Feeling bad because I didn't "go with my gut"

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Here is a situation that happened at work today-I would appriciate any feedback! Without going in too much detail, here is what happened...

Have a pt whos been with us for approx 3 weeks (SNF)...came from Hospital, and was bedridden for aprrox 3 1/2 weeks while there,due to some medical dx and background pt thats not important-important fact is pt was bedridden for sig. amt of time. completley immobile. Anyways, pt get up OOB with PT at hospital for first time after 3 1/2 weeks-MD decides is ready for d/c shortly after...maybe 2-3 days later. pt having minimal amt of pt at time. Sent to our facility for rehab purposes, with goal of going home. Pt sent to our facility with orders for Lovenox 40mg sub q qday UNTIL pt ambulating. pt NOT ambulatory at time of comming to our facility...administrators ect were riding me about having lovenox d/c'd ASAP when pt started PT due to the cost of medicine..insurance would not pay for, facility to pay out of pocket. pt with us for 2 days and PT picks up-pt doing very well in rehab however i would not call it ambulatory. Unit manager gets on phone with MD after 2 days of PT and rec's order to d/c lovenox-MD states since pt is rec'ing PT should be fine. Ok, all is fine and dandy....I think 3 days later, asses pt, o2 sats 69% on 3LPM (COPDer), pt confused to the max, alert to self only, normally A&Ox3, flushes, inceased temp 101.5 ect....can't maintain sats, nebs ineffective blah blah, lungs diminished....MD say send to hospital...send pt out.......

pt stays at hospital about 2 1/2 days and returns to our facility-at hospital some cardiac workup was done and labs ect. pt comes back to our facility, with lovenox ordered 40mg sub q qday...this time does not specifiy when to D/C. I rec phone call from admin on my day off saying "i thought u got this taken care of, pt comming back on lovenox again, please clear with MD tomorrow, pt doesnt need to be on it, is ambulatory" I say ok will look at re-admission papers tomorrow on return to work. I do some research while im at home, I am not too familiar with lovenox, dont frequently use it. So i read some stuff about how its to prevent blood clots in immobile pt's or after surgery ect...I read about how DVT's can lead to PE's and so on....the PE part really stands out to me, im thinking "pt must be coming back on it for a reason, perhaps MD is worried about PE". I return to wrok and read the re-admission papers, still thinking about the PE. Admin still riding me about d/cing med. Unit manager talks to MD, MD states "is pt moving around", unit manager says yes. MD says ok d/c it then pt doesnt need it. The whole time my gut is telling me "pt does need it, and should have been rec'ing it for the last several days" pt is not ambulatory in my mind, some PT to the arms and the legs doesnt count I dont think. pt gets from bed to WC but a lift is used-heavy pt.

Anyways fast forward to today-I get to work 7am, another nurse is on phone with MD...same pt o2 sats drop again to 70's...cannot maintain, go through the same things as before...MD says "oh crap maybe pt has a PE she needs to go to hospital now". pt refuse to go to hospital, very upset blah blah blah, MD says ok well give pt lovenox 80mg sub q STAT and set appt for chest CTA and xray and pt needs to have that ASAP at hospital...I talk with pt and explain whats going on possible PE, importance of proceedures...pt says ok il go to hospital if you promise me that ill come back today...I say go to hospital and have tests and HOPE you will come back but cant promise....pt goes on to hospital...they call me a couple hours later say pt admitted, with dx PULMONARY EMBOLISM.

I am upset with myself because number one, I am the pt advocate first and foremost. i KNEW pt needed to stay on lovenox, i KNEW pt not considered ambulatory. I know the MD gave the order but in all honesty because the MD is only in house 1 x a week, us nurses are the eyes and ears for him. I feel terrible like I should have stood my ground and said to admin and unit manager, NO pt needs to con't on lovenox for a while longer, or something along thoes lines. I feel like this could have been prevented. I have never felt this BAD before. I feel like my judgement was not of a good nurse. I had that gut feeling, the one you shouldnt ignore. Im not sure that the lovenox would have prevented the PE altogether but my gut is telling me the outcome probablly would have been much different had I been the pt's voice and gone with MY instinct, something I knew was RIGHT. Since when did we put money before patients saftey and needs? I am so frustrated with myself. Everyone says "well the MD gave the order, all you did was follow it through" but in reality the MD was only going by what WE had to tell him...

