manage bottomed out BPs with IV vassopressors. A septic patient requires frequent monitoring, frequent vital signs, etc. I doubt many LTC nurses want to deal with that amount of observation and care with 20-25 other patients to deal with. It actually surprises me that an LTC nurse would respond that way. Most I know complain that LTC/Rehab is more and more like Med Surg every day (with 3X the patient load.)What can the hospital provide for sepsis that we can not? IV antibiotics? We can do those. Supplemental O2? Yes...that we can do.
Quote from CapeCodMermaidThis situation does sound very different. Is that patient palliative care? Does she have a DNH order? If not, maybe she should. That nurse probably did over-react.Clearly every situation is different. We had a nurse want to send a resident to the hospital today because it took her a few minutes to respond. The woman is 101 and has stated on more than one occassion, she is ready to die. What would be the point of sending her to die with strangers? We gave her a liter of fluid because the MD insisted and kept her in the facility...her HOME for the last 4 years where everyone knows and cares about her. When I left tonight, she was comfortable in her bed.
- Nov 28, '12 by DSkelton711You did fantastic. This is still a young patient, not a 101 year old, and you knew her baseline. If my loved one had any kind of sepsis, I would want them in the hospital. Too bad for the DON and ER nurse for having attitude. I've called ER to give report many times and as soon as they hear I am calling from a LTC/Assisted Living about an older person, they don't seem interested. You did the right thing.