For other ED nurses out there, I don't mean any offense with this post. I'd rather vent here than take it out on someone who isn't even involved. I may have just bumped into a nurse with an awful day or something.
So I'm still in a LTC/SNF dealing with my patients at night we were overstaffed so we actually had a reduced patient load for once 29 instead of 38 to 40. I was so happy so I could catch up on paperwork. However about an hour and a half before my shift ends I have two patients acting up. Using ABC's I had to prioritize what patients had to be attended to first.
One is a patient with respiratory issues with audible crackles when breathing that basically with lower level of consciousness and lethargy. Pulse ox was 82 and even with the rebreather it did not improve so I arranged to get the patient sent out. I gave report to one of the ED nurses and she asked me what the blood sugar was. I said I didn't take a blood sugar because it didn't occur to me since the patient had audible crackles and a non improving pulse ox. She proceeds to go off on me: "It's standard procedure! Are you new or something? We'll be waiting for the patient"
The second one was complaining of chills and had a temp of 101.5, so I gave him the existing order of tylenol for fever orally and told him to call me if he feels worse. An hour later I took his temp and it went up to 103 so I paged the doctor. The doctor asked how his wound packing drainage looked like, I come to see the patient and I see the patient is in the bathroom looking as if trying to vomit. I tell the doctor about the new onset of nausea and attempted vomiting. Doctor orders to be sent to the ER. I have to call yet again to the ED for report. Sadly it's the same charge nurse I explain the situation and this time she decides to blast me again: "What is it with you people? Don't you understand oral tylenol won't work in older patients. Next time do a suppository first before calling, not even worth sending him at this point." *I explain the doctor ordered the patient being sent out* "You should have still done the suppository, still does not change things. You nursing home nurses are something else."
Seriously, I've been working for less than a year and these are the first two patients I ever had to send out. Was I in the wrong in my actions? I wanted to lash out at the nurse for being an ass but I was seriously too busy trying to help my patients out. Giving a suppository to a patient who is alert and oriented as well as able to swallow pills did not occur to me anyway.
If my patients don't get admitted, I'll be happy to take the writeup from administration for wasting time waking up doctors, clocking out 15 minutes late, and ******* of the ED at the affiliated hospital. I thought I made the right choice sending them out. But to be put down by another nurse, I can see why a lot of my classmates have switched careers already.
Wow, it's sad that you were treated so poorly. Good job focusing on what the actual problem was.
Pulse ox was 82 and even with the rebreather it did not improve so I arranged to get the patient sent out.
I don't want to be "that guy," but what was the flow rate for the O2 and was the bag on the nonrebreather inflated? That low of a sat on a nonrebreather is certainly an emergency that warrants aggressive intervention, which in a LTC place would include prompt transfer out.
What exactly is the "line of reasoning" you are accusing me of? Don't put words in my mouth. Are you having a bad day? I hope it gets better for you. I am starting to wonder if you are the nurse the OP encountered on the phone today. You don't have to like the reason the doc sent you the patient. You are blaming the nurse for the MDs decision. You do see that, right? I understand the logic just fine, thank you. You are the one that seems confused by it. Are you suggesting this nurse ignore the MDs order to send out the patient? Whatever for?
Its our job as nurses to make sure the patients are getting appropriate care and to advocate for the patients. If you do not know or do not understand the logic behind the transfer, you shouldn't bother calling report because you can not offer any insight, just information out of context. If we followed your line of reasoning, we would be cocktail waitresses handing out pills and medications without stopping to check WHY the patient is getting this. Waitressing doesn't require a license. Mistakes happen and people who aren't present don't always think clearly. It is our job to shed light on it for the MD.
And for the record, the staffing at the SNF is not my fault either and not my problem. The law allows for these folks to be dumped on us because you aren't staffed for it and I can't wait till that changes. As for the lawsuit, I am not dignifying that with a response. Defensive medicine and nursing are not in the best interest of the patient, the system or society and have no place in decision making. I consider those practitioners who think like that to be sadly misinformed (I was a paralegal for five years) and not confident in their skills.
