Frustrating case at clinical

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I had a very frustrating situation yesterday in my clinical on a ms floor. I had a 45 yo cancer pt with DM type 2, stage 4 renal failure (caused by previous cancer chemo) the pt was in for fever and possible PE. They didn't do a ct because of the kidney damage so they did a vq to test for PE and it came back as a 20-80% chance of PE. (Really narrowed it down) the pt was complaining of leg pain when I went in to do a head to toe and when I checked and the nurse assigned to them also checked we suspected a DVT. The Md. Had ordered a new script for elliquis that the pt. had that morning and then ordered discharge for the pt that afternoon. No pt/Inr was done no d dimer. Nothing to make sure the meds were at a therapeutic level. Not to mention the pt couldn't walk across the room without sob. The pt blood glucose was also climbing all day even after getting sliding scale coverage twice and was in the 400's upon discharge. I was freaking out on the inside and went and told my instructor of the situation but ultimately the pt was discharged. I know I'm a student and I let the appropriate people know my findings and concerns, but should I have done more or am I over reacting?

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Specializes in Complex pedi to LTC/SA & now a manager.

Was this a palliative/comfort care patient by chance?

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Specializes in Critical Care.

There was "Nothing to make sure the meds were at a therapeutic level" because that's not recommended for eliquis. The only way to measure it is an anti-xa test, which hasn't been proven to be of any use in managing eliquis. If they've already chosen to treat the patient for PE/DVT then there's not much use in a D-dimer, and in cancer patients D-dimer levels can be of limited use. The decision to discharge the patient is based on a number of variables; the patient's goals which may include limited duration hospitalizations, particularly if there is a terminal condition, the severity and stability of symptoms (just having symptoms doesn't mean a patient shouldn't be discharged), etc. The BG is certainly concerning, although sometimes the best way to get a patient's BG controlled is to get them out of the hospital if their BG is normally well controlled on their own.

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Definantly not palliative the pt was currently in treatment, and other than the effects of chemo, realitively healthy. The patient was doing all adl's on their own and wasn't emaciated from treatment or anything.

Thank you for the information on elliquis. I hadn't been told that by my instructor. I think I may have had a bit of counter transference as the pt was close in age to a relative that had cancer not too long ago. I was just worried about the clots traveling and making a bad situation worse.

Also I know the pt. was concerned about being discharged in their condition also.

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Does Eliquis act as a thrombolytic? I'm looking in my drug book and it says it helps prevent clots but nothing about being a thrombolytic. Are they expecting the clots to be taken care of by the body?

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Specializes in psych, addictions, hospice, education.

Your situation would be very identifiable to anyone who knew about it, especially if that's your real name you're using. Please don't post so many details...

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Ok I tried to be as vague as possible

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PT/INR is of no value in determining therapeutic drug levels with Eliquis. D-Dimer is of no value here, as the pt is already being treated for PE. No, Eliquis is not a thrombolytic- it simply acts to prevent thrombus progression, and the formation of new thrombi. The PE will be broken down by the body's own defenses over time. SOB with exertion and CBGs in the 400s aren't reasons in and of themselves to keep a person in the hospital. I would expect someone with a PE to have symptoms, and blood glucose control is possible on an outpatient basis.

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Thank you. That answers my questions and I guess I was more worried than I should have been

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Specializes in Critical Care.
Does Eliquis act as a thrombolytic? I'm looking in my drug book and it says it helps prevent clots but nothing about being a thrombolytic. Are they expecting the clots to be taken care of by the body?

Eliquis is not a thrombolytic, but then again neither are coumadin or heparin. There is a balance in your body of clotting mechanisms and clot lysing mechanisms, basically what all these drugs do is to help correct that balance that results of the lysing of inappropriate clots and the preventions of additional inappropriate clots, often through different specific mechanisms.

I should have pointed out earlier that your instinct of questioning the appropriateness of a discharge is not something you need to unlearn, that's a good start.

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Specializes in Critical Care, Med-Surg, Psych, Geri, LTC, Tele,.

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Specializes in Neurosciences, stepdown, acute rehab, LTC.

Some of this is concerning but still manageable at home. Patient education is necessary in this case, and maybe they went home with services. Insurance only covers so much.

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