Would you send this patient to the unit? - page 2

Patient gets sent to me after getting report and learning that she was dehydrated with acute kidney injury. Vitals stable, but labs were a little off. Ok so the patients slow but she's a&o. Within... Read More

  1. by   annmariern
    I once got report from another unit for a transfer. 35 year old woman, came from the Er went unresponsive a couple of hours ago........what? Stop right there? She came in A/O x 3 and now shes unresponsive and your sending her to another med/surg floor because we have tele? I have had several ED pts come and immediately had to call to go to ICU. Several PACU pts come and found mysteriously their BP bottomed out on the ride up, their temps at 95, or hypoxic and needing to be vented. Not just your hospital. And yes, it is scary.
  2. by   MunoRN
    Part of what I do as a rapid response nurse is help make sure patients are going to the right floor out of the ED. The biggest issue I would have had with this patient going to floor, even a monitored one, would have been the sodium. I would have asked that the ED send another set of labs prior to bed assignment, since that initial sodium of 120 is a borderline ICU-admission-required value. Far more important though is the trend. Getting a second set of labs does far more than just double the amount of data you have, it increases it exponentially since it adds something you didn't have before; trajectory. With a follow up sodium of 109 that's a pretty straightforward ICU/SD admission.
  3. by   0.adamantite
    Quote from MunoRN
    With a follow up sodium of 109 that's a pretty straightforward ICU/SD admission.
    I agree. This patient is at risk for seizures with a sodium that low. Also, a K of 2.4 is very low.

    However, I work on an un-monitored floor so I have a few "dumb" questions.
    How could the patient have a K of 2.4 with a Cr so high?

    Of note, I have seen patients with a high Cr have bad reactions to meds built up in their system due to the inability of their kidneys to clear them.
  4. by   Anna Flaxis
    Quote from Birdy2
    Well I'm not sure but I get confused trying to make sense of the labs. Sodium would be high if she were dehydrated which she was. And yes, potassium would be high with renal failure.
    Is she on diuretics, has she had diarrhea, or does she have some sort of intestinal malapsorbtion problem?

    Couldn't the BUN/Cr be a result of dehydration?
    The BUN/Cr ratio suggests an intrarenal cause, such as nephrotoxic medications or a systemic illness.

    Is the patient on diuretics, SSRIs, antibiotics, or receiving cancer chemotherapy (tumor lysis syndrome)?

    It could be that the fib/flutter isn't new for her.

    As described, I agree with you this patient needs closer monitoring than can be realistically provided on the general medical unit.

    Is there anything more to this picture that might have made a difference as far as bed placement decision? For example, what was her code status, and did she want aggressive intervention?
    Last edit by Anna Flaxis on Apr 6, '15
  5. by   NurseLexx
    Definitely!! You must work at my hospital. We get these types of patients on the floor often!
  6. by   Dazglue
    We get these kind of patients on our floor and I work in a skilled nursing facility. I'm constantly fighting with our house supervisor and admission coordinator when we get patients like this.
  7. by   whofan
    If the patient is alert and oriented and all vss are stable then no, but patient should definitely be on a step-down unit.
  8. by   rumwynnieRN
    To answer your question about ICU-type pts being sent to the floor, the answer is yes, we've had that problem. It's easier now to make sure we don't get them with EPIC. I have mixed feelings about the ER not even bothering to call report (we have a program now where we want the critical care and ER nurses to shadow the floor nurses for a shift because some of them where I work don't think we do anything) because they have sent us patients who are most definitely not appropriate for our floor. They assume we will have looked up the patient and send them -- room isn't ready and the nurse doesn't even know he/she's getting a patient.

    Bed file has decided in the past that (I work on a med surg floor -- we are ENT/Eye/Urology mostly) we can take insane traumas because we deal with trachs and chest tubes. As in traumas that are by no means stable (BPs 60/40, insane blood loss, requires closer cardiac monitoring than what we can provide).

    Last Saturday, they tried to send us a patient who was dx-ed with sepsis. It's a good thing I looked because the pt was definitely not hemodynamically stable (BP was trending down from 111/80 to 80/60 to 75/51), and no, the ER would not have called report.

