Could I be in trouble? (New nurse)

[megananne7]

On Tue afternoon one of the aides told me about a resident at the asst. living place I work at who was refusing to walk for her and leg "looked bad"... but this had started over the weekend. She had fallen about a 2 weekends ago and bumped her head and got a bruise on her R leg... midway between hip& knee but had been fine from that was seen by Dr... no other reported falls since then. I didn't get to assess pt until right before I left that day (we are understaffed by way of nurses..) . She wouldn't let me remove her pants enough to look at her thigh/hip. She refused me to look far enough down than I could get her pants w/ her sitting... couldn't see jack. She was more concerned with the skin tear on the L leg- Kept asking me if I was going to rebandage it. No abnormal rotation that I noticed, no shortening of leg. No pain in either leg, pedal pulses present, etc.

I should have probably called the Dr but the pt has a UTI and I figured maybe she was having some increased confusion and/or fear of falling from last fall. =( Was that a boo boo? Could I be in trouble for that?

Anyway, the next day (Wednesday) I told the two other nurses about how the patient wouldnt let me look at her leg and asked if either one or both of them could try and look at it. I was kind of blown off but they said OK. One of the nurses (temp - from our sister facility) and I had to go upstairs to the floor this resident lives on to dispose of some old narcs & other d/c'd meds and had to walk past her room so I said "Oh lets go look at Ms. ____" and we both went in there. Neither one of us could get the pants down far enough to look but together we got it down enough to see some yellowing bruised area. Again, pt denied pain, more concerned with skin tear, neither of us nurses noted any abnormal rotation or shortening of leg. Everything was OK except she just didnt want to walk. She said the skin tear was keeping her from walking (It wasnt a pretty skin tear.. shes on ASA). We figured we'd put her on Dr list for the next day.

Dr. sees her, orders Xrays of R hip & femur. I called the company that does them in-house and told them needed it today. Never heard anything about them no coming (they have calling before and said they couldnt make it). None of the aids or med techs said they called but apparently they didnt come until this morning.

Results just got back (I left work about 3 hours ago... im nurse on call this weekend. new nurse, never been on call before... no evening or night nurses where I work. Great.) Med tech paged Dr (there are two Dr.s that come. One Tue, one Thur. Dr that saw her came on Thu but the 2 docs are "associates" and work together from my understand) that comes Tue and she was "upset" by not being notified =( oops. Anyway, Dr said send her out b/c she "doesnt know anything about a Fx" . Med Tech told me report said "R hip & femur Fx - Distorted femur . Presumbly old".

I'm a new nurse and I still have a lot to learn. Havent gotten jack's worth of training at this place. I feel like I should be worried about getting in trouble but the Pt had no Sx of hip Fx that me or other nurse noted other than refusal to walk but I figured increased confusion from UTI and fear of falling since her last fall.

[TazziRN, RN]

"Presumably old" means old enough to have healed. If it is truly old, no worries.

HOWEVER......let this be a hard lesson: not all hip fxs have shortening or rotation. Yes, this should have been addressed right away because of her age, the mechanism, and the fact that she was refusing to walk. Even confused people will refuse to do something because of pain, even though they may not be able to tell you why.

[leslie :-D]

any time there is a fall, rom must always be checked.

a visual assessment is not enough.

also many people deny pain.

just for the fact she stopped ambulating would have warranted further intervention.

it doesn't sound like you were the only one who 'overlooked' crucial steps, however.

the fall happened 2+ wks ago?

yes, there are concerns.

thankfully she's finally getting the help she needs.

leslie

[kmoonshine, RN]

Don't worry about getting in trouble. See this as a learning opportunity.

While reading your post, the first thing that comes to my mind is your mentioning of "confusion"; but you assumed it was secondary to the UTI. Never assume anything, especially with confusion. You really should have removed her pants all the way to assess the leg - it doesn't look good if a patient is refusing something but at the same time is confused/unable to make sound decisions. I'm not saying that you should abuse or force people to do things, but as a nurse you had every suspicion to believe there was something going on with the right leg.

