Did I need to call the Doc?

zofran · Jan 12, 2010

Based on the info you gave, I would not have called the doc in this situation. Vital signs do fluctuate.... so since alll other vitals looked ok, labs were ok, and the pt looked good I would not worry about this drop in BP. Just watch it.

Maybe next time if you are unsure about calling, could you run the situation by another nurse? Ask if she would call?

Dont beat your self up over this. All of us have been where you are. Just learn from it!!!

Magsulfate, BSN, RN · Jan 12, 2010

I work nights now and to me that is the hardest thing for me... when to call the doctor and when not to call the doctor at 2am. I have seven years of ICU experience and sometimes I work on the step down or tele unit now for a change of pace and this is where I was at when.....

For example,, the other night a patient woke up feeling "bad". All vital signs were normal, patient looked normal, no diaphoresis, no fever,, no NOTHING. Just stating that he felt bad and wanted me to call his wife and call the doctor.. at 2AM. This patient was an end stage CHF patient and on telemetry with 100% paced rythm that did not change at all (of course it won't).

Here's what I did... I thought about it in my own head and weighed the data with the the patient's statement.... thought about what the doctor would tell me and what interventions I should be doing before I call the doctor... for example, the patient was about to get his morning blood draw,, and I could continue to monitor vital signs more closely. After all.. what would the doctor do when the only symptom is "I feel bad" and no pain,, no shortness of breath,, nothing else.. completely.. no other symptom, real or stated.?? Tylenol maybe? He darn sure would not rush him off to the cath lab..

One very important step after that was I called the charge nurse and told him of the situation and asked him what to do. This is key. If you have a charge nurse, utilize him or her at this moment. THey are there to help you with these decisions. My charge nurse wieghed all the data with me and decided that calling the doctor at 2am, even though the patient insisted on it, would not be appropriate at this time. UNLESSSS there was an additional symptom or vital sign that became abnormal.

Now fast forward a few hours....... At 7am during shift change the patients blood pressure began to drop. FAST.. SBP was around 70. That is when we called the doctor and he moved to ICU. His labs came back shortly after that and his WBC's went from normal to 50k! ! This is a rare case of a very fast onset of septic shock, but how would anyone know this at 2am with a symptom of feeling bad and nothing else? There is no way that any of us could have predicted this would happen, even the doctor is not expected to know that feeling bad leads to septic shock.

Keep in mind you have to make a decision based on facts, vital signs and help of your charge nurse and you have to be able to back up your decision with that data. Those middle of the night cases are not so cut and dry. But I also agree that if the blood pressure was normal that you did not need to call the doctor. Ask yourself... can this wait until 7am when the doc starts waking up? In that questions, again, you have to weigh all the data and symptoms,,,

Calling the doctor at 2am is not something that you should take lightly,, but then again, if it NEEDS to be done, do not hesistate.

I hope my rambling helped a little :)

ChiSmile6 · Jan 12, 2010

Thanks you guys. I guess I am just scared that the MD will come in the a.m. and ask "why wasn't I called about this?" b/c I have heard it happening before to other nurses for situations that seemed to be not so urgent. I also am confused at who needs to be notified for issues when there are so many consults for one patients, guess it all takes experience.

meandragonbrett · Jan 12, 2010

As long as there was an acceptable MAP and no change in UOP. I would not have called anybody.

babyjr · Jan 12, 2010

I agree with Magsulfate. It is sometimes necessary to call the doctor even if there were no physical symptoms. Sometimes, we need to trust what our patient verbalized because it might be real. Such as when it comes to assessing the level of pain that our patient is experiencing, we trust that what he/she will verbalize is real and must be dealt with.

Oftentimes, neglecting our patient's complaints will lead to something serious. Hope that it will not be too late and we can still find remedies for the patient when that time comes.

SteffersRN87, BSN, RN · Jan 12, 2010

My personal theory is that you need to learn by doing. You will learn through experience what you should do in situations like this. But for now, utilize your resources - fellow staff nurses, charge nurse, educator, manager, etc. ASK ASK ASK!!!

