Hmm, what do you think..

[Cat_RN, ASN, BSN, RN]

I'm a new nurse with a (probably) pretty novice question, but here goes. Pt of mine in late seventies, admitted with ARF, UTI, dehydration, anemia, and COPD. Has hx. of an AAA that is currently inoperable. Over the last 3 days he has had 2-3+ pitting LE edema, BP's sometimes reaching over 200 systolic, 100 diastolic ( and PRN clonidine), SOB, and some crackles in the lower right lobe and heartburn. Both times of SOB his sat's have been 95%+ and his pressure WNL. No c/o tightness in chest or pain, just unable to catch his breath. No hx. of anxiety issues.

My nursing judgment had me worried so I called the doctor at 3am expecting SOMETHING from him, but got nothing other than clonidine. Not even a CXR or BNP! I gave him the exact list of symptoms that I wrote here but he did not seem concerned. I know the feeling of doctor's not listening to me, since I sound very young on the phone and am new. Meanwhile, this pt has continuously high BP's, renal issues and an AAA and edema that is unaffected by his current dose of torsemide. I really feel there is something more going on here but doc isn't concerned... I personally have no rapport with this doctor and I don't know how he practices since he has very few pt's at my facility. I think the poor guy needs more of a work-up but doctor is apparently waiting for him to go into (if not already) CHF or have an MI.

What do you think?

ETA: I also want to mention that his heart sounds were muffled. Not necessarily 'adventitious' (if that can be used as a cardio term), just somewhat difficult to auscultate. Every patient sounds different and some people are harder to heart than others, I guess due to their anatomy. Then again, I don't have a super duper cardiologist stethoscope either.

[Penelope_Pitstop, BSN, RN]

I'm worried about that AAA blowing with those hypertensive episodes.

Also, methinks someone needs diuresis! How are his Renal Function labs? He may need dialysis. With the ARF, he probably isn't a candidate for heavy-duty lasix, but CHF is probably going to kill him quicker than renal failure.

The muffled heart sounds make me think immediately of a pericardial effusion. If that's the case, we don't want his pressure to drop too much. There's a very delicate balance there!

I'm not as worried about an MI in his case, but I think there are more than enough issues for some worry, that's for sure.

[ShannonRN2010, BSN, RN]

Oh I loooooove docs that don't listen! Be persistent....remember that you are your patients advocate, you have the knowledge that is screaming at you there is something wrong with this pt., so by all means, be persistent with this doc.

AND make sure that you are charting when you notify the doctor of pt. change in condition and the response (or lack of) he gives you.

And don't be afraid to say "Dr. Jones, I really think that we need to get a CXR/BNP/ect on Mr. AAA because of ______________"

I think this shows the doctor that your just not talking to hear yourself talk, but because you know there is something wrong.

[Cat_RN, ASN, BSN, RN]

I'm worried about that AAA blowing with those hypertensive episodes.

Also, methinks someone needs diuresis! How are his Renal Function labs? He may need dialysis. With the ARF, he probably isn't a candidate for heavy-duty lasix, but CHF is probably going to kill him quicker than renal failure.

The muffled heart sounds make me think immediately of a pericardial effusion. If that's the case, we don't want his pressure to drop too much. There's a very delicate balance there!

I'm not as worried about an MI in his case, but I think there are more than enough issues for some worry, that's for sure.

Renal labs are surprisingly not that bad. (I can't remember exact values). He voids as normal, goes several times in the night about 200 cc each time. Urine is pale yellow. Output WAS much less tonight than last come to think of it, but he still is voiding. BMP results should be in tonight. He is on sodium chl. QID, possibly to be d/c'd soon since his last level was 134. I don't think the excess is helping him now.

[SitcomNurse, BSN, MSN, EdD, RN]

Cat, are you in LTC or hospital? It can mean the difference between "doing" and "not doing"

I work LTC, and we run plenty of codes. So Im not trying to say 'all who of a certain age shoud receive lesser care." I dont believe that at all.

But another spin.. cresting 80 years of age, is there a hcp? poa? lw? did he make anything known in the hospital? DNR? Is family breathing down the backs of the staff to do something.. anything to keep him alive? or has the family accepted that this is his ending, and no extreme measures should be institued.

YES, there are alternatives that would and should be used, and you are knowledgeable enough, and resourceful enough to figure them out, if you dont already know the answers. But only if he or the family expressed a desire to do all of them.

