Advice for a new grad on sending patients out to ER?

[Cynnie24]

Hello everybody,

I am a new grad RN in a sub-acute rehab/LTC facility. I have been here for a month and am on my own, off orientation. When it comes to being cautious and sending patients to the ER r/t a patient condition change, I live by the saying "when in doubt, send them out". As much as I am on my toes and always on the lookout for anything that could go wrong so I could prevent it, I am worried that something wont be so obvious to me (especially because I am brand new and my assessment skills are not great and I have 20 patients). I am constantly running around throughout my shift. I am worried that a patient will end up being sent to the ER by the next nurse because I missed something and that I will be to blame because I delayed treatment. It would be very hard to live with myself if I thought I could have caused a patient to decline due to being swamped or just too new to identify an abnormal finding. How often does this happen, and how do I prevent this? This is a huge source of anxiety to me about my new job. I have seen this happen once to a nurse at my facility where the patient was hypotensive and the nurse did not send the patient out because the patient was stable other than the blood pressure, only to discover that the next shift nurse sent the patient out only one hour later r/t even worsening hypotension and the patient became symptomatic whereas he was asymptomatic before. I really appreciate all of the advice and wisdom on this forum. Thank you in advance.

[PequeSD]

Ive been working as an RN in rehab/LTC for a year now and the only advice I can tell you is ask your fellow nurses for help. If you feel something is off, ask someone else for their opinion/help.

[casi, ASN, RN]

LTC is a juggle of keeping them in their "home" and sending them out. In LTC you can do a darn lot to manage acute concerns.

When you are looking at hypotension you need to look at the big picture. If their BP is low how low is it? What is their baseline? What is new? New meds? New routines? Are they in a different position, are they sound asleep, are they orthostatic? If someone is asymptomatic and hypotensive I wouldn't be sending them out. I'd be pushing fluids. If their pressures were really low for them, I'd be asking for labs and maybe for IV fluids.

[CapeCodMermaid, RN]

If your facility doesn't provide information on it, look up INTERACT 3. There is an SBAR tool to help you collect your thoughts and be ready when you call the MD. Know what you want before you call. There are also clinical care pathways that help walk you through major problems and guides you through the decision making process.

[casi, ASN, RN]

I second the SBAR tool. I've been a nurse for over three years adn will still pull out this tool to organize myself.

[sankinrn]

Interact has some excellent tools. Especially the SBAR. Also, you may want to ask your supervisor what resources are available to assist you with your assessment skills. Working as a Director of Nursing, I encourage my staff to always ask questions. I am constantly educating, encouraging and giving constructive criticism. Hopefully, your director can assist you. You should feel confident when you are working and after you leave. We all make mistakes, as long as you learn from your mistakes, thats what important. Your skills will improve, never be afraid to seek assistance from your peers and always ask questions. Good Luck, things will get better. Let me know if I can assist you in anyway possible.

[TardisMom]

Another bit of advice I would give is ask for help but don't let anyone bully you into not sending a patient you strongly feel needs to go out. There is a tendency in LTC/Rehab to push for treating in house if we can for many reasons and other staff can get downright aggressive about it. I had a DON at a facility try to bully me into putting a lady with a clearly fractured hip back into bed to wait for a mobile x-ray while she was screaming in agony. Guess who was being picked up by EMS within a few minutes?

[ktwlpn, LPN]

>>>>I am worried that a patient will end up being sent to the ER by the next nurse because I missed something and that I will be to blame because I delayed treatment. It would be very hard to live with myself if I thought I could have caused a patient to decline due to being swamped or just too new to identify an abnormal finding. How often does this happen, and how do I prevent this?

You make walking rounds and really look at each resident with the oncoming nurse before you leave....Feel better now?

These folks can tank pretty fast,we are all aware of that. The "Monday morning quarterbacks" just like to put others down to puff themselves up.