Going from Med/Surg to LTC thinking is hard

[dorselm]

I worked in acute care for 5 yrs, then I come to Ltc and find that's it's a totally different nursing world that's gonna take some getting used to. Recently I was caring for an 86 yrs old man. The day before the CNA was preparing to shower him and he began to complain of a severe HA and stated he was too weak to get up. VS: 97.2-92- 148/98-20-96% RA. I gave him Tylenol and told the aide to bathe him in bed. He said headache was gone. Next day aide comes to get me and he's very clammy small emesis and weak. VS: 99.1-120-96/42-26-93% RA. I lower his head elevate his legs and call the supervisor because I'm calling the doc to send resident to the hospital because I think he's septic. Blood cultures were taken recently for possible UTI. Super comes and elevates his head and gets BP 120/48. Now this resident recently. He had lab work done which showed WBC' S 64K. He had an appt already setup to see and Oncologist

the next day. The supervisor saw his bp improve and said let's get an order for Cipro and wait for his

appt tomorrow. But with residents head up he

felt sick so I lowered his head again and now bp

88/42 hr 100 temp 100.2. I gave him Tylenol an hour later temp is 100.6 and he's still clammy. I call the doc on call again and he said send resident to hospital. I checked POLST he is DNR but limited intervention. Doc comes in next day and was very upset he went out because he went to hospital already once within 30 days and he was going to see Oncologist the next day. At hospital he was found to be retaining urine and pseudomonas in urine. The supervisor told me given his age and Co morbidity and possible leukemia if he had gone septic and died it would have been labeled natural causes. That the resident no matter what did not require immediate care. Can someone tell me what I should have done differently?

[psychgeribuff]

The only thing I would have done differently would be to speak to the health care surrogate. Did they want him sent to the hospital? I personally think you did the right thing. His cancer wasnt diagnosed yet and you had the post form with limites interventions. In the end the MD made the decision you just gave him the facts. You will get the hang of it!

[sallyrnrrt, ADN, RN]

you did what i would of done

[Tankweti]

If a patient has to go to the hospital, then he has to go. Obviously there was a difference of opinion between the 2 physicians - one saying send him out and the other the following day objecting to it based on readmission status. I think it would have been a good idea to call the family but in the end you will have to live with yourself as to how you would have felt if you had not sent the patient out and he suffered terribly in the interim. All I know is that if it were me in that man's place, I would want to be comfortable and having urinary retention, an infection and probable sepsis ain't comfortable.

[ScudderRN31]

This is a touchy subject..I work full time in acute care and PRN in LTC. I also work PRN in case management so I see the full picture in situations like this. The issue with the 30 day readmit is the hospital won't get paid by Medicare..doesn't matter if it's a different diagnosis or a different hospital which is why docs are getting upset about readmissions. I think the acute care experience makes me more comfortable caring for these types of patients in a LTC setting. So what I would've done different is try to get orders to do in the facility. Residents can have IV ATB, IVF, redraw labs, X-rays, you could do the PVR there to determine the retention. Not saying you made the wrong choice..this would be the choice most would make and there is nothing wrong with it.

[benegesserit]

I think you did right. Unless a specific and documented decision had been made to not send him to the hospital, that is what you needed to do.

[dorselm]

Thanks to all who responded I see that everything that was done in the hospital could have been done in house. I'm learning to put all of the pieces together.