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.
I didn't suggest it is, nor do I require a tutorial on the cause of PEs or the mechanism of DVT. I am pretty clear on that. I was merely responding to your verbatim quote that stated:
I currently have a father on coumadin for stroke phophylaxis due to AF, a brother on coumadin for DVT recurrence prevention after a large DVT earlier this year, and a mother on coumadin for PE recurrence prevention after a PE earlier this year.
those examples you pointed out for Coumadin are for prophylaxis after PE/DVT, which is completely appropriate. Virgo was pointing out about inital meds for DVT/PE would be Heparin drip/Lovenox, not Coumadin.
Thanks to all who relied. I am feeling a little better about the situation today. Heard that my pt is doing fairly well in hospital so that makes me a little happy! Some answers to the replies-No, there was no dx of PE when the pt return from hospital. That def would have red-flagged me to keep the lovenox. No CXR done in hospital either. Could have been for a multitude of reasons, who knows what they are! Not sure why facility didnt want to switch to a generic brand, and i certinaly didnt think of that. I think from the get go they were so concerned with the $$ that they just wanted it gone ASAP. Pt allergic to coumadin so that not an option. In regards the low o2..a mask was placed on pt and o2 bumped up, but was ineffective. the highest it would go was 84 and then drop right back. Also im a firm believer that simply "pushing o2" does not solve the problem. o2 sats drop due to an underlying cause generally, and if breathing tx are ineffective and whatever else MD may order are ineffective then i certianly dont want to just keep pushing o2. EMT's came in one time and said "oh you called for low o2 sats but my machine is reading 93%" This was AFTER the bagged pt and put o2 up to 15 liters-OF COURSE ITS GOING TO READ HIGH NOW!!. My co-workers, while most of them are very helpful and very educated-there are thoes few who act like "know it alls" and feel like the have to belittle thoes of us who may not know as much as they do, or they THINK they do. I cant stand it. I may not know everything, but I pride myself on the fact that I ALWAYS try to seek learning opportunities and I never am afraid to ask questions.
To NurseL156-Yes, they called me at home, on my day off from work to ask me about this pt. I was very irritated I said to the person who called me "please look in the chart and you will see where I d/c'ed the order on such and such date". They then proceeded to say "when you come to work tomorrow i need you to page the MD and get it d/c'ed again". My response was-its 12:00 noon and there is a perfectlly capable nurse in the building right now who can page the MD and get this taken care of right now, if thats what neccessary, please dont call me on my day off unless its an emergency". So when i return to work, they tell me "oh we paged the MD like 5 or 6 times and he never called back". While that is belivable sometimes, i doubt it was this time. I get sooo frustrated because things like that happen all the time. And EVERYONE Talks to the MD, like the DON, the ADON, the unit manager, nurses who work on different halls...but like when the unit manger takes orders, she will only write the order and not sign it, and not take it off in the chart. Us floor nurses have to rec the order, send to pharm, note in chart, talk with family ect. And then half of the time weeks later, someone else will question the order and because i signed it, i have to take all responsiblity. It sucks and i have brough it to mgmt's attention thousands of times, that when nurse's write orders they need to SIGN THEM THEMSELVES so they can take the accountibility. Its helpful to have the unit manger to talk to the MD and rec orders, but its not helpful when the unit manager doesnt know the patients like us floor nurses do, and then all hell breaks loose when you question why they got an order for something...i guess thats why they hole that oh so important "title". Hmmmm...sorry for the mini vent.
As for my post being a violation of HIPAA....maybe I should take it down????
I don't see any violation of HIPAA. As for your public profile, your information states you live "anywhere" or something to that effect. We don't know where you live, where you work, etc. This story has nothing easily identifiable about it to make it easy for any of us to find out where this is... no way is it a violation of anything. Please!
Wow, nurses not signing off their orders?? What The! Since when is that normal practice, and to not be challenged? I'd become nurse Ratchet there, I swear...
I currently have...... a brother on coumadin for DVT recurrence prevention after a large DVT earlier this year, and a mother on coumadin for PE recurrence prevention after a PE earlier this year.
What you describe is not "prophylaxis". It is "prevention of recurrence".
prophylactic: a preventive measure. the word comes from the greek for "an advance guard," an apt term for a measure taken to fend off a disease or another unwanted consequence.
a prophylactic is a medication or a treatment designed and used to prevent a disease from occurring. for example, prophylactic antibiotics may be used after a bout of rheumatic fever to prevent the subsequent development of sydenham's chorea. a prophylactic is also a drug or device, particularly a condom, for preventing pregnancy.
prophylactic is an appropriate term for use of a med designed to prevent something from occurring regardless of whether they have had a disease or not. before surgery, after surgery or after an actual dx of say a dvt. coumadin is being used as a prophylactic med to prevent another dvt from occuring. now a thrombolytic drug or clot buster would not be called a prophylactic treatment. (what would the term be for that? did i ever know, and if there is one, am i going to kick myself when one of you brilliant all nurses nurses come up with it?):)
the op can't use iv heparin. we give heparin sq sure, but never something that requires close monitoring. typical ltc/subacute/rehabs have labwork sent out once a day in the morning. the phlebotomist comes and draws it. a "stat lab" is one that gets done in a few hours - the time it takes to page the lab and for them to send a phlebotomist on call to come draw it. anybody needs anything faster is going back to the hospital. i would bet it is the same where the op works.
Hey Virgo, I respect all you have to say, really, not in a ******* match with you, honest. There is plenty of stuff I don't know, and plenty you can teach me. It's just that when I am sure of my info, and there is a source to quote, I'll quote it. It is one of my good qualities and I am sure one of my annoying ones right now too. :) Have a good night.
To the OP-I know you feel bad for not going with your gut. I would lay odds, that after having this experience you will never let it happen again. I applaud you for researching lovenox and it's uses and actually putting the picture together that it might be a PE. Chalk it up as a learning experience and never be afraid to question your superiors or the docs.
Specializes in Peds/outpatient FP,derm,allergy/private duty.
LuVnLpN08-
but like when the unit manger takes orders, she will only write the order and not sign it, and not take it off in the chart. Us floor nurses have to rec the order, send to pharm, note in chart, talk with family ect. And then half of the time weeks later, someone else will question the order and because i signed it, i have to take all responsiblity. It sucks and i have brough it to mgmt's attention thousands of times, that when nurse's write orders they need to SIGN THEM THEMSELVES so they can take the accountibility.
I don't blame you one bit for being upset! Signing an order taken by another nurse is a very bad idea. You're right. If something bad happens they will hang you out to dry. In fact, this place is starting to sound more and more like those places experienced LTC-SNF nurses will say, "run for the hills while you still have your license!"
On the plus side, learning what not to do is at least as important as learning what to do!
Virgo RN- sounds like somebody needs to turn into Nurse Ratched and kick some tail around that place!!
:) Have a good night.
MassED, BSN, RN
2,636 Posts
those examples you pointed out for Coumadin are for prophylaxis after PE/DVT, which is completely appropriate. Virgo was pointing out about inital meds for DVT/PE would be Heparin drip/Lovenox, not Coumadin.