Also, you should have tried getting the patient up out of bed and assessing if she could ambulate. Again, try not to assume she was scared to walk. Pedal pulses and pain, while nice to assess, are not enough.

What concerns me the most is this fall happened two weekends ago, and it seems like she has not been out of bed walking since then. There are so many things that could have been going on: DVT, fx, hemorrhage secondary to fx, etc. Also, since she appears to have been bed confined, she is at high risk for developing skin tears/ulcers. So a full skin assessment is a must.

I'm sorry you are short-staffed, but patients at high risk for falls need to be checked when you start your shift. Just imagine if, at the end of your shift, you walked into the room and found her on the floor. And since you had not been in the room during your entire shift, she could have been laying on the floor for hours, and hours, and hours...aides can check on patients, but you are responsible for their care. And since you say this patient had confusion and a UTI, that should validate seeing this patient sooner, rather than later. Then, you could have charted "Pt in bed, resting, call light in reach; reoriented to surroundings, lights on in room, bed in low position, temp = X, ...". This at least shows you believed the patient to be at risk for falls, and that you did everything possible to ensure their safety. It also shows that you knew of the patient's status when you first started your shift.

There's always things that we as nurses can learn to do differently. It's all part of nursing - you learn from things that you "should have done". In the future, what you learn and take away from this situation will benefit another patient.

On a side note, perhaps you should look for another job. If you haven't had adequate training and are understaffed, you're just asking for trouble. And it sounds like the nurses you work with aren't that helpful, and I'm sorry for that. Good luck and hang in there!

[passionate]

This would be a great pt. hx. question for a nursing board. When you read your post what do you think should have been done? You, not what others did or didn't do. What does your gut say? You may not be in trouble but your patient could very well be.

[UM Review RN, ASN, RN]

We all have learning experiences, megan. :)

Ask five different nurses and you'll get five different answers, but here's my take on it:

If the patient had any visible injury along with confusion, the ER could put fears to rest by doing X-rays of her hip and her head.

Confused patients fall. You all know that confusion tends to increase at night.

Elderly bones can be very brittle. I've had more than one osteoarthritic patient who had compression fractures of the back without falling (one says she sat down on the couch and heard a sound from her back like Rice Krispies - it was a compression fracture!) or who coughed hard enough to break ribs.

Elderly patients fear losing their independence. I've seen some who truly put themselves through a lot of pain to live as independently as possible. Some will deny to themselves that they're in a bad way. Elders also don't feel pain the same way we do. I've had patients post- surgery who did just fine on Tylenol where a younger person would need Morphine.

If I'm getting what you're saying, this patient fell three weeks ago and was ambulating fine until this past weekend. If that is correct, I doubt that she broke anything on the weekend you question.

However, given the patient's history and mental status, is it possible that the patient had another unwitnessed fall?

For future reference, if the patient has another fall within the month, it might be a good idea to send her to the ER and tell them she's having frequent falls. It's important to find out why she is falling and fix the problem.

While a UTI or Sundowning can be the source of confusion and falls, other things such as a heart attack, a stroke (TIA), hypotension, anemia, or an electrolyte imbalance can cause confusion and falling, and these things can be tested faster with labs and diagnostics in the ER.

If you have any more questions, we're happy to help. :)

[lsyorke, RN]

Not able to walk with a fall history should have been evaluated in the ER. But this isn't the first time a fx was missed and won't be the last time. Take is as a learning experience for the next time.

[megananne7]

Thanks everyone. Im off today but am on call but I stopped into work b/c I was in the area. I talked to one of the med techs on the floor who had been there for years and years and she mentioned she didn't know the patient WASNT able to walk... the patient had walked since her fall two weekneds ago but had now had an unsteady gait. She also told me the family had ambulated her to the bathroom on Thursday.

She was sent back last night, no treatment for the "old" fracture.. nothing changed. Just said to make appointments with Dr. if symptoms worsen.