    We also don't have negative pressure rooms, and when they don't call report, we end up taking pts who have active TB or shingles or chickenpox. x.x; We have to notify the supervisor immediately and get them moved to a floor with negative pressure rooms.
  9. by   loveu123
    I think this patient is appropriate for a step down unit but I guess it will also depend on what type of hospital you work at. When I worked surgical unit in a busy, teaching hospital we did get this kind of patients on the floor. As an ER nurse, I would have definitely had the patient on a monitor and also asked for more potassium. I am also wanted to point to the fact that though patient arrived at a certain time, he may not have been by nurse till hours later. It's unfortunate that you have to care for him in addition to your other patients but that is becoming the reality these days. Your admitting doctor should not also have accepted the patient if it is not an appropriate admission for your unit. We sometimes have to have about 5 patients including intubated ICU patients and ambulances do come in non stop especially in Level 1 trauma centers and that is why we have to send the patients to the floor asap. This is the reason why most nurses are leaving the bedside. I understand how you feel because I have worked in different specialties but it is just unfortunate the way nursing is becoming these days.
  10. by   Twinmom06
    I work step down and we are 5:1...I actually admitted a patient the other night with a Na+ of 112 - we just put up the seizure pads and had fluids running - by the time we transferred him to med surge he was up to 130.

    The K+ of 2.4 would be more concerning (to me anyway) - especially since they only gave 40 mEQ of PO replacement. In my hospital that would buy you at least 4 K+ riders.
  11. by   MissM.RN
    OP, you should be thanked for your advocacy and getting this pt to the unit where they belong. As a charge RN, I would simply not accept this patient to my unit, not assign a bed or nurse, and maybe even file a union "unsafe staffing" report.
  12. by   eukaryote
    Our floor also accepts these types of medical patients as our hospital doesn't have a step down. The floor I work on hyponatremia is often managed (SIADH, etc..) I admitted a patient this weekend with a Na+ of 113, K and low Mag...can't remember what it was. These patients have to be managed closely, but as long as they are otherwise stable and assigned to an experienced RN, I would not send to the unit.
    Last edit by eukaryote on Apr 7, '15
  13. by   SierraBravo
    Quote from Twinmom06
    I work step down and we are 5:1...I actually admitted a patient the other night with a Na+ of 112 - we just put up the seizure pads and had fluids running - by the time we transferred him to med surge he was up to 130.

    The K+ of 2.4 would be more concerning (to me anyway) - especially since they only gave 40 mEQ of PO replacement. In my hospital that would buy you at least 4 K+ riders.
    A K of 2.4 is most definitely concerning, but there is no way I would be pumping in 4 runs of K on top of the 40meq that the patient got orally with a SCr of almost 12. Keep in mind, giving IV K can worsen the patient's SCr so you want to cautiously replete electrolytes in patients with renal failure. The 40meq of PO K was appropriate and I would have done a repeat CMP a couple of hours after that administration to recheck electrolytes. With renal failure, the patient's K will often times increase more than if you gave someone with a normal SCr that same amount of K. Typically, 10meq or 20meq will raise the serum K by 0.1 and 0.2, respectively, in a patient with normal renal function. However, I have seen a patient with a SCr close to this patient's SCr get 40meq of K and it bumped up her serum K by 0.9 (as opposed to the expected 0.4). Since the SCr is so high, they likely won't be producing much urine (if at all). Yes, you have to worry about arrythymias, but you also don't want to overshoot and then have to deal with a critically high K. This is why a renal consult should have been called immediately.

    I would have also asked for a VBG or an ABG because the patient is clearly acidotic. Metabolic acidosis can cause electrolyte disturbances. So correcting the acidosis could also help correct some of the electrolyte abnormalities.

    The other thing to consider is that you want to correct the sodium slowly so as to not cause any cerebral edema.

    I also agree with the PP that said a repeat set of labs should have been drawn immediately as there could have been a problem with how they were drawn or a lab error. You don't want to go correcting a K of 2.4 if in fact is was actually 5.4.

    This patient would have been appropriate for the floor only if the nurse taking him was very experienced. Otherwise, a step down unit would have been the right place for him since he would likely require frequent labs and electrolyte replacement as well as close monitoring.

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