Did I jump the gun?

leopold · Aug 13, 2005

We had a resident fall out of the wheelchair and two nurses (good nurses) assessed her and decided she was OK. She was alert and moving around, denied pain, got in her wc and went back out to the common area. The next day they discovered she had a broken hip and a broken shoulder. You never know.

renerian, BSN, RN · Aug 13, 2005

Seems smart to me. What is your policy too? Sometimes I have done things related to safety that are not policy to CYA due to nursing judgement and what would a prudent nurse do? Plus if you did not and something was wrong someone would be right behind you saying the Nursing Judgement stuff.

renerian

Daytonite, BSN, RN · Aug 13, 2005

Estogen. . .I have been a charge nurse and supervisor in long term care, so I am going to say this as gently as possible, but I suspect someone has already told you this or something similar or you wouldn't have posted. When a resident has fallen, after you have assessed them you don't leave them lying on the floor. A "little bit of a painful response when [you] moved her hip" is not enough to justify that. You suspect a hip injury and then get three or four people into the room and coordinate the moving of this patient off the floor and back into a comfortable bed. You could have slid the patient onto a people mover or coordinated the staff to splint her hip and leg while she was being lifted. The paramedics did what you and your staff should have done. Your first call should have been to the patient's doctor, or whoever was on call for him and you should have spoken with them personally, not by leaving a message with an answering service. Your second call should have been to the patient's family. The third call should have been to the DON to inform her what happened. If the doctor had ordered transfer to the hospital you would have followed your facility's protocol and contacted the appropriate ambulance service and not called 911.

The paramedics are going to talk about this one back at the firehouse for some time. (I'm sorry, but it's true.) Suck it up as a learning experience. Now, you need to look up the symptoms of a traumatic broken hip. You've left out something in your description of your assessment of the patient that you should have looked for with a broken hip. There are two very specific signs of a broken hip that you don't mention assessing for. Decide on what you should have done differently after discussing this with your manager. Have a plan for what you will do the next time something like this happens.

All is not lost. . .we learn from our mistakes. In the end, you did no harm to the patient, but I am concerned that you could have made her more comfortable.

estrogen · Aug 14, 2005

Estogen. . .I have been a charge nurse and supervisor in long term care, so I am going to say this as gently as possible, but I suspect someone has already told you this or something similar or you wouldn't have posted. When a resident has fallen, after you have assessed them you don't leave them lying on the floor. A "little bit of a painful response when [you] moved her hip" is not enough to justify that. You suspect a hip injury and then get three or four people into the room and coordinate the moving of this patient off the floor and back into a comfortable bed. You could have slid the patient onto a people mover or coordinated the staff to splint her hip and leg while she was being lifted. The paramedics did what you and your staff should have done. Your first call should have been to the patient's doctor, or whoever was on call for him and you should have spoken with them personally, not by leaving a message with an answering service. Your second call should have been to the patient's family. The third call should have been to the DON to inform her what happened. If the doctor had ordered transfer to the hospital you would have followed your facility's protocol and contacted the appropriate ambulance service and not called 911.
The paramedics are going to talk about this one back at the firehouse for some time. (I'm sorry, but it's true.) Suck it up as a learning experience. Now, you need to look up the symptoms of a traumatic broken hip. You've left out something in your description of your assessment of the patient that you should have looked for with a broken hip. There are two very specific signs of a broken hip that you don't mention assessing for. Decide on what you should have done differently after discussing this with your manager. Have a plan for what you will do the next time something like this happens.
All is not lost. . .we learn from our mistakes. In the end, you did no harm to the patient, but I am concerned that you could have made her more comfortable.