Will add: I specifically refer to the fever. As for the low O2 sat, I don't know the hx there but I am a little suspicious that this problem was either avoidable or a part of a bigger picture for the patient that with a little prevention (nebs, lasix, who knows?) could have been avoided but I was assuming OP had already tried coughing, all medications available, and that the patient looked distressed.
What exactly is the "line of reasoning" you are accusing me of? Don't put words in my mouth. Are you having a bad day? I hope it gets better for you. I am starting to wonder if you are the nurse the OP encountered on the phone today. You don't have to like the reason the doc sent you the patient. You are blaming the nurse for the MDs decision. You do see that, right? I understand the logic just fine, thank you. You are the one that seems confused by it. Are you suggesting this nurse ignore the MDs order to send out the patient? Whatever for?
I am never rude to anyone who calls report. I am not personally seeing the patient at that time and I don't want to judge just because someone left something out of the report or because their skills limit their perspective (ie they don't work in emergency care and don't know that this is pointless.)
The line of reasoning that you use suggests that if you call the MD and he or she says send the patient out, you do so regardless of your own input into the situation or whether or not you think that's appropriate. Transferring a patient because "the MD wanted to" is the same as administering a medication "because the MD ordered it." This is not the job description. It is intended for the nurse to make judgment and advocate for the patient.
I am blaming the nurse for refusing to take any responsibility for it. Instead of saying, "The patient looks and sounds distressed." She says, "The MD ordered it and I am following orders." as though she is a mindless automaton.
I never said the argument was illogical. Its perfectly logical and perfectly bad at the same time.
I am suggesting that the nurse advise the MD, "Hey, I hear what you are saying but this patient has a fever that I think we could try medicating with something else and have her visited by primary care tomorrow (note its a night nurse)" INSTEAD of just, "OK, whatever you say doc." when she thinks it isn't the best choice for the patient. (and IF she thinks so.)
IF she doesn't think its wrong, then don't complain to the ER nurse that "The MD ordered it."
To answer your "whatever for?" question, the answer is because as an RN you have hardly begun to try and treat the fever and have many many options other than transferring the patient to an area that is intended for LIFE SAVING MEDICAL CARE and not primary care. FURTHER, and entirely more relevantly, I would seek to avoid the actual order. IF your stuck with it, you're stuck with it and just say so. Say, "I think this patient is probably ok but the MD is just some loser worried about his license more than the patient."
BUT for goodness sakes, don't hide behind the MD. you can make an assessment, I know you can.
That is some pretty big leaps and assumptions you are making there! Is this how the conversations take place in your head? Taking quite a bit out of context. You know you should never assume.......
I am never rude to anyone who calls report. I am not personally seeing the patient at that time and I don't want to judge just because someone left something out of the report or because their skills limit their perspective (ie they don't work in emergency care and don't know that this is pointless.)
The line of reasoning that you use suggests that if you call the MD and he or she says send the patient out, you do so regardless of your own input into the situation or whether or not you think that's appropriate. Transferring a patient because "the MD wanted to" is the same as administering a medication "because the MD ordered it." This is not the job description. It is intended for the nurse to make judgment and advocate for the patient.
I am blaming the nurse for refusing to take any responsibility for it. Instead of saying, "The patient looks and sounds distressed." She says, "The MD ordered it and I am following orders." as though she is a mindless automaton.
I never said the arugment was illogical. Its perfectly logical and perfectly bad at the same time.
I am suggesting that the nurse advice the MD, "Hey, I hear what you are saying but this patient has a fever that I think we could try medicating with something else and have her visited by primary care tomorrow (note its a night nurse)" INSTEAD of just, "OK, whatever you say doc." when she thinks it isn't the best choice for the patient. (and IF she thinks so.)
IF she doesn't think its wrong, then don't complain to the ER nurse that "The MD ordered it."