As far as your patient, I would keep an eye on their BP through the night, even if it means checking it once an hour. Your patient's BP came up after they had went to the bathroom, so it was probably low because they were sleeping. I know it is very easy to excited over things like this when you are a new nurse, but just increase your monitoring of the patient. In this situation, I definitely would have not called the doctor at 2am. But, like I said, this knowledge comes from experience.

Ask yourself, can this wait until the morning?

Tait, MSN, RN · Jan 12, 2010

Thanks you guys. I guess I am just scared that the MD will come in the a.m. and ask "why wasn't I called about this?" b/c I have heard it happening before to other nurses for situations that seemed to be not so urgent. I also am confused at who needs to be notified for issues when there are so many consults for one patients, guess it all takes experience.

9 times out of 10 they won't ask that. Calling for the low BP was appropriate. Booty covered. When the BP came back up I would just breath a sigh of relief and go back about my day, especially if the patient was asymptomatic. (A little hint on very thin patients, if you take the pressure on the closest arm on top on someone laying on their side they often have a lower pressure while sleeping.)

In the case of the poster and the patient that felt "bad" I would have called on that. I have called docs at 3am on patients who said anything like "I am going to die, don't let me die" to "somethings wrong". Usually I get a quick order for labs in the am, which at least covers the bases.

As far as consults look at what you are having issues with. Always call the primary first unless say it is a GI surgeon and your patient is having BP issues and you have a cardiologist on board. Also looking through the chart to see who wrote the order for which med (aka you need parameters on Metoprolol because you pts HR is 55). When in doubt ask someone else. After awhile you will get in the rhythm of who your floor normally calls. I generally default to internal medicine when I can since they are more often than not up and about the hospital.

Take care,

Tait

leslie :-D · Jan 12, 2010

Thanks you guys. I guess I am just scared that the MD will come in the a.m. and ask "why wasn't I called about this?" b/c I have heard it happening before to other nurses for situations that seemed to be not so urgent. I also am confused at who needs to be notified for issues when there are so many consults for one patients, guess it all takes experience.

in a nutshell, you call the doc when you have something abnormal to report.

there is no reason to call the doc when a situation has improved back to normal.

just make sure you document very thoroughly, and pass it on to next shift.

leslie

webmansx, ASN, RN · Jan 12, 2010

chismiles6,

don't feel bad at all. i struggled with this when i was brand new as well, and got yelled at several times for what was thought to be "unnecessary" calling.

in fact i think its a good thing that you are that cautious early in your career. can you imagine a nurse that will say, oh well, i let the morning shift deal with whatever it is and just leave it at that? they say it is better to over call than under call. the yelling will end, but the consequenses of missing to call when needed may be permanent.

on the flip side, i would not have called for this particular case. as time goes by you will find that it is better to go with the 'whole picture' as opposed to "a reading". bps fluctuate, but you must also look at the heart rate, temp, respirations, associated symptoms and previous trends in relation to that bp. a low bp with a fast heart rate may mean more than just a low bp. "sob" may mean nothing if the o2 sat is at 100 %...if a pt has diarrhea and vomiting with dropping bp i would call as opposed to a sleeping pt with dropping bp, who is easily aroused and orientated, with normal labs...i hope i'm making sense.

like others have said, ask another nurse, charge or something. worst case scenario, you could call the rapid response team to take a look at the pt if your hospital has one.

good luck, it will get better.

:redbeathe:redbeathe

Tait, MSN, RN · Jan 12, 2010

chismiles6,
don't feel bad at all. i struggled with this when i was brand new as well, and got yelled at several times for what was thought to be "unnecessary" calling.
in fact i think its a good thing that you are that cautious early in your career. can you imagine a nurse that will say, oh well, i let the morning shift deal with whatever it is and just leave it at that? they say it is better to over call than under call. the yelling will end, but the consequenses of missing to call when needed may be permanent.
on the flip side, i would not have called for this particular case. as time goes by you will find that it is better to go with the 'whole picture' as opposed to "a reading". bps fluctuate, but you must also look at the heart rate, temp, respirations, associated symptoms and previous trends in relation to that bp. a low bp with a fast heart rate may mean more than just a low bp. "sob" may mean nothing if the o2 sat is at 100 %...if a pt has diarrhea and vomiting with dropping bp i would call as opposed to a sleeping pt with dropping bp, who is easily aroused and orientated, with normal labs...i hope i'm making sense.
like others have said, ask another nurse, charge or something. worst case scenario, you could call the rapid response team to take a look at the pt if your hospital has one.
good luck, it will get better.
:redbeathe:redbeathe

oh yes i love rapid response!