What??? Excuse me, but as a nurse and as someone who undoubtedly took many BLS courses, you should know that you don't move someone, unless you are CERTAIN, that they don't have head/spinal cord injury and/or you have to proper equipment to immobilize them. (I wasn't certain.) Well, we don't have that kind of equipmnet in the facility, the paramedics do. Secondly, in nursing school I'm sure you learned (as I did), that if not certain, you leave the patient on the floor and make them comfortable with pillows and blankets, untill they can be transfered properly. Even in the hospital where I used to work untill recently this was common sense. Thirdly, my first call was to 911 so that the paramedics can come as soon as possible and the lady does not have to lay on the floor for very long. My second call was to the MD and yes, he did pick up the phone right away so I didn't have to leave a message with the answering service (but if he wouldn't have picked up I would have had him paged by the answering service of course). He agreed with my judgment and said if I feel they should be checked out, he concurs (of course he would, he doesn't see the patient via phone an sure he wouldn't like to drive out there in the middle of the night first, to decide wether 911 should be called or not). My next call after that was to the husband. He didn't answer his phone at three in the morning so I left a message for him to call the facility. He thanked me in the morning and was glad everything seemed fine. Afther the paramedics left, I called the MD one more time, to inform him, that she wasn't transported to the hosp. He said, okay, ...again, he trusted mine and the medics judgment. The paramedics also mentioned, that they have ride outs like this one quite often... you know, the elderly fall... They didn't seem particularly amused or apalled by my call... My DSN told me in the morning that I did just fine, that it never hurts to be safe, after all. Thank you very much. And obviously, most nurses here agree aswell, so I guess that's what a prudent nurse would have done.

Lastly, if you're talking about swelling and deformity as signs of an injury, well, I wasn't sure.... As I said she is very stiff and flexed - end stage Parkinsons - and she was laying on the floor. She was rotating the leg, but I wasn't sure, wether that's normal for her or not. As far as swelling goes... I wasn't sure... didn't see any.... But you just never know, right. After all, I'm not a physician to diagnose (nor are the paramedics).... I don't know, are you?

With all due respect, concidering your judgement and the the way you speak down to me, I'm glad you are not my charge nurse.... but wait a minute, at night shift, where I work ... I am the only nurse. Therefore I AM the charge nurse... :chuckle

...anyway, I'm glad she's fine (at least I believe she is - haven't been back yet since) and I'm glad I can sleep at night because I covered my nurse behind... If anyone wants to laugh at it or talk about it at the fire house, knock yourself out. It's worth it to me. Cheers! :specs:

lady_jezebel · Aug 14, 2005

Last night a resident was found on the floor. She normally doesn't move much at all (very stiff) and is non-verbal. I have no idea how she got on the floor, when I assessed her however, her VS were fine, neuros where fine also, she had a small bruise on her temple and it seemed as if she had a little bit of a painfull response when I moved her hip. I called 911, because I just didn't feel comfortable picking her up from the floor and manipulating her in this state with just my CNAs. The paramedics checked her out, put her back in bed and didn't think she had anything broken. I called the doc and he ordered a portable X-Ray in am. She doesn't have any history of falls. Do you think that I went overboard?

you did an awesome job! you're obviously a FABULOUS nurse! :)

and by the way, i was an RN on a hospital ortho floor for 2 years (hips, knees, spines). when we "found" a pt on the floor, we would NOT always assist them back up. it's a nursing judgement call. it was our protocol to stat page the MD for an assessment before moving them if deemed appropriate by the nurse; dislocations are not always obvious, and moving the pt incorrectly can cause secondary injuries. it's a nursing judgement call. it sounds to me like you made very appropriate decisions.

the nurse manager who critiqued your style was only trying to help by offering her best advice, though. don't take it personally.

Cute_CNA, CNA · Aug 14, 2005

I think you did what's best for her. I'd rather find out right away is something was wrong, rather than find out later and be held responsible.

estrogen · Aug 14, 2005

you did an awesome job! you're obviously a FABULOUS nurse! :)
and by the way, i was an RN on a hospital ortho floor for 2 years (hips, knees, spines). when we "found" a pt on the floor, we would NOT always assist them back up. it's a nursing judgement call. it was our protocol to stat page the MD for an assessment before moving them if deemed appropriate by the nurse; dislocations are not always obvious, and moving the pt incorrectly can cause secondary injuries. it's a nursing judgement call. it sounds to me like you made very appropriate decisions.
the nurse manager who critiqued your style was only trying to help by offering her best advice, though. don't take it personally.