Maybe I am over-reacting for being so upset???? Has anyone else been in a situation like this before? Thanks for letting me vent, I am just feeling crappy right now! Sorry its so long, and if there was too much info in there that anyone thinks could violote HIPAA, PLEASE let me know ASAP...this is my first time posting a scenerio like this.

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Specializes in ORTHOPAEDICS-CERTIFIED SINCE 89.

You have every right to be upset. They are turfing this sick lady to your facility when she belongs in an acute setting. Get your director to talk to the chief of medicine and explain how this has been being handled. You should NOT be bearing the brunt of this all by yourself.

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Specializes in Pediatrics, ER.

Yikes. My gut feeling is that if your facility is one that is so unfamiliar with an anticoag drug like Lovenox then it shouldnt be taking high acuity patients like that. Secondly, it sounds like the patient had the same exact symptoms the first time you sent him/her out. Did they have a PE as the dx when they came back? It sounds like they perhaps should have been anticoagulated better/longer in an acute care setting with more education. I hope if the patient comes back again they have an IVC filter and a longterm plan for anticoagulation therapy. It also sounds like your facility may benefit from some DVT/PE/anticoagulation education since it isnt something you come across regularly. You learned an important lesson: to always listen to that nursing instinct. I hope your patient is okay!

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The almighty dollar...how sad! I think all of us experience something like this, and then realize how crazy our system is.

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Specializes in ER.

sounds like they should have worked him up for a PE when he went in the first time - Cardiac workup, ok, but do you know if they did a CT chest? I wouldn't beat yourself up too badly - sounds like you were firm on the pt not being ambulatory, sounds like he was a huge PE risk from 3 weeks being bed bound - probably had a DVT and just waited to go. Sounds like it would've happened anyway once PT got their hands on him. I still would wonder if the CT Chest was done on his return to the hospital, prior to coming back to you the second time. And that's a load of crap about admin caring about the cost of Lovenox for a patient - it was ordered. Geeezzzz!!! I couldn't work there. I'd flip my lid.

PS - my gut is my best friend. Always always listen to it. When I don't, I regret it. Even if it's to voice your concern, better to sound a bit neurotic then to keep your mouth shut and have something happen.

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Specializes in Cardiac Telemetry, ED.

I'm wondering why they couldn't have switched to tinzaparin, if they were so worried about cost.....

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Specializes in Rehab, LTC, Peds, Hospice.

Why not coumadin? Don't forget, Plavix, Aspirin or Heparin either. FYI, lots of ambulatory patient's get blood thinners for a variety of reasons, AFIB is a big one. People who have had CVA's, hx: Of DVT and/or PE like your patient. Regardless, when your gut speaks, listen. It sounds like you have a smart one.:)

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Specializes in Cardiac Telemetry, ED.
Why not coumadin? Don't forget, Plavix, Aspirin or Heparin either. FYI, lots of ambulatory patient's get blood thinners for a variety of reasons, AFIB is a big one. People who have had CVA's, hx: Of DVT and/or PE like your patient. Regardless, when your gut speaks, listen. It sounds like you have a smart one.:)

Coumadin, Plavix, and ASA are not indicated for DVT prophylaxis.

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Specializes in Oncology/BMT.

Just so you know, if your COPD patient has a SPO2 of 69%, they need a little more than 3L of O2... In this situation, it is OK to put them on a higher concentration of O2! Hypoxia only complicates the situation...

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Specializes in ER.

3 L of oxygen just might get that COPD'er up to 80%, where they might live, you never know. A face mask might've been good for a short bit, but likely the NC oxygen would have been just fine.

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Specializes in Rehab, LTC, Peds, Hospice.
http://emedicine.medscape.com/article/284371-overview no offence but please refer to this emedicine article regarding blood thinners/prophylatic for prevention of DVT complications post surgery. Plus I wanted to give the heads up about other conditions that the patient might have. Typically the hospital setting uses low molecular weight heparin- at least the ones in my area did. Often as a rehab nurse we gave lovenox and coumadin until the INR was greater than 2. Prophylactically. Remember the subacute setting is very different than the hospital. Same with long term care.
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Specializes in Cardiac Telemetry, ED.

No offense taken. The article backs up my assertion. It states that platelet aggregation inhibitors, such as aspirin (Plavix is not mentioned, but is also in this class), are ineffective in preventing PE. As far as Coumadin, sure I can see it being used in high risk patients, but it is not first line therapy for DVT prophylaxis.

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