Perhaps you could turn it on the doctor then, to be able to provide more comfort, because you know a B/P that high may cause headaches, as just the first symptom. The internal feeling of every cell in your body filling up with fluid and your skin being tight on the legs.... try non medicinal measures.. legs elevated over the heart(slightly) when in bed, if appropriate.

Sometimes the 'something' that can be done, is really 'nothing' that comes from a bottle.

[Cat_RN, ASN, BSN, RN]

Oh I loooooove docs that don't listen! Be persistent....remember that you are your patients advocate, you have the knowledge that is screaming at you there is something wrong with this pt., so by all means, be persistent with this doc.

AND make sure that you are charting when you notify the doctor of pt. change in condition and the response (or lack of) he gives you.

Oh, yes ma'am on the charting! Even though I'm more worried of his condition declining further in the meantime more than I'm worried about myself. I HATE when doctor's don't listen, most of the doc's here are GREAT and trust what you're telling them.. this also would not be the first or second time a doc has not heeded to what I've given him regarding a pt's situation/condition- when they should have, in hindsight at the end.

[Cat_RN, ASN, BSN, RN]

Cat, are you in LTC or hospital? It can mean the difference between "doing" and "not doing"

I work LTC, and we run plenty of codes. So Im not trying to say 'all who of a certain age shoud receive lesser care." I dont believe that at all.

But another spin.. cresting 80 years of age, is there a hcp? poa? lw? did he make anything known in the hospital? DNR? Is family breathing down the backs of the staff to do something.. anything to keep him alive? or has the family accepted that this is his ending, and no extreme measures should be institued.

YES, there are alternatives that would and should be used, and you are knowledgeable enough, and resourceful enough to figure them out, if you dont already know the answers. But only if he or the family expressed a desire to do all of them.

Perhaps you could turn it on the doctor then, to be able to provide more comfort, because you know a B/P that high may cause headaches, as just the first symptom. The internal feeling of every cell in your body filling up with fluid and your skin being tight on the legs.... try non medicinal measures.. legs elevated over the heart(slightly) when in bed, if appropriate.

Sometimes the 'something' that can be done, is really 'nothing' that comes from a bottle.

Well, he is in actually pretty good shape for his age, has no family (which saddens me), is a full code, no POA. He's here for rehab, to go home. He's alert and oriented, and VERY aware of his condition He is a very interesting, intelligent fellow who doesn't seem to have a soul in the world who cares about him. Sad really.. that's why it's MY job to do that, and in my (very) limited experience, I want to be sure trusting doctor is the most prudent thing to do here unless he doesn't improve soon.

[imintrouble, BSN, RN]

Some doctors think that nothing can happen at night that can't wait until the morning. Until he gets a call about a code.

[nurse12b]

so why are they not going to fix the AAA, you can't live long with one. I had a pt with a AAA and it was asending and desending and they had it fixed that night.

I know some Dr. don't want to try that hard when pt's get older, it's not you...

[Penelope_Pitstop, BSN, RN]

so why are they not going to fix the AAA, you can't live long with one. I had a pt with a AAA and it was asending and desending and they had it fixed that night.

I know some Dr. don't want to try that hard when pt's get older, it's not you...

Depending on the size and location of the AAA, it can be stable, especially with a well-controlled BP. Also, sometimes the risk of surgery is too much due to comorbidities.

[Scarlette Wings]

we use a form of report called sbar when we call the doctors that includes making recommendations. we call the doctors and tell them the pts situation, background, our assessment findings, and our recommendations. that is where we ask if we can do x,y.z tests and maybe get an xray and abg ekg etc. or i have many a time asked to transfer pts into icu. it helps politely but professionally guide the doctor into ordering the tests that needs doing and gives you the freedom to make suggestions. it works really well for us. and our doctors are not the most polite divas to do these verbal dances with hoping to get orders from. they even respond well.

[traumalover, RN]

Maybe he needs a high bp to perfuse renally since he already has issues with his kidneys. They may be worried anything long acting could drop his pressure for a period of time, and push him over the edge to complete failure requiring vascath and dialysis. Also, some triple AAA's are in a spot that is not operable. if he is already in renal failure, going on pump for an extended period of time could be disastrous. Obviously I don't know the patient, soo....just a few things to think about! Also, next time maybe get with a senior nurse or charge nurse and perhaps outline what they think needs to be done. That way if he doesn't seem worried, you can ask about a BNP, or X-ray, or CT. If he says no, simply say You are not sure why not, could he explain it. He will either explain himself, get annoyed and hang up, in which case he was probably annoyed at being called in the first place, or just order it. I have learned a lot from asking, but I also have half a butt since it's been chewed so many times