To answer your "whatever for?" question, the answer is because as an RN you have hardly begun to try and treat the fever and have many many options other than transferring the patient to an area that is intended for LIFE SAVING MEDICAL CARE and not primary care. FURTHER, and entirely more relevantly, I would see to avoid the actual order. IF your stuck with it, you're stuck with it and just say so. Say, "I think this patient is probably ok but the MD is just some loser worried about his license more than the patient."
BUT for goodness sakes, don't hide behind the MD. you can make an assessment, I know you can.
I am suggesting that the nurse advise the MD, "Hey, I hear what you are saying but this patient has a fever that I think we could try medicating with something else and have her visited by primary care tomorrow
You don't know what you don't know. A little understanding from both sides goes a long way. Our Drs are required by law to only visit every 30 days if they are receiving skilled care. If they are a long term care resident, the Dr is only required to visit every 60 days. Trust me..they do not come just because we tell them too. This is part of the reason they will insist on having them sent out. I had a conversation very recently with an MD who informed me he only gets about $20 reimbursement for seeing a LTC resident. His words "Why would I come see them in LTC when I can work in my office or in the ER and make a whole lot more".
And yes, I am required by law to do what the MD says if he/she instructs me to send to the ER. I have been doing this job 5 times longer then you were a paralegal.
Actually, I agree with you for the most part - (just not sure I agree where you are choosing to place the blame). The system sucks. Many, many, many times I'm begging the Dr to keep them on site. I try my best to educate families on disease process and the dying process (because they are calling the Dr on their own and asking Dr to send out 96 year old Mom w/ hx of 5 CVA's and failure to thrive dx). These people don't always listen to us...and then in the process of just doing our job we get yelled at by another nurse too.
Specializes in Geriatrics, Hospice, Palliative Care.
As someone else said, SNFs are not for the faint of heart; you have many patients to take care of, and you don't have the equipment and staff to get the dx quickly like you do in a hospital. I think that a SNF is a great place for a new nurse to learn assessment, prioritization, and time management, assuming that you are fortunate enough to find a decent SNF.
Sounds like you did great with your care for these patients; I didn't know about oral vs rectal tylenol - would love so see the EPB for that - but agree with others to always get a blood sugar.
e
I talked to my mom as she is a seasoned nurse about the situation and told me: "Your intentions were right so do not feel bad, you probably should have done the blood sugar. I have to get you out of that place, I'm scared if you finally get the hospital job you might forget some basics."
I do fear though my skills are degrading in that place.
Specializes in Certified Med/Surg tele, and other stuff.
If it comes down to annoying an ED nurse or losing my license because granny suddenly went south and could not be saved, I would rather err on the side of caution and annoy the ED nurse and have the patient taken to the ED.
I think she must have just had suppositories on her brain because it sounds like she had a stick up her rectum.
Add me to the list of the stupid. All that time working in LTC facilities and no one ever told me oral tylenol did not work on old people, use suppositories instead. I wonder where it says that and why the order wasn't written that way to begin with? I guess I'm really, really stupid.
Specializes in LTC, assisted living, med-surg, psych.
I was thinking the same thing, caliotter. I've worked with elderly folks for 17 years and this is the first time I've ever heard that PO APAP doesn't reduce fever in them. Wonder why their temp is so often down an hour or two after I've given it??
vicedrn, I know you're upset with the sytem, but it's not LTC nurses that created it. And your posts sound like you're blaming the LTC nurses, whether or not you mean to be or whether or not you're rude to a LTC nurse giving report.
LTC MDs are going to send to the ED. We can want them to direct admit to the floor. We can want the LTC nurses to have the resources to do most of the care that would turn these patients around at the LTC. But until then, the system is what the system is.
.thumb.gif.a0171653eaae518ecf728198d692fc48.gif){kind=avatar}
Perpetual Student
682 Posts
Wow, it's sad that you were treated so poorly. Good job focusing on what the actual problem was.
I don't want to be "that guy," but what was the flow rate for the O2 and was the bag on the nonrebreather inflated? That low of a sat on a nonrebreather is certainly an emergency that warrants aggressive intervention, which in a LTC place would include prompt transfer out.