Bad Nursing?

[Unique X]

Scenario 1 : An EMT points out to the RN , that the patient is bleeding from the mouth. The patient is in a hemodialysis center. The RN states" This is just a dialysis center, I'm not trying to save the world". Note: in dialysis, heparin is typically given to clients to prevent blood clotting.

Same situation 25 minutes apart. A lady finishes hemo dialysis and there blood pressure ending the treatment is 226/ 82. The nurse states " your blood pressure is a little high" , turns around and indicates to the EMT" I could give them something for it but it's probably not going to work"... They should be good to go"

Comment: I'm losing my sight in nursing, I thought we were suppose to be proactive and at the same time an advocate for our patients. The above scenarios are real... Names, locations, and identifiable have been removed for privacy issues.

[Indy, LPN, LVN]

There should be standing orders for the BP management, they would probably give p.o. clonidine and the effectiveness would not be all that great long-term, but in the short term it should prevent a stroke. Meaning, the patient may be non compliant with their home meds, OR they may just be stuck with hypertension long term (something killed their kidneys, after all) and the statement is less a judgement than a statement of fact.

For case one, it's not acute care and if the patient is not bleeding badly enough to aspirate blood and/or code, seriously there is not much the nurse can do. The patient is probably already on erythropoetin, and gets regular labs done as part of dialysis. A little bleed is not going to be something that will have an impact on the dialysis treatment, because the bleed is small and the dialysis is what keeps the patient alive. The nurse isn't trying to be a bad nurse; the nurse is just prioritizing.

[Been there,done that, ASN, RN]

Scenario #1 Was the patiient bleeding... or oozing. It may happen during dialysis, but it is a temporary side effect that does not warrant interrupting dialysis.

Scenario #2 End stage renal patients have chronically high blood pressures.Nurse probably knew this patient well enough to know that post dialysis , the blood pressure will quickly stabilize. Administering anti-hypertensives immediately post dialysis can be dangerous.

In either case, you had a concern for the patient... and you felt your your concerns were not properly addressed. If you felt the patient was NOT stable for transfer, you have every right to pursue the nurses rationale for discharging them.

[Anna Flaxis, BSN, RN]

Scenario #1: What would you have had the nurse do? Gingival bleeding r/t heparin administration isn't in and of itself a medical emergency. Without s/s of a head bleed or a GI bleed or something more serious, what exactly is the nurse to do?

Scenario #2: Dialysis nurses often get to know their regulars. Maybe this person has chronically elevated BP that does not respond to the meds in the dialysis center's standing orders. Without focal neurologic symptoms, this is not a medical emergency. What do you think the nurse should have done differently?

[Aeterna, BSN, RN]

It's difficult to say without knowing the situation in full. The previous posters have already given possible rationales, which look sound to me, working on a medical floor where we see a lot of dialysis patients.

However, there are times when I, too, question rationales. I've seen patients return to me from hemodialysis in critical condition or very obvious things have been missed, and the dialysis nurse has very little to say about it >_>