Dumping on the ER?

%D#2 · Jan 29, 2016

To clarify I am an LPN. We always have RN on call and during the day but it's not required 24/7

%D#2 · Jan 30, 2016

I've seen people with comorbidities admitted for less than that. I probably would not have thought much of it as an er nurse, but that doesn't mean they won't admit to monitor. Obs/ medsurge monitoring has resources and staff so far beyond what a ltc can have.
I've had so many dump jobs from ltc places. They don't sound anything like the op. They go like this: unresponsive, dka, major urosepsis, huge decube's that seem to be in weeks old dressings.
Btw unresponsive could be hypoglycemia, oversedation, sepsis, dead (yup).
Sounds like a nurse sent someone to the Ed cause something wasn't right. Turns out this time it was a big deal, and shouldn't have waited until the am.
Good for you OP! You'll raise that flag a lot and it will be nothing. Enjoy the time it mattered and keep trusting your gut!

Wow now I don't feel so bad. I guess being over cautious is better than being negligent!

%D#2 · Jan 30, 2016

If the pt is not always in afib, which I suspect due to the Coumadin, then her elevated troponin could be contributed to her going into afib, not necessarily an NSTEMI- any irritation/stress of the heart muscle can cause an increase in troponin. I would be interested in her actual result. They may not even do anything for her but adjust her medications- perhaps a cath, but I suspect they won't due to her history.

Her BNP is in the 600s. She is still there at the hospital. And positive for pulmonary effusion. But thank you for your input I am really learning a lot from all the experienced nurses on here

%D#2 · Jan 30, 2016

NO she/he is the LPN

Yes I'm an LPN.. I do think we should have an RN or at least another seasoned LPN but I don't make these rules lol

%D#2 · Jan 30, 2016

I am wondering how come that there is no RN in the building - just you and CNA?

We are 90% assisted living. We have a small ten bed subacute unit. And 40 patients in AL. I do think there should be an RN or at least another LPN because it's very hard to care for all these people on my own. I do have great staffing of CNAs and they are a godsend but being the only nurse there is tough. I am trying to get good assessment skills but it's so hard when I am running around rushing.

WKShadowNP, DNP, APRN · Jan 30, 2016

Idk. This is why I feel dumb sometimes and why I asked. She had a hist of a-fib but since she's been with us she hasn't had an irregular pulse. I see the other nurses doing things like this and so I get confused.

I wouldn't think you should feel dumb. I see your line of thinking, and it is clear you wanted to advocate for her. It is great to identify the risks she has and I'm glad to see that critical thinking. It is good to ask questions to find out why the ED thinks the transfer was unnecessary.

My only concern with your OP is that the family did not want the patient sent and you did anyway.

And now that I'm at the end I see it was a good thing you did. The family probably changed their tune.

I hope this thread helped.

%D#2 · Jan 30, 2016

I wouldn't think you should feel dumb. I see your line of thinking, and it is clear you wanted to advocate for her. It is great to identify the risks she has and I'm glad to see that critical thinking. It is good to ask questions to find out why the ED thinks the transfer was unnecessary.
My only concern with your OP is that the family did not want the patient sent and you did anyway.
And now that I'm at the end I see it was a good thing you did. The family probably changed their tune.
I hope this thread helped.

Thank you yes this thread helped a lot :)

ED Nurse, RN · Jan 30, 2016

Her BNP is in the 600s. She is still there at the hospital. And positive for pulmonary effusion. But thank you for your input I am really learning a lot from all the experienced nurses on here

That BNP is really not that elevated. Like I said, if they called it an NSTEMI that does not mean it actually is an NSTEMI- due to her fluctuation from NSR to afib- her trop could be elevated more than likely from the onset of this episode of afib. BNP is not used in diagnosing an NSTEMI either- it's indicative of vascular congestion and an imbalance in fluid in the vascular system. A bnp is typically used to diagnose the severity of a CHF exacerbation. I too suspect this pt typically has a slightly elevated bnp, like currently, due to the inability of her heart to properly contract, which would cause an excess of fluid in the vascular system. This pt also probably has a hx of CHF, which would shed light on the pleural effusion-

Her new found effusion, which could just be CHF related, or is possibly a pneumonia is more than likely contributed to her new femur fx- without being able to move around we need to make sure pts are using an incentive spirometer to prevent effusions from forming. Effusions are not typically life threatening and most resolve on their own- which I suspect was the case with her bc she had no other sxs that would indicate a large effusion such as SOB, chest pain, and fever, and her BNP is only 600. I would even venture to say this may not be a new effusion but an incidental finding- you'd want to compare previous cxr.

When she returns the priority for this pt is pain control and the incentive spirometer. She has a lot of potential for continuing issues without proper monitoring by you and the other nursing staff and her primary physician.

Hope this helps you learn some additional things and gets you thinking about the how and why's when it comes to assessing patients. Don't be afraid to ask questions! You're a new nurse, of course you are going to second guess yourself! Just try to always think situations through logically and you'll be fine.

SororAKS, ADN, RN · Jan 30, 2016

Good call Lupie. I understand the anxiety. I worked in LTC as a supervisor, and had to deal with similar situations; as well as being at the other end as an ED nurse. I'd rather err on the side of safety rather than wait until the person has more symptoms further down the line.

**NickiLaughs, ADN, BSN, RN** · Jan 30, 2016

This may have been a case where her symptoms were minor, but you knew "intuitively something was wrong." Many nurses have that ability, usually comes with experience and time, but sometimes I feel like some have a 6th sense.

Case in point, I had a little old lady once in ICU, and I just knew she was gonna code. I got the intensivist involved, her Symptoms hadn't changed per him and she was tolerating bipap, but I talked him into a slew of labs, EKG and an ABG because even though I didn't have a clear reason, I just knew.

Well the labs didn't reveal anything but then she went asystole 15 minutes later. We coded her and got her back. Only for her to go home on hospice two days later.

I'm still not quite sure how I knew but I did. I've had other similar happenings and I'm sure many nurses have.

As others have said, always trust your gut. I can't say I would have sent her in with those symptoms, so I'm betting something instinctual or something you knew about her contributed.

nutella, MSN, RN · Jan 30, 2016

It is always hard to make a good comment on those examples because there is a lot that we do not "see" when we read the descriptions. It is not only VS and symptoms but also how the pat presents in general and such.

Because you are a LPN and also a newer nurse it would be good to have some more guidance in person - but apparently that is not the case. When you are in doubt you will have to send the pat out.

And it does not really matter if your coworkers would have done something different because they were not there.

As you become more experienced you will feel more secure in your decision making.

nurseactivist · Jan 30, 2016

Not all states require 24/7 RN coverage in LTC. especially the smaller places.

Totally terrifying. The fact that there is only a tech at night is unbelievable.

I believe in nurses following that "little voice" in their head. Intuitive skills are important and increase with experience. It is like I used to tell new mothers, all babies haven't read the book, neither have all patients. Good job OP.