Hi guys. Little background I am a novice nurse working in LTC. Been a medic since I was 21 and was also a pct since I was 18 so I am not "stupid" but sometimes I feel that way when I send PTs out to ER.
tonight I sent a pt with hx of HTN, and a-fib and a newly fractured femur to the ER. My reason, her HR was more thready and irregular than usual and her BP was 160/110. I didn't want her to have a stroke.. She's got the a-fib, fracture and high BP risking her for blood clots and stroke. So although her family was against it I sent her out. The ER nurse in report said, if she has a hist of a-fib then the irreg heart beat isn't so much of a concern. I said yes but I am more worried about her BP and risk for clots. She is on warfarin for the fib but still, better safe than sorry. Or am I wrong?
i send out people because I do not have the resources at my facility do treat people as an ER would but I only send them for really abnormal or major things..
im just trying to get oter people's input to see if I did the right thing or if I am being over-caughtous and dumping on the ER?
What were the patients baseline blood pressures? Was her orientation intact? Some people will sit in pain without saying a word. instead of saying are you hurting or are you in pain maybe try do you feel any discomfort in your leg or does your leg feel sore.
Look, the ER doesn't want anyone to come through the door so don't base anything on an ER nurse opinion. You did the right thing
The ER doesn't want anyone who doesn't need to come through the door. The initial clinical picture didn't sound warranting of ER and I used to work in an ALF. There must have been more subtle additional symptoms that told OP to send her. That BP wouldn't get our slightest attention in the ER, we honestly would have simply sent her back so something else must have appeared to warrant labs and a total work up. Perhaps she was working a bit more to breathe than usual? That's my best guess. Hard for us to say as we weren't there.
When I worked ALF 10 years ago, it was frustrating to be the only set of eyes with no RN usually present and our director who was on call 24/7 was incredibly difficult to get a hold of. It's very hard to make those decisions with no one else around, but you always go with your gut and what's prudent.
Live seen so many pts brought to the ER who didn't necessarily need to be there, but half the time, it's a b & c or a group home and it's not their job to make medical determinations. I have to remind my coworkers it's just like if a family member brought them in. Yes the non critical pts come in and take resources we need for the sicker ones, but it comes down to education that we need to provide. It's def a big challenge though.
What were the patients baseline blood pressures? Was her orientation intact? Some people will sit in pain without saying a word. instead of saying are you hurting or are you in pain maybe try do you feel any discomfort in your leg or does your leg feel sore.
She's usually around 130/70. Just out of curiosity for any future situations what would be a BP that screams "send her out" lol. As a medic we always transport people if the family wants/patient wants. Even if the BP isn't really that high. we take anyone to ER from another facility if they call 911 and want to go, even if it seems like "nothing"
I didn't read all the responses so sorry if this is a repeat. My biggest concern is "the family didn't want her sent out". Is this patient a DNR? It the patient alert and able to make own decisions? Despite the outcome of the MI - I would not have sent unless the family wanted her sent and assuming she was a DNR (unless of course she could make her own decision to go).
Specializes in LTC,Hospice/palliative care,acute care.
Hi guys. Little background I am a novice nurse working in LTC. Been a medic since I was 21 and was also a pct since I was 18 so I am not "stupid" but sometimes I feel that way when I send PTs out to ER.
tonight I sent a pt with hx of HTN, and a-fib and a newly fractured femur to the ER. My reason, her HR was more thready and irregular than usual and her BP was 160/110. I didn't want her to have a stroke.. She's got the a-fib, fracture and high BP risking her for blood clots and stroke. So although her family was against it I sent her out. The ER nurse in report said, if she has a hist of a-fib then the irreg heart beat isn't so much of a concern. I said yes but I am more worried about her BP and risk for clots. She is on warfarin for the fib but still, better safe than sorry. Or am I wrong?
i send out people because I do not have the resources at my facility do treat people as an ER would but I only send them for really abnormal or major things..
im just trying to get oter people's input to see if I did the right thing or if I am being over-caughtous and dumping on the ER?
So,you called the covering physician,gave him or her your assessment and they gave the order to send the resident out? Don't see a problem,as you said the emergency depart. Can complete an assessment much faster.However.I dont understand why you would push this against the wishes of the family.Do you have a comfort care program?
Specializes in Med Surg, ICU, Infection, Home Health, and LTC.
There won't always be an RN in the building 24 hours a day when you are in long term care. It is only required for 8 hours of the day in my area. Either way, whether she is an RN or LVN, she is a new nurse and I would be scared to death when I was a new nurse being alone in the building.
It seems to me that if a nurse has not worked in LTC then they don't seem to see the other side of an issue. When all I had ever worked was ED/ICU I used to wonder why on earth a LTAC patient had been sent in to be admitted or checked,and we all joked that around holidays LTACs did all they could to empty out or dump a Pt so they could have a lighter load. Now I realize how naive I was and how little I understood the heart and soul of the LTAC nurse.
I know better now but only after having "walked in their shoes" so to speak. I learned very quickly how subtle the changes in the elderly can be and that it may be a very very small change or gut feeling that separates the septic shock and code Pt from the UTI Pt. I learned how frequently ED nurses talk to you like you are stupid when you call them report. I learned how often sarcastic even the doctors can be about their nursing home Pts.
You are doing great at learning not only Pt care, but also gut instinct. It is always a wise idea when there is just one licensed person working in a facility, to have a second license with more experience a phone consult away. We all need to discuss things sometimes and it is experience that can be of even more value than a degree, IMO. It is rough to be by yourself, regardless of how many years you have been a nurse, with a buttload of elderly Pts that can go from stable to unstable in less than 60 seconds!!!
I didn't read all the responses so sorry if this is a repeat. My biggest concern is "the family didn't want her sent out". Is this patient a DNR? It the patient alert and able to make own decisions? Despite the outcome of the MI - I would not have sent unless the family wanted her sent and assuming she was a DNR (unless of course she could make her own decision to go).
Hey that's okay. The family was against it at first.. Now they are pretty grateful. She's a full code.
The only problem I have with your story is whether the family or patient consented first to the transfer. If they were against it and you talked them into, I would say good for you; however if they were against it and you called anyway then you have disregarded a fundamental patient right to choose.
As for the all the ED nurses saying that blood pressure doesn't concern them at all...I think you need to take a step back. I'm an ED nurse, and while I may not be terribly worried about her stroking out, it would at least raise an eyebrow. Especially in a patient who is (I'm assuming) on pain medication and without any complaints of pain or anxiety. She also stated the BP is typically in the 130/70 range...that's a significant difference. Sure, we wouldn't treat that BP alone, but I wouldn't ignore it either. To do so I think would just be negligent. I also want to add that if she is in fact on a bunch of pain medication for her recent femur fracture, then symptomatic pain could have been masked.
I try not to give our ALFs and SNFs a hard time when they send someone in. I may secretly be thinking all sorts of nasty things, but I'm also not in their shoes. And for all the times I've gotten a patient that should have come in days or weeks earlier, I try and appreciate when someone has taken the time to see something in a patient and get ahead of what's going on.
Look, the ER doesn't want anyone to come through the door so don't base anything on an ER nurse opinion. You did the right thing
Insightful. I was wondering when someone else would realize I should get paid out the waz to sit on my duff and pin to my recipe board and do 0 patient care. It's the whole reason I busted my butt in nursing school. Finally someone recognized my true value.
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TriciaJ, RN
4,328 Posts
Yes, yes. A thousand times yes.