Did I did not do enough?

EGspirit · Dec 15, 2017

I worked in nursing home in sub acute unit . I have patient that was c/o a lot of pain on left leg . Pt has left hip replacement and on rehab for that . I noted patient was medicated with pain medicine at 9pm and that she was still on a lot of pain at 11pm . I worked 11-7 shift . So I went assessed patient , neurovascular check complete . Left hip surgical site was fine but noted increased swelling on left leg , faint pulse , and from knee down the extremity feel cool to touch , she's able to wiggle toes and denies numbness , movement was limited on that leg . Vitals was checked as expected HR and Bp was elevated . I called the doc and told him about my findings and that even though pt is medicated for pain medicine oxy and hydomorphone alternately per order she only have minimal relief and that I'm concern about it . Doc did not order X-ray . He just basically told me that he will see patient early on am . I also notified him about the vitals . No reported recent fall . So all throughout the night I just medicated pt with pain medications , reposition her , applied ice for comfort . In the am they did X-ray and found out it has dislocated hip . Patient was sent out to hospital . The problem now pt states that When CNA put her to bed she heard something puff out . She didn't not mention this to me . My question .. did I didn't do enough? I asked pt if she want to go to hospital she refused . So I'm not sure what else could I have done aside from notifying the doc and medicating her ? Now my facility want me to write a written statement about the incident . So I'm going to write exactly this .

Well, you have to write a statement. That's not you being in trouble, that's just standard anytime there seems to be any kind of incident. And what you wrote up there sounds perfect. And you did, in my opinion, everything you should, and everything you could do for her.

nursemike, ASN, RN · Dec 15, 2017

It sounds like you did about all you could. When I worked as an orderly on an ortho floor, I was keenly aware of how careful you have to be moving a patient after joint replacement--especially a hip. So I was thinking "uh-oh" within a few lines of your post. But as long as the patient had circulation, movement, and sensation, emergency surgery was not required. Doc seeing her in the morning was appropriate, treating the pain as best you could and watching her CMS and vitals was about all there was to do non-surgically. I can't tell from your post how alarmed you were by the faint pulse, coolness, and limited movement, but if the doctor was made aware of them he was probably alarmed enough. Increased vigilance was in order, not panic. You did good.

Wuzzie · Dec 15, 2017

I noted patient was medicated with pain medicine at 9pm and that she was still on a lot of pain at 11pm . So I went assessed patient , neurovascular check complete . Left hip surgical site was fine but noted increased swelling on left leg , faint pulse , and from knee down the extremity feel cool to touch , she's able to wiggle toes and denies numbness , movement was limited on that leg . Vitals was checked as expected(were assessed. HR and Bp was elevated . I called the doc and told him about my findings and that even though pt is medicated for pain medicine oxy and hydomorphone alternately per order she only have minimal relief and that I'm concern about it . Doc did not order X-ray . He just basically told me that he will see patient early on am . I also notified him about the vitals . No reported recent fall . So all throughout the night I just medicated pt with pain medications , reposition her , applied ice for comfort . In the am they did X-ray (obtained in the morning) and found out it has dislocated hip (noted) . Patient was sent out to hospital.

When writing a statement you should just state the facts without any opinion or other editorial comments. In your post remove the bolded words, add the words in parentheses and check your grammar. And, no you did what you could. The only thing I might have done differently as a new grad is to get the charge nurse/supervisor to also assess the patient to confirm your findings. She may have been able to escalate the situation. As you gain more experience you will become more comfortable speaking with physicians and advocating for your patient. For example I might have said "Hi Dr. Grumpy, This is Wuzzie. Your patient with the hip replacement is in pain despite being medicated. This is a change for her and I'm really concerned about the appearance of her leg(followed by your assessment). I would really like to get an x-ray now to make sure everything is okay." But remember, this is a skill that comes with experience. You're still learning to be an expert in the basics but the care you gave was spot-on. Keep up the good work.

Depressnewgrad, ADN · Dec 15, 2017

Hi! I did mention to the physician that this was a significant findings/ changed that I see . Pt a week prior was ambulatory with cane assist x 1 . Physician was annoyed at me and told me this is not a significant change since pt never been ambulatory and that he only see her in WC all the time . I told him also that I'm very concern about how the legs look ( swelling) and the coolness of leg knee to foot plus the increased bp and HR . The only thing I did not do I should Harare recommended X-ray stat to physician . I learned a lot . My main concern was my patient . The 3-11 nurse was not there when I arrive he just left me note with report . Nothing was mentioned about patient left leg the only thing I noticed was the last time pt received medication . I did call my supervisor that night ( she's an LPN) I'm the RN and told her that I'm concern about my patient . Arggg.. I should have been a better advocate to my patient . This lesson I will learn for life . The next time I will be a better advocate . Thank you all .

