New RN - Wants to know when to wake up the doc

[suzem]

I am a new RN with limited experience. Out of desperation in this job market, I had to take a job in a LTC facility / rehab where I am all alone at night with 30 residents to care for, 3/4 of these are skilled! I am having so much trouble deciding when to call the on-call doctor at night when the situation is questionable, not an emergency situation. I will give an example...

PT is a few days to a week post-op. She has returned to the facility s/p open cholecystectomy. Her current problems include widespread edema (she has history of +1 edema to lower extremities, now she has +2 edema to BLLEs, +1 to arms, hands, and face.) VS are all stable except her O2 sats, which have been 88% RA, 92% 2L NC throughout the evening shift. Lungs are CTA, resident alert and oriented, little fatigued. C/O slight SOB when on RA. Resident states she really does not want to return to the hospital.

On my shift, while resident is asleep, her O2 sats are 84% on RA, 88-91% 2L O2. No other abnormals except for the edema and some slight upper respiratory congestion, presents with weak, moist, occasionally productive cough. Lungs remain CTA. Resident is not taking any additional pain medication.

Evening shift was unconcerned about her present condition, I was unsure if there was any correspondence with the MD, except that the records from the hospital were faxed over upon her readmit.

On-call doctor has history of not ordering anything at night, unless there is an emergency he will give order to send resident out to hospital.

What I did: Monitored the resident frequently throughout the night, assessing her orientation status and lungs several times, turned O2 up to 4L to keep her sats at 90-91%.

This is one of the many questionable situations that I face working NOC shift. I hate this because during the day you can contact the doctor for this and that, and you can get a hold of the doctor that is familiar with the resident.

What else could I have done? I didn't want to send the resident out to the hospital, and she kept reassuring me that she was fine and didn't see why I would consider sending her out. I guess I could have gotten an order for a nebulizer treatment or something?

Just want to know what any experienced nurses would typically do in this situation///:nurse:

BTW, the day shift nurse stated that there was no reason to wake the doctor for this situation, that the PCP had followed the client at the hospital and was aware of her current status, but how was I to know that?

[Katie5]

On my shift, while resident is asleep, her O2 sats are 84% on RA, 88-91% 2L O2. No other abnormals except for the edema and some slight upper respiratory congestion, presents with weak, moist, occasionally productive cough. Lungs remain CTA. Resident is not taking any additional pain medication.

quote]

Pain is controlled(seemingly). No other abnormals.then what do you want to wake the doc. up for?

PS- If the pt is crashing, no one will tell you when, you will jump(hopefully).

[classicdame, MSN, EdD]

I work in a hospital, not LTC, but I believe the purpose of the nurse is to assess for CHANGES in condition. If the changes indicate a near emergency you need to call. I would not practice medicine by determining what to do in those situations yourself. You need protocols approved by MD's that outline what can be done before calling 911. "Being aware" of the patient's situation is not the same as doing something about it.

[T.H.R.N.]

Hey suzem,

You are in a tough situation. It is so hard coming out of nursing school and being thrown in to these types of situations. You did all right. Sounds like this is her range for o2sats. Request a parameter range from the doctor and a prn for neb treatments and anything else in his bag of tricks. You can always call your DON or ADON for guidance. Ask questions of your previous shift nurses. That is the trick however isn't it. Afraid they are going to think less of you or that you don't know everything. We all have to learn... I hope you can find a nurse you feel comfortable with to ask. Hang in there it gets better. Be sure and follow your doctor's orders and check your facilities standing orders.

[canesdukegirl, BSN, RN]

Did the pt have an incentive spirometer? Had she been ambulating much? Is she in Semi-Fowler's position? Is she constantly in the bed, or is she up in a chair? Does she have SCDs on?

Post op pts need to ambulate. They need to clear their lungs with IS, or they run the risk of pneumonia. I would have encouraged IS, ambulating, and fluids to keep her peeing. I would have done all of this prior to turning up the O2. The resident is going to complain about how much she has to move around, but if you give pain meds 30m before ambulating, she should be fine.

If your pt had dropped her sats to the low 80s on 2L NC and she was becoming progressively edematous, I would have then alerted the MD. But you can use the above interventions first, and if that fails, then time to wake up the doc!

[Patchouli]

maybe this resident is a candidate for bipap or cpap. i would definately get some standing orders for nebs, and maybe see if physician needs to order overnight oximetry for this patient. i don't think ambulating her would be a good idea if she was really tired or dyspneic on exertion as you could exacerbate her condition. coughing and deep breathing are great, but won't work if your patient has a weak or poor cough. if sats continued to drop and her work of breathing or resps went up, or lung sounds changed, i would call as that signals that her condition is worsening. waiting for sats to drop into low 80s i would think would be waiting too long, unless your patient is a end stage copder and normally runs mid to upper 80s.

[Isabelle49]

Just curious, how long have you been out of school? How long was your orientation in LTC?