I am taking this as a learning opportunity and I know I missed some things but I also feel frustrated that I'm a new nurse and my "supervisors" with much more experience than me didn't really offer much input. This entire facility has quite a few problems and I'm actually looking at getting out.

[AnnieOaklyRN, BSN, RN, EMT-P]

hi,

Remeber that you cannot assess for shortening or rotation if the patient is in a sitting position and I know it can be hard to assess patients that probably do not want a ride to the hospital becasue they will deny deny deny to avoid it, which is probably why the patient was telling you it was just the skin tear that was halting her abilty to ambulate; however if the patient will not ambulate on a leg than that warrants calling the doctor and an xray. Also in my expereinces patients will try and hide the fact that they may have fallen again or there may be miscommunication, so always er on the side of caution.

Oh and remember hind site is 50/50 so do not dwell, just learn as you go.

Swtooth EMT-P, RN

[ZippyGBR, BSN, RN]

We all have learning experiences, megan. :)

Ask five different nurses and you'll get five different answers, but here's my take on it:

If the patient had any visible injury along with confusion, the ER could put fears to rest by doing X-rays of her hip and her head.

depending on the clinical assessment of the professionals between scene and the ED doc...

Skull X rays are only rarely indicated in this day and age the otions generally being watch and CT if the patient deteriorates or just irradiate them anyway...

Confused patients fall. You all know that confusion tends to increase at night.

true - acute confusion should equal some kind of sepsis screen as the primary investigation - a urine dip for blood, leucocytes , ntirite and pH uis a simple rule in / ruleout for UTI as a cause... obviously while it may suggest that someone has a UTI you aren't going to A.) known exactly what the pathogen is and B) whether the UTI causes the confusion without lab culture and sensitivity and empiric or C+S based treatment for the UTI ...

sadly no real test for nighttime increased confusion - t's purley an observational assessment

Elderly bones can be very brittle. I've had more than one osteoarthritic patient who had compression fractures of the back without falling (one says she sat down on the couch and heard a sound from her back like Rice Krispies - it was a compression fracture!) or who coughed hard enough to break ribs.

quite possibly

Elderly patients fear losing their independence. I've seen some who truly put themselves through a lot of pain to live as independently as possible. Some will deny to themselves that they're in a bad way. Elders also don't feel pain the same way we do. I've had patients post- surgery who did just fine on Tylenol where a younger person would need Morphine.

If I'm getting what you're saying, this patient fell three weeks ago and was ambulating fine until this past weekend. If that is correct, I doubt that she broke anything on the weekend you question.

However, given the patient's history and mental status, is it possible that the patient had another unwitnessed fall?

Quite possibly

For future reference, if the patient has another fall within the month, it might be a good idea to send her to the ER and tell them she's having frequent falls. It's important to find out why she is falling and fix the problem.

While a UTI or Sundowning can be the source of confusion and falls, other things such as a heart attack, a stroke (TIA), hypotension, anemia, or an electrolyte imbalance can cause confusion and falling, and these things can be tested faster with labs and diagnostics in the ER.

If you have any more questions, we're happy to help. :)

i suppose it also depends on the support setup you have in place both medical ( i.e. availability of primary care and Elderly medicine specialist and lab wise - for gettign the bloods etc done...

[iheartyou]

First off, don't worry. You sound like you are learning at the right pace; even us older nurses NEVER stop learning. This is one of those experiences that you will always remember, and therefore YOU will be passing your experience on to other new nurses who will inevitably have the same occurence, as we all have. But I do have a few questions. How did the aid know her leg looked funny? Did the aid see it? How did she see it? Did the pt. allow her to see it when she helped with showering or toileting? What about the original assessment done right after the fall..... did they say the legs were equal in length with no internal or external rotation noted? Was THAT nurse allowed to see the leg? Did she perform ROM? Were there no Xrays ordered that day? (I may have missed that when I read it). I find the entire situation a little bit fishy, like they just swept it under the rug and hoped it would go away, just ASSUMING it was okay. Good luck sweety. You sound like you have your head on straight and I would work with you any day of the week. :kiss