I appologize. I just got frustrated with her tone. I find you hear this sort of "I know, you don't" tone way too often in nursing... I found it to be derrogatory. but I responded, vented, and I'm over it now. :)

DG5 · Aug 14, 2005

I had a similar situation on night shift when a resident fell just before day shift arrived - couldn't quite see any external rotation or if any limb was shorter than the other - but I felt my nursing judgment calling loud and clear "Send her", so I did. The day RN came in shortly and when I told her what happened, was rather abrupt and annoyed with me that I had sent her! I felt really awful and thought "Oh no - I really went overboard - she must think I'm really stupid" (although the paramedics didn't) Turns out the resident did have a hip fracture. I think this is one of the things we all seem to struggle with - when support and validation from colleagues is not always forthcoming its hard to know if you should be sticking to your guns and not waiver with the original assessment. But after all, YES, we have gone through all those years of blood sweat and tears, joys and sorrows of nursing school and life just to be here right now for this PARTICULAR resident at this particular time, so, yes, a good decision was made! :yelclap: That's what is so great about this board - so many people cheering you on your way.

rn/writer, RN · Aug 14, 2005

What??? Excuse me, but as a nurse and as someone who undoubtedly took many BLS courses, you should know that you don't move someone, unless you are CERTAIN, that they don't have head/spinal cord injury and/or you have to proper equipment to immobilize them. (I wasn't certain.) Well, we don't have that kind of equipmnet in the facility, the paramedics do. Secondly, in nursing school I'm sure you learned (as I did), that if not certain, you leave the patient on the floor and make them comfortable with pillows and blankets, untill they can be transfered properly. Even in the hospital where I used to work untill recently this was common sense. Thirdly, my first call was to 911 so that the paramedics can come as soon as possible and the lady does not have to lay on the floor for very long. My second call was to the MD and yes, he did pick up the phone right away so I didn't have to leave a message with the answering service (but if he wouldn't have picked up I would have had him paged by the answering service of course). He agreed with my judgment and said if I feel they should be checked out, he concurs (of course he would, he doesn't see the patient via phone an sure he wouldn't like to drive out there in the middle of the night first, to decide wether 911 should be called or not). My next call after that was to the husband. He didn't answer his phone at three in the morning so I left a message for him to call the facility. He thanked me in the morning and was glad everything seemed fine. Afther the paramedics left, I called the MD one more time, to inform him, that she wasn't transported to the hosp. He said, okay, ...again, he trusted mine and the medics judgment. The paramedics also mentioned, that they have ride outs like this one quite often... you know, the elderly fall... They didn't seem particularly amused or apalled by my call... My DSN told me in the morning that I did just fine, that it never hurts to be safe, after all. Thank you very much. And obviously, most nurses here agree aswell, so I guess that's what a prudent nurse would have done.
Lastly, if you're talking about swelling and deformity as signs of an injury, well, I wasn't sure.... As I said she is very stiff and flexed - end stage Parkinsons - and she was laying on the floor. She was rotating the leg, but I wasn't sure, wether that's normal for her or not. As far as swelling goes... I wasn't sure... didn't see any.... But you just never know, right. After all, I'm not a physician to diagnose (nor are the paramedics).... I don't know, are you?
With all due respect, concidering your judgement and the the way you speak down to me, I'm glad you are not my charge nurse.... but wait a minute, at night shift, where I work ... I am the only nurse. Therefore I AM the charge nurse... :chuckle
...anyway, I'm glad she's fine (at least I believe she is - haven't been back yet since) and I'm glad I can sleep at night because I covered my nurse behind... If anyone wants to laugh at it or talk about it at the fire house, knock yourself out. It's worth it to me. Cheers!

If you were really asking a question in your initial post, then it seems kind of disingenuous to blast the one person who gave a dissenting opinion from the rest, regardless of tone. All but that one poster patted you on the back and told you what a great job you did and said you were awesome. We need that at times, but Daytonite brought up some important points to for you to consider and your reaction seemed to be one of defensivness. Your reply suggests that you had the answers to your beginning question and were looking for affirmation rather than information. That isn't wrong per se. But it can be confusing for someone who truly disagrees with your actions and thinks you're looking to expand your knowledge and consider other ideas.

I've been an EMT for 17 years and a nurse for 11. I can see both sides of this situation. Calling paramedics was not an overreaction in and of itself. They would most likely have used a scoop stretcher, which is a highly efficient way to lift someone with a hip fx. And if you were short staffed, the extra manpower might have been needed. But, assuming you had the staff, there are safe ways you could have lifted her as well. Knowing, or even suspecting, that a person has a fx doesn't mean you absolutely don't move them. It means you get creative and try to achieve the goal of safe movement, using whatever means you have available. One example would be to lift her using a rigid slide board and pillow splinting anchored by gait belts. Hip fxs. are notoriously difficult to manage because you normally immobilize the joint above and the joint below and with a hip, there is no "joint above." You splint to the opposite leg and pad for support and comfort and hope for the best outcome.

