Frustrating case at clinical

[Jrhemming]

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?

[jadelpn, LPN, EMT-B]

The fever can suggest some sort of process--and with it, a higher blood glucose. There are some medications (I can think of prednisone, for instance) that can also cause a spike in blood glucose.

The Eliquis is on board.

The kidney failure may require some sort of follow up if the patient is not on dialysis. Could they have started a process for looking for a suitable site for dialysis access--and sometimes it can be in the upper leg? Additionally, nerve issues d/t both diabetes, as well as sometimes a side effect of chemo.

Pain control is an issue, and also would need addressing.

I would most definitely use a "case management"/ patient education approach to this, should you need to do a follow up paper/assignment for your class. The VNA is an invaluable resource, as is palliative care. Managing side effects of chemo/treatment, what to do about advancing kidney failure. Pain control. PT for gait. And managing the anxiety. All of which are problems for your problem list.

In your clinicals, you will see any number of patients who have complex sets of dynamics, complex sets of issues, and complex needs. You can only take on one issue at a time. Pain, fever, blood thinning...all of which can be followed up with home health. And often times you may find that patients have a desire to go home, and to be cared for at home.

Best wishes, and I really admire your thought process!! Keep it up!!

[nursephillyphil, BSN, RN]

well if the pt is receiving chemo then they are in a hypercoaguable state. depending what type of chemo they are getting, it can cause high bg levels even with ss insulin. good observations of your pt though, keep it up and keep asking questions!

[donsterRN, ASN, BSN]

I really admire your thought process!! Keep it up!!

Yes, this. Exactly.