New Nurse question:
I have been told I will learn the nuances, like when to worry. What to do if, etc... but I don't think my patients can wait, so I tend to over worry right now.
So, dumb question.
If pts are fairly new ED admits and they develop high(er) bps, high(er) temps etc, what do you do BEFORE you panic and call the doc.
For instance, hypothetically but ususal case:
older lady with COPD comes in for gallstones, NPO, fluids running about 100 hr., UA clear. Over next six hrs she pees only 225 cc,concentrated (foley), temp 37.9, hr 101, bp 150/100. Im thinking dehydration, she is COPD already distressed resp (on home o2) so dont want to fluid overload her either.
Some nurses tell me,dont worry thats not unusual with pain (hard to elicit pain scale as she has dementia) and her bp is high not low. Others freak because her output is low and want to call doc and get bolus order, others I have heard say wait and see, doc will be in in the morning. She has course crackles and is on home o2 and RT is treating her every 3-4 hours.
I have lots of pts who suddenly their BP will go up but they may be in pain or agitated stroke or dementia pts. Every hemodynamic change sets off alarms in me, but I want to get better at knowing when to worry.
Any suggestions guys?? I cant just slap an aspirin/tylenol in em and call in the morning....
Oct 4, '06
You are already thinking like a critical thinking nurse and this is good.
Sometimes the old jaded nurses who don't panic miss things with their casual attitude. Their patient crashes and you always hear "they were fine a minute ago, I was just in here.........". It's your patient, your new license so continue to think like this.
However, you do develop over time a sixth sense that something just isn't right.
She probably is indeed dehydrated but the rales may indicate that she's holding on to some of her fluid. How long has the 100 cc/hr been running? The 225 cc in six hours is 30 cc/hr, which is my minimum level of comfort, so I wouldn't panic just yet.
The BP is above my comfort level, but it could indeed be pain, so a thorough pain assessment using nonverbal cues, such as guarding, grimaces, pain to palpation, etc.
The respiratory distress bothers me as well. I'm sure this distress is not her baseline. Is there documentation that the MD is aware of this. Was she like this in the ER and just hasn't gotten any better?
I guess besides the hemodynamic changes, and change of any sort is signicant, what I would look at is the patients presentation. How has that changed? What was the urine output in the ER when they put the foley in. What did her lungs sounds like in the ER. What was her BP in the ER. What's her BUN/CR - which would be the telltale of dehydration vs. overload. What was her baseline CXR, are the rales a pleural effusion/pneumonia? If nothing really has changed since then, perhaps she just needs continued treatment as ordered and a watchful eye.
If her lungs were clear, if her BP was lower, etc etc. then a prudent call to the MD is in order to maybe order a chest xray, etc. because the patient is experiencing a change in condition the MD might not be aware of.
Last edit by Tweety on Oct 4, '06