Nursing Home Chest Pain

[aloha57]

I am a 20y veteran of stepdown cardiac who now works in a nursing home by choice. I need help with a scenario. Resident presented with chest pain 7-8/10, non radiating,dyspnea on minimal exertion SBP 172 (far above pt norm. Resident has extensive cardiac hx (Aortic valve replacement, chronic afib with anticoagulation, AMI, angina) Nitro on hand 3 given with minimal relief. Order to call Dr if nitro does not relieve. Substitute supervisor did not want to call Dr until I showed him order to call. Then he said he would call after he spoke to DON @ 4a. Couldn't get in touch with her and wanted to wait for callback. I told him by order we were to call Dr. He said he would call and I told him I would since I was more acquainted with circumstances hx etc. By this time he's mad but allowed me to call at and ED after saying "she always does this' however resident has only been with us for

[CelticGoddess, BSN, RN]

Sometimes you just have to over ride the supervisor. I have had to do that in the past. (2 years of LTC experience).

I had a resident fall and hit his head. He lost consciousness for at least 15min and as I was unable to contact the MD (I didn't actually call, I had my orientee call), the admin was notified. She informed me that I was to go ahead and send pt out via med transport. I ignored the order and called 911. It's a good thing I did because said resident had a subdural hematoma.

I called 911 for chest pain, signs of stroke, or loss of consciousness, regardless of what admin said. IT was called covering your butt.

[MunoRN, RN]

Your supervisor doesn't work under your license, only you do. While a supervisor is free make suggestions about your professional practice, it's up to you to make your own decisions. That does sometimes put nurses in a pickle, since taking actions that are necessary to protect your license can also be considered insubordination, but in the end would you rather lose your job or your license. And more importantly, your first obligation isn't to your license but to your patient, an idiot supervisor comes in a distant third.

[Karou]

Your supervisor infuriates me. I hope you documented your attempts to communicate with her and the physician, and that she was the one who called the non emergency medical transport.

Chest pain are my two most dreaded words to hear from a patient. I have never had a pt with c/o CP have a true cardiac event... But we still work it up as one because it certainly could be. Anything less would be neglectful.

I would have asked my supervisor. "Okay to clarify you do NOT want me to call 911 for a patient complaining of chest pain unrelieved by nitro, who has a cardiac history and abnormal vital signs? Please tell me exactly so I can quote you and document why we are not calling 911."

In the future you can call 911 and feign confusion when she gets upset. Oh you wanted non emergency transport? I thought you said emergency. You could also ask the doc on the phone, "do you want me to call 911 for an ambulance?". And document that the doctor does. It might get you chewed out by the doctor but then if your supervisor refuses, she is going against what he said.