New Nurse, when to send a patient out.

tokmom, BSN, RN · Jan 27, 2012

To some people that have a high baseline, that would be low. I read your update, so good for you. I think I would have asked for an amp of D50 to see if she would have perked up a bit. Granted, it would have been only a band aid, but wouldn't have been interesting to see if she would have responded. Anyway, You have to fix the cause of the lower levels, so sending her out was the right thing to do. Your dr is probably munching on crow.

Just for the record, you will become more confident, but even season nurses will second guess themselves at sometime.

GitanoRN, BSN, MSN, RN · Jan 27, 2012

i mentioned to him that she was becoming lethargic and not herself. he snapped at me that her sugar wasn't low enough to cause these symptoms. then i mentioned to him that she usually runs around 200-250 so that is low for her. then he snaps "well then send her out if you want" end of quote.

first of all i would like to applaud you for your efforts :yeah: in addition, over the years of my career in nursing, i learned that in order to get what you need for your pt. is not only to inform a doctor of a problem. however, also you have to present the solution to them; and suggested it, in a manner that makes them think that they came up with the solution themselves. trust me i know it sounds like we are playing to their ego, but we have to think was best for our patients. lastly, i'm certain he has had time to rethink his actions regarding this incident, and also your don although, don't expect a thank you note, you will get those from us nurses~ great job!!!!

mazy · Jan 27, 2012

A good idea is to read the hospital summary. Did they do anything there that you couldn't have done?

This is a very good suggestion. I always do that when a patient comes back from the hospital. Because then you can see how what you assessed was diagnosed and treated, and that is more information you can store in your bank of assessment skills when similar issues come up in the future.

And it's also helpful sometimes to see in the hospital report that what you thought was going on was actually going on.

CoffeeRTC, BSN, RN · Jan 27, 2012

We have a program in place that is to prevent the hospital transfers. At first I was a bit miffed with it. It seems like it took the critical thinking part out of nursing BUT it really is a good program for newer nurses or nurses that don't do LTC and would just send the resident to the ER.

With time and practice, situations like these will become easier. Sometimes the dx that you get for admit are blanket ones....seems like just about everyone gets a DX of dehydration and UTI even when I sent them out for cardiac arrest and was doing CPR on them....Haha but it is for real!

Other things you could have done was try to get some food (carb/ protein in her) what about the other vitals? What about UTI? When you get a resident with the low blood sugars (or really high ones) try to figure out what was causing it in the first place.

We have a rather unstable resident with resp problems, IV antibiotics, tube feed...had a really low blood sugar..nurse was getting ready to send her out turns out the tube feed was turned off for hrs and this person got hs coverage and a huge dose of Lantus.

Aem1215 · Jan 31, 2012

Don't sweat too much. You did the right thing or the resident wouldn't have been admitted to the hospital. Speaking from the point of view of a DNS who has been working for a long time in LTC, sometimes we can see things in hindsight that maybe could have been taken care of in house as opposed to the hospital. That doesn't mean you did anything wrong. Also, don't let a cranky doctor get to you too much. I had a doctor scream and swear at me on the phone once because I didn't call him and report a change in condition before a resident of his died. He ranted and screamed and berated me for a good twenty minutes before he told me to tell him everything that had happened since the previous nurse had called him with the initial change. So I told him about how I gave the resident morphine as ordered, called in his family, and the hospice nurse, who were at the resident's bedside when he passed. Response from the MD: " Oh, I forgot he was hospice." Click. Egos are common. Don't let it get you down.

pnurse68 · Feb 1, 2012

Also might be helpful for you to request the diagnostic testing from the hospital that supports the admitting diagnosis. They sometimes add diagnosis that are questionable. Such as dehydration but the BUN/Creat dont support that dx, or impaction but never did a flat plate.

Even when the diagnostic testing supports the diagnosis, reviewing those labs and comparing with her baseline and medical history is a great way to learn. I found it helpful when I could attach lab values and such to a face and a circumstance. So much different than memorizing book stuff.

Long Term Care Columnist / Guide · Feb 2, 2012

I have one rule when it comes to resident emergencies: When in doubt---ship 'em out!! :redlight:

Unless, of course, the resident is a DNR/DNI/Do Not Transport (or do anything except comfort measures), we'll at least call the paramedics and let them evaluate the need to transfer to hospital. Often they simply treat at the scene, e.g. give an amp of D50 for a hypoglycemic episode, but again, when in doubt........It's when they decide that they will not transport and the resident isn't really stable enough to be safely cared for in an assisted living environment that things get sticky, but that's a story for a different day. :)

beatrice1 · Feb 2, 2012

*michelle126, is the program you are rerering to Interact? funny thing is we had a meeting about this the day before i sent this woman out! However, we were not implementing it at this time yet, still waiting for all the information and tools

Bea

mparker · Feb 3, 2012

Always Always Always CYA Cover your ass. Documentation is so Important. You know what even old nurses keep learning. It is an ongoing every day process. When you stop learning you stop growing, stop improving your nursing skills.