If I were the only nurse on the noc shift, I might have called EMS for help simply because it would be a quick solution and it does leave open the possibility of transport. But after a tough call, maybe brainstorm a bit and challenge yourself to come up with alternatives for that rare time when paramedics are tied up on a previous call or the road is washed out or there's plague of locusts chomping up the highway. It isn't always about being right or wrong. Sometimes, it's about pulling a solution out of thin air because you've trained your mind to exceed expectations.

I hope your patient is having a good recovery.

Miranda

Daytonite, BSN, RN · Aug 14, 2005

If you were really asking a question in your initial post, then it seems kind of disingenuous to blast the one person who gave a dissenting opinion from the rest, regardless of tone. All but that one poster patted you on the back and told you what a great job you did and said you were awesome. We need that at times, but Daytonite brought up some important points to for you to consider and your reaction seemed to be one of defensivness. Your reply suggests that you had the answers to your beginning question and were looking for affirmation rather than information. That isn't wrong per se. But it can be confusing for someone who truly disagrees with your actions and thinks you're looking to expand your knowledge and consider other ideas.

I appreciate your comments. I sent a PM to the originator of this thread with similar thoughts.

mhull · Aug 14, 2005

I think you made a very good decision. I work in an ER and have seen falls go bad lots of times. I can see you look out for the best of the pt. Where I work the medics would have done full C-spine immoblization and brought the pt in. especially since it was a un-witnessed fall.

estrogen · Aug 14, 2005

If you were really asking a question in your initial post, then it seems kind of disingenuous to blast the one person who gave a dissenting opinion from the rest, regardless of tone. All but that one poster patted you on the back and told you what a great job you did and said you were awesome. We need that at times, but Daytonite brought up some important points to for you to consider and your reaction seemed to be one of defensivness. Your reply suggests that you had the answers to your beginning question and were looking for affirmation rather than information. That isn't wrong per se. But it can be confusing for someone who truly disagrees with your actions and thinks you're looking to expand your knowledge and consider other ideas.
I've been an EMT for 17 years and a nurse for 11. I can see both sides of this situation. Calling paramedics was not an overreaction in and of itself. They would most likely have used a scoop stretcher, which is a highly efficient way to lift someone with a hip fx. And if you were short staffed, the extra manpower might have been needed. But, assuming you had the staff, there are safe ways you could have lifted her as well. Knowing, or even suspecting, that a person has a fx doesn't mean you absolutely don't move them. It means you get creative and try to achieve the goal of safe movement, using whatever means you have available. One example would be to lift her using a rigid slide board and pillow splinting anchored by gait belts. Hip fxs. are notoriously difficult to manage because you normally immobilize the joint above and the joint below and with a hip, there is no "joint above." You splint to the opposite leg and pad for support and comfort and hope for the best outcome.
If I were the only nurse on the noc shift, I might have called EMS for help simply because it would be a quick solution and it does leave open the possibility of transport. But after a tough call, maybe brainstorm a bit and challenge yourself to come up with alternatives for that rare time when paramedics are tied up on a previous call or the road is washed out or there's plague of locusts chomping up the highway. It isn't always about being right or wrong. Sometimes, it's about pulling a solution out of thin air because you've trained your mind to exceed expectations.
I hope your patient is having a good recovery.
Miranda

Thanks for this firendly, supportive and unassuming input and constructive criticism. :) Again, I appologize to anyone who took offense to my response to Daytonite.

I was the only nurse on night shift and I had two CNA's. I suppose I could have called the sub-accute unit for additional manpower... I have only been in this facility for two weeks, so i wasn't quite familiar with the equipment we have there. After questioning everyone and asking for a slider board, I found out that they don't have one. (I don't understand why.) The only tool they had for lifting was a Hoyer. If I had a board, I think that I maybe would have had lifted her back into bed w/o calling... This way I wasn't sure exactly what to do at that moment, but I knew that at that moment, my gut was just screaming: Don't do it!