bigbub3000 · Jan 12, 2010

I work nights now and to me that is the hardest thing for me... when to call the doctor and when not to call the doctor at 2am. I have seven years of ICU experience and sometimes I work on the step down or tele unit now for a change of pace and this is where I was at when.....
For example,, the other night a patient woke up feeling "bad". All vital signs were normal, patient looked normal, no diaphoresis, no fever,, no NOTHING. Just stating that he felt bad and wanted me to call his wife and call the doctor.. at 2AM. This patient was an end stage CHF patient and on telemetry with 100% paced rythm that did not change at all (of course it won't).
Here's what I did... I thought about it in my own head and weighed the data with the the patient's statement.... thought about what the doctor would tell me and what interventions I should be doing before I call the doctor... for example, the patient was about to get his morning blood draw,, and I could continue to monitor vital signs more closely. After all.. what would the doctor do when the only symptom is "I feel bad" and no pain,, no shortness of breath,, nothing else.. completely.. no other symptom, real or stated.?? Tylenol maybe? He darn sure would not rush him off to the cath lab..
One very important step after that was I called the charge nurse and told him of the situation and asked him what to do. This is key. If you have a charge nurse, utilize him or her at this moment. THey are there to help you with these decisions. My charge nurse wieghed all the data with me and decided that calling the doctor at 2am, even though the patient insisted on it, would not be appropriate at this time. UNLESSSS there was an additional symptom or vital sign that became abnormal.
Now fast forward a few hours....... At 7am during shift change the patients blood pressure began to drop. FAST.. SBP was around 70. That is when we called the doctor and he moved to ICU. His labs came back shortly after that and his WBC's went from normal to 50k! ! This is a rare case of a very fast onset of septic shock, but how would anyone know this at 2am with a symptom of feeling bad and nothing else? There is no way that any of us could have predicted this would happen, even the doctor is not expected to know that feeling bad leads to septic shock.
Keep in mind you have to make a decision based on facts, vital signs and help of your charge nurse and you have to be able to back up your decision with that data. Those middle of the night cases are not so cut and dry. But I also agree that if the blood pressure was normal that you did not need to call the doctor. Ask yourself... can this wait until 7am when the doc starts waking up? In that questions, again, you have to weigh all the data and symptoms,,,
Calling the doctor at 2am is not something that you should take lightly,, but then again, if it NEEDS to be done, do not hesistate.
I hope my rambling helped a little :)

I am not putting you down but I would know. You asked how would anyone know the pt was headed south. I would and I'll tell you why.

An aide came to get me once and said Mr. Jones didn't look right. We were on Tele. NSR. rare pvc's; VS were completely normal, I did my system by system exam. A & O x3 (which was the standard then), skin w&D, nailbeds and mucosa pink, Lungs clear, Heart RRR, no edema, 4+BS, no tenderness of abdomen, just a basic once over. I agreed that he did not look right, despite all the normal things.

His face was shiny and he was sort of hyper alert, if anyone understands that description.

Not nervous, not anything you could put your finger on - at least, not with my then level of knowledge and experience. I have since seen this type of face one other time. A friend's father died. She had that look on her face the next day. I think epinephrine, who knows what other hormones were at work.

I called the intern (yes, there were interns then.). He came to see him, did his exam, agreed that the man didn't look right, rechecked his VS, which were still WNL. He told me to keep an eye on him and call if anything changed.

The intern wasn't 5 minutes gone when the aide came running, yelling, He coded! We did manage to resuscitate him and get him to ICU. I'm not sure what happened from there.

For OP: You should not call the doc to report normal VS at 0200. You did right to call the low VS earlier. Yes, try to avoid phone calls at night but call when needed to be safe. It does get easier, so don't worry. Definitely involve the Charge Nurse or the Supervisor. Think through what the doctor will ask you and what possible orders will be given. Good luck to you.

I just remembered another patient who had that look. She was post-partum a couple of hours and became septic.