pomegranate · Feb 4, 2012

I have been on the floor as an LVN in a LTC/SNF a little less than a year, this would've been my thought process if it were me:

77 isn't that low, but with these people who have long-standing norms in the 200s, it is unusual. The other VS were ok? With new or increased confusion in the elderly, what I've learned is you always want to check for a possible UTI, dehydration, or pneumonia. These are the biggies that cause changes in condition imo that can be treated without absolutely requiring a return to acute care. Part of SBAR is the recommendation/request at the end. So in this case, if I had been you, I would have requested for a stat* CBC, BMP, UA with C+S, and to monitor VS including FSBS (I would get an order for VS even despite it being a nsg action, so you have a means to document it in the MAR/wherever you document that kind of thing, and to ensure that there's continuity, so next shift doesn't just blow it off.)

Those 3 tests will give you a wealth of information, and monitoring the VS will give you a means to make sure the resident isn't going downhill while you're waiting for them to come back. In your resident the BMP would've most likely shown elevated creatinine or BUN, when the UA came back it would've shown whether they had an infection or other abnormalities associated with renal failure, the CBC for the WBC count (and just to rule out any new onset of anemia or any other crazy thing.) Depending on the doctor they might also order some extra things like an anemia workup, CRP, D-dimer, etc...but usually they will wait for the results of the first round of tests to do that, unless for some reason they suspect another cause.

I have to say your doctor sounds pretty rude. Ours were impatient with me at first when I was brand new because I was so nervous and I didn't know anything. But as time goes on, I have learned some things; I still feel stupid half the time calling them, though. Make sure you always have a copy of the updated chart/MAR, recent labs, VS, and think out what you are going to say before calling! I write a list of things to report, that way I don't forget any, because I get flustered on the phone (esp with some of our 'nicer' doctors.)

Saying she seems a little more lethargic than usual is going to frustrate some types of doctors because that varies from person to person, you saying that could mean that she's just having an off day, nurse xyz saying that could mean that the patient is halfway to comatose. know what i mean? however, most doctors will take your word for this kind of thing because you know (or will get to know) the patient much better than they do half the time, especially when it comes to how they behave on a daily basis.

I know this post is long, hope it helps a bit.

*I say this because our lab comes within a couple hours to draw the stats and we get the results pretty soon after that, these may not work for you if your lab only comes in the AM or whatever.

beatrice1 · Feb 6, 2012

I have been on the floor as an LVN in a LTC/SNF a little less than a year, this would've been my thought process if it were me:
77 isn't that low, but with these people who have long-standing norms in the 200s, it is unusual. The other VS were ok? With new or increased confusion in the elderly, what I've learned is you always want to check for a possible UTI, dehydration, or pneumonia. These are the biggies that cause changes in condition imo that can be treated without absolutely requiring a return to acute care. Part of SBAR is the recommendation/request at the end. So in this case, if I had been you, I would have requested for a stat* CBC, BMP, UA with C+S, and to monitor VS including FSBS (I would get an order for VS even despite it being a nsg action, so you have a means to document it in the MAR/wherever you document that kind of thing, and to ensure that there's continuity, so next shift doesn't just blow it off.)
Those 3 tests will give you a wealth of information, and monitoring the VS will give you a means to make sure the resident isn't going downhill while you're waiting for them to come back. In your resident the BMP would've most likely shown elevated creatinine or BUN, when the UA came back it would've shown whether they had an infection or other abnormalities associated with renal failure, the CBC for the WBC count (and just to rule out any new onset of anemia or any other crazy thing.) Depending on the doctor they might also order some extra things like an anemia workup, CRP, D-dimer, etc...but usually they will wait for the results of the first round of tests to do that, unless for some reason they suspect another cause.
I have to say your doctor sounds pretty rude. Ours were impatient with me at first when I was brand new because I was so nervous and I didn't know anything. But as time goes on, I have learned some things; I still feel stupid half the time calling them, though. Make sure you always have a copy of the updated chart/MAR, recent labs, VS, and think out what you are going to say before calling! I write a list of things to report, that way I don't forget any, because I get flustered on the phone (esp with some of our 'nicer' doctors.)
Saying she seems a little more lethargic than usual is going to frustrate some types of doctors because that varies from person to person, you saying that could mean that she's just having an off day, nurse xyz saying that could mean that the patient is halfway to comatose. know what i mean? however, most doctors will take your word for this kind of thing because you know (or will get to know) the patient much better than they do half the time, especially when it comes to how they behave on a daily basis.
I know this post is long, hope it helps a bit.
*I say this because our lab comes within a couple hours to draw the stats and we get the results pretty soon after that, these may not work for you if your lab only comes in the AM or whatever.

Pomegranate, Thank you for the very infomative response... It was very helpful to remind me of the way I need to start thinking. I am still so new at this and can't wait till the day that critical thinking comes naturally. It's so much easier after I lookback or someone helps explains things like this.

Thanks again.

Bea