[guest358111]

I am a fairly new graduate (graduated in May). I worked as the only RN at night for about 5 months in LTC with about 80 residents, now I fill in as day and evening supervisor. I think that you monitored this patient fairly well.

I would just suggest a few things for the next time you get into a situation like this....some homework to do while you are trying to process the decision to call the Dr. I agree that the Dr. did not need to be called in this situation, but any little change in your 'data' and he might have had to been called. But here is a good game plan I think...

1)Make sure you look into the patient's history. Read the discharge summary from the hospital. The patient was around a week post op? Maybe she was running that level of 02 sat on discharge. 88 on 2L is ok...below 85 is concerning. You can always bump and recheck...but then again be careful bumping oxygen. Make sure you know your patient's diagnosis. For example, does she have COPD? If she does, you need to be careful how much you bump up the O2. I would start with 2 1/2 L...try 3L and see what the O2 sat does. Don't just go from 2L to 4L whiz bang boom. Check the 02 sat over time as you increase the O2.

2) You have to know what you need before you call the MD. Not always...sometimes it's ok to know that 'something' just isn't right. When in doubt, err on the side of caution. But if your data just doesn't plug into 'serious', at night...monitoring is the best bet. If she has a history of edema, a little more edema at night isn't anything to write home about, leave a note for the day supervisor and maybe they can get some Lasix from the MD in the am if it is warranted.

3)What is her DNR status? This sounds awful but, you said she was saying she didn't want to go to the hospital. She was talking, breathing, moving. She very well might know when her own body is 'going downhill' and when it isn't. If she is a full code, you might want to consider sending a person out more than someone who is a DNR. I don't mean that in a cruel way, but she does have the right to her own decisions.

If she is going to be congested, it is easy enough for the day supervisor to get an order for a neb treatment if needed at a later date-a neb treatment in the middle of the night might be needed for someone in serious respiratory distress, but even then, if they are that bad you probably will be sending them out.

This might have been a bit rambling and not made a whole lot of sense, :) but I think I could sum it up like this...

Know your patient's baseline before you make decisions about calling the MD. Look at their medical history, their discharge summary, notes from the shift before you, vitals from the shift before you. Plug that info into the data you have in front of you at the moment. Think about "what would I need from the MD if I call him?" Sometimes you don't even get the actual MD, you get the on call MD who might not know the patient at all, so you need to know what you need. I mean, you need a really good reason to call in the middle of the night, especially in LTC! Ask the opinion of some you are working with. Ask the patient if you can. After a while you will get a better handle on what to do when. Frankly, in my experience, sometimes the best thing to do at night in a nursing home is to not freak out about 'little' things like increased edema etc. unless of course it is REALLY serious. At night I worried about non- responsiveness, really low blood sugar (under 60), severe shortness of breath even after nebs and 02 with a history of COPD, crazy low blood pressure, a fall with a ton of blood that requires stitches, really high pulse rate, pain meds that didn't come from pharmacy and I need to give them from ER box and I needed an order for, and or but not all inclusive, death.

That is not everything, but my highlights of serious stuff to call the Dr. with at night. Other things can usually coast until morning.

But when in doubt, trust your nursing instinct. Even when you are new, trust me, that instinct is there. It just took me a little while before I understood what it was telling me!

[suzem]

Did the pt have an incentive spirometer? Had she been ambulating much? Is she in Semi-Fowler's position? Is she constantly in the bed, or is she up in a chair? Does she have SCDs on?

Post op pts need to ambulate. They need to clear their lungs with IS, or they run the risk of pneumonia. I would have encouraged IS, ambulating, and fluids to keep her peeing. I would have done all of this prior to turning up the O2. The resident is going to complain about how much she has to move around, but if you give pain meds 30m before ambulating, she should be fine.

If your pt had dropped her sats to the low 80s on 2L NC and she was becoming progressively edematous, I would have then alerted the MD. But you can use the above interventions first, and if that fails, then time to wake up the doc!

This patient was immobile prior to being hospitalized. She is totally bed bound.

[suzem]

Just curious, how long have you been out of school? How long was your orientation in LTC?

Out since June, 8 months, started working 2 months after graduation, had 3 days of orientation.

[caliotter3]

When in doubt, call the MD. You will be told if calling was inappropriate. If the DON does not want you to do so, she will have you call her and she will make the decision.

[canesdukegirl, BSN, RN]

This patient was immobile prior to being hospitalized. She is totally bed bound.

Ah. Another set of problems entirely. Can you sit her up? I would worry about pneumonia in an elderly fresh post op pt. Try to encourage her to do IS. This is soooo important.

BTW, I think you did everything right. You will get the gist of when to alert the MD and when you can try every intervention first. The important thing is to have all of the recent information in a concise and organized manner prior to calling the doc. Don't hesitate to rely on your seasoned co-workers for their opinions.

Another thing I would do if I were in your position would be to have a journal (without pt names) of the incidences you have encountered that you were doubtful about. Take this list to your NM and talk it out. He/she will give you some guidance. After you get a few more months under your belt, you will feel more confident in your assessment skills.

It takes time, but you will get it!