Quote from flashyrn2be
Hello - I have been an RN for about 2.5 weeks. I am currently in an orientation program for a tele/PCU floor.
I have some questions. I do not want to appear uneducated at work. But alot of things I just do not feel were covered in school or in text books. I have asked some questions, but get unclear responses.
How do you tell if a patient is going bad? I know I have gut feelings.....but when do I call the doctor? I don't want to call the doctor just because.....what are my key warning signs? I want to be able to provide the doctor with logical, objective observations that they may not have picked up on during their rounds. Do my instincts count?
When is a blood pressure too high?
When is a blood pressure too low? Is there a panic level?
What if there is a huge difference in the ortho B/P's? Do I call or just chart?
Is there any interventions I can do without a doctors order?
I know you call a code if someone is not breathing or no heartbeat. That much I did get out of school and BLS. But how do I know it is coming......
I had an instructor tell me she did not experience codes because of her excellent assessment skills. I was like *WOW*. She is super nurse. So too shall I strive........
Can anybody help me and my future patients?
Many thanks in advance.
Hi Flashy, I'll attempt to answer some of your questions, but please remember that my answers are based on being a night shift nurse. Our protocols will be different from other shifts.
Vague answers also bothered me when I started working Tele. I quickly learned that whether the doc was called was dependent on other things. That's why your answers seem vague. Tele nursing is a lot like English grammar
--there are rules, but there are also plenty of exceptioins.
Bearing that in mind, the key is to be able to recognize trends and know your protocols for different conditions. Also bear in mind that being new to tele, you might be calling the doc and telling him something he's heard oh, about a hundred times before. Read the orders, the doc's progress notes, and the patient history. Does the doc know that the patient's K is 3.4 by writing it in the progress notes? If so, he might've added some K to the IV fluids or he might just wait until tomorrow's labs to treat it. Does the patient have a trend of flipping in and out of VT? If so, maybe those 8 beats you just saw might not need to be called asap, especially if the patient is symptomless.
Know your protocols. If you have a newly diagnosed stroke patient whose temperature is 99, you give them Tylenol 650 mg either po or pr. You would not give the post-op patient Tylenol for a temp of 99, however, because an elevated temp up to 101 is actually desirable in a postop, but it's not good in a stroke patient.
In general, you can call the doc if the patient's BP is dropping fast--say the patient's normal BP is up over 100, now they're BP is low 80's and they're feeling lightheaded. You have two bad symptoms there. In that case, I would tell your charge--she might be able to help you--then put a call out to the doc and try to get the patient to lie flat till you get orders. Some of our docs like to start a bolus of NS to get more volume on board.
You also would want the doc to know of rhythm changes, especially if someone goes from Sinus to A-Fib with RVR. Even if the patient has a history, the doc might want this patient to get on a Cardizem drip.
Instincts do count, but try to be specific: "The COPD patient's color was ruddy before but now his breathing is more labored, resps are high, he's c/o SOB, and his color looks dusky. Even though is vitals are ok, and his O2 sat is ok, he has deep sternal retractions as he's breathing. He refuses to even lie down in the bed due to the SOB. I don't have a good feeling about this fella right now.
I called the RT, the patient had a nebulizer treatment, but hasn't improved much. Do you want ABG's? a CXR? Lasix??"
That last one actually happened by the way. We really had no proof by the numbers that this fella was going bad--his ABGs came up fine--we just really felt like his heart couldn't take much more of the respirations at 47 a minute. We sent him to the unit on a Bipap after some IV Lasix and he was much more comfortable. When he came back in a few days, the official dx was that he'd had CHF. We must've caught it early.
I guess my point is that there's no substitute for experience. I remember being completely wowed as a new tele nurse when I came into a patient's room to assess her and she was completely unresponsive. I panicked and hit the Code button.
One of the more experienced nurses came into the room and TOOK OFF the O2. But it proved to be the right thing to do--some visitor thought the patient would do better at a higher rate of O2 and had jacked our CO2-retaining patient up to 5L, causing the patient to pass out a couple of hours after the visitor left!!
So in general, you read the chart. You read the orders, do an overview of the labs and test results, then look at the doc's progress notes. Look at the vitals and history and note any trends. THEN if your patient looks badly, you might be able to figure out why and if it's a change that warrants calling the doc. As a new nurse, I'd err on the side of calling.
I called one doc in the wee hours because I had a patient flip into A-fib with RVR at a rate of about 140 while she was asleep. She was asymptomatic. I called the doc and he was annoyed. He said something like, "She does this all the time. What are you doing, calling me about it?" Irritated and upset by his tone, I snapped back, "I am LEARNING, that's what I'm doing, and I wanted to do what's safest for the patient." Immediately his attitude changed. He had me give a bolus of Cardizem and start a drip on the patient.
I did great except for one tiny thing--I hadn't taken my unit's Tele test and wasn't officially certified to give Cardizem as a bolus!
I freaked. But my charge just handed me the test and said, "Just pass the darned thing already" so I did and became "official."