JKL33 · Dec 15, 2017

Random thoughts: It sounds like the patient is able to communicate appropriately - was she able to follow any commands as far as moving the leg? Any deformities noted during your assessment? Now you know you can add on specific questions when assessing changes in condition, "When did this get this bad?/What were you doing when this severe pain started?" - but honestly this is part of learning and this is as good a situation as any to learn it.

This delay didn't happen because you failed to recommend an x-ray. The x-ray is the main/obvious thing that would have been useful and by saying that the patient didn't need to go to the hospital after hearing all of your information, he basically said he didn't think she needed an x-ray.

Agree w/ Wuzzie that the communication finesse involved [AKA "getting what you think is necessary"] is something that comes with experience. Don't be afraid to be pleasantly persistent and don't let your perception of a physician being annoyed change that. Who cares whether they're happy about hearing from a nurse or not.

I think you did very well, even though I've written a couple of items for next time. :) Your concern for the patient is evident in what you've written, and it is especially good that you did all you could to try to mitigate the pain during the night. So kudos for that!

Write the events succinctly as Wuzzie showed you, including the fact that you notified the supervisor.

Oh, BTW - is leaving a note about report the way things roll usually?

Depressnewgrad, ADN · Dec 15, 2017

Thank you! Makes me feel better knowing that I did what I could do to make pt comfortable during my shift . I love my job so much and I'm learning everyday though sometimes I don't trust my judgement and I needed to always call someone for back up lol the only thing that I need to put down in my written statement is the 3-11 nurse left me written report . He stated he medicated pt for pain and that she was in a lot of pain . I didn't talk to the nurse directly since he was not there when I get there . Should I put it in my written statement? I don't want to cause anyone in trouble . As I think I already did because I chatted that pt was in excruciating pain rated 10/10 when I received her .

nursemike, ASN, RN · Dec 15, 2017

If there was any room to question your advocacy, it might be regarding the patient's pain. As far as the x-ray goes, your recommendation would not have changed anything. If the doctor chose to see the patient before ordering one, that seems like a reasonable decision to reduce the chance of ordering a test that might have been unnecessary. It sounds like he didn't like being paged at night, but that's his fault. Way better to be informed by a nurse at 3 am than by a lawyer at noon.

As for the pain, I think we're all going to have to realize that being an effective advocate and getting what we want are not the same thing. You informed the person whose scope of practice includes prescribing meds and ordering tests. To say you should have done more is like saying you should have taken the patient to the OR and fixed the joint. It's not your job. You could have fussed more about the unrelieved pain and maybe the doc would have given in, but that's less likely in the present climate than it might have been a few years ago, and there's ample reason to think the climate a few years ago needed to change. I personally think we've swung too far in being stingy with narcotics, but if that pendulum ever does settle to equilibrium, it will probably be at a place where some pain just has to be lived with. If you think about it, if you were the doctor, what reasons would stop you from writing whatever it took to make the patient comfortable? Meanwhile, it sounds like you did what you could with non-pharmaceutical interventions.

I don't know what we're going to do when stories start appearing in the press about the guided imagery epidemic...

Orion81RN · Dec 16, 2017

Way better to be informed by a nurse at 3 am than by a lawyer at noon.

I am SO using this next time I deal with a grumpy doc. LOL

cleback · Dec 16, 2017

You did well. Even if she were sent to the hospital, she would likely have just been given pain meds and then had ortho assess her in the am. The oncall and surgical team would not have been called in the middle of the night unless it were a limb threatening emergency.

Agree with the PP to take editorial comments out of statement.

bgxyrnf, MSN, RN · Dec 16, 2017

Your assessment was incomplete and missed the strongest indicators for a dislocated hip (which should have been the number one differential given the patient's history).

Specifically, dislocated hips typically result in shortening and/or internal rotation. I say typically to recognize that nothing is 100% although in nine years of ED nursing, I can't recall ever encountering one that wasn't either shortened or rotated.

The other piece of the assessment should be range-of-motion of the hip while maintaining hip precautions.

Your handle suggests that you're a newbie and I don't blame you for not knowing how to perform a complete assessment but, you didn't do one. You probably should have asked for guidance from a more senior nurse, if there was one.

nursemike, ASN, RN · Dec 16, 2017

Your assessment was incomplete and missed the strongest indicators for a dislocated hip (which should have been the number one differential given the patient's history).
Specifically, dislocated hips typically result in shortening and/or internal rotation. I say typically to recognize that nothing is 100% although in nine years of ED nursing, I can't recall ever encountering one that wasn't either shortened or rotated.
The other piece of the assessment should be range-of-motion of the hip while maintaining hip precautions.
Your handle suggests that you're a newbie and I don't blame you for not knowing how to perform a complete assessment but, you didn't do one. You probably should have asked for guidance from a more senior nurse, if there was one.

I wonder if you could explain how to assess for shortening. I don't see a lot of ortho patients, but I do see a lot of old folks.