Would you send this patient to the unit?

Nurses Safety

Published

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 30 minutes new labs came back. BUN 112, Cr 11.7, Ca 6.6, K 2.4, Na 109, C02 13. I had orders to give her NS @ 100, 40 PO K, and really nothing else. The K, Ca, and Na were low before, but not that bad. I think Na was 120 in the ED. The patient had been in the ED since 5pm. She came to me at 10:30 pm. No consults had been called in that the ED dr had ordered when he saw the patient. There was a renal and cardio. So at 11:30 when the patients labs are called to me Im calling and waking up someone when they don't even know the patient. I got orders to transfer the patient to the SICU, but I had to fight with the supervisor for that bed. I don't understand why that patient was ever sent to my floor.

I get that we were out of beds and not enough nurses, but the paitient could have started having seizures and died while I was helping one of my other 5 patients. It just worries me that they're sending people to our floor like this and then we end up having to transfer patients all night. I just wonder if this is normal and happening other places. Sure is scary.

Specializes in progressive care, med-surge.

Should have gone to the ICU from the ED.

Some people are saying things like, "If the vitals are stable and pt is a+o x 3, they should be OK on a step down unit."

What? If those numbers are accurate, there is no way she should be on a step down unit. She needs a central line, tele, 3% sodium drip, frequent lab draws (like q2h?) - all of which can technically be done on a step-down unit if you have a nurse that can be 1:1 with that patient for a while, but the CRAZY labs force her into ICU territory. One person said, "if the floor RN is experienced, the patient could be on the floor." Seriously?

This is obviously an ICU patient and thank G-d you were able to get her there!! Hopefully your charge RN was there to back you up.

It really bums me out when nurses say things like, "And I had to wake up the doctor at 11:30 PM." The doctor is on call. So he or she should expect to be woken up if there is an emergency. I would like to go further and suggest that non-teaching hospitals have a noc hospitalist covering the attendings. I work a teaching hospital; all of our docs (with few exceptions like ENT, URO, etc) are on call in-house. I wonder how often nurses are too intimidated to call a physician at night making the patient's condition suffer.

Good job! You got the patient to the right place!!

Specializes in progressive care, med-surge.

Where do you have 12 patients on the floor, some with vents? I will stay away from that state/hospital if I ever get sick! That sounds like the most unsafe place EVER.

Personally, the first thing I thought of when I saw those labs was rhabomylosis.

Interesting thought, but wouldn't the K+ be elevated in rhabdo?

Specializes in Emergency, Telemetry, Transplant.

In my hospital, based on the initial Na they would have gone to a floor (likely telemetry). Na of 109 would almost certainly go to an ICU. Also, if the pt has a H/O A fib, they may not be on a monitor in the ED, but a 12 lead was probably done (especially given the electrolyte abnormalities).

This is not really directed at the OP, but to everyone--I have seen comments of "I [the nurse] would send them to the ICU." Does an RN at your hospital have the authority to send someone to the ICU? At my current hospital and at my previous job, only the critical care medicine doc could "authorize" an admission/transfer to the ICU. This is done to prevent the "overuse" of the ICU by overly cautious doc (and the cynic may say to prevent sending patients to the ICU to increase one's bottom line.) ICU beds are usually much tighter than telemetry beds, so this is why the hospital "protects" them. Someone might say, "just call an RRT." Well, part of the team is the critical care doc. He/she would still have to approve transfer, and just because an RRT was caused, this does not mean that the doc has to accept them to the ICU. Anyway, just curious how it works at other hospitals.

Specializes in Cardiology.
And it is absolutely a great idea for floor nurses to spend a week or two in the ED so that you can understand the stress levels are extremely high compared to the floor. Nothing like walking into a room expecting to come back and see your pt. and they are already gone upstairs.

And I think every ER nurse should spend some time as a floor nurse as well. The ER isn't the only high stress area in the hospital.

Specializes in Emergency, Telemetry, Transplant.
She needs a central line, tele, 3% sodium drip, frequent lab draws (like q2h?)

Whoa! Hypertonic saline is reserved for the worst of hyponatremia cases. What about a fluid restriction…maybe some salt tabs. Hypertonic NaCl has some pretty serious side effects, which is why it is a last resort. While we don't know everything about this pt's situation, it sounds like he/she is not in last resort territory yet. More conservative measures need to be tried first before we skip to the 3% saline.

Specializes in Critical Care.
Whoa! Hypertonic saline is reserved for the worst of hyponatremia cases. What about a fluid restriction…maybe some salt tabs. Hypertonic NaCl has some pretty serious side effects, which is why it is a last resort. While we don't know everything about this pt's situation, it sounds like he/she is not in last resort territory yet. More conservative measures need to be tried first before we skip to the 3% saline.

A sodium level of 109, particularly a drop to 109 from 120 in 5 hours, in my experience is well into the territory that suggests the need for 3% and very close serial monitoring of sodium levels. Fluid restrictions and increasing PO salt intake is fine for 125, maybe even 120 if the level is stable or rising, but 109 with a downward trend indicates the need for more aggressive care.

Specializes in med/surg/tele/neuro/rehab/corrections.

Yes it happens in my hospital too. :( They are in a rush in the ED to make room and send patients up to telemetry. But those labs are the scariest I've ever seen! Good job advocating for the patient!

Specializes in CVICU.
And I think every ER nurse should spend some time as a floor nurse as well. The ER isn't the only high stress area in the hospital.

I agree ED nurses should spend time on the floor…..but most have. The floor is 90% stressful because of task completion, not acuity.

I have worked the floor (med-surg-teley), ED, & ICU. I respect all nurses, but each one has different priorities. ED and ICU =critical care.

I would've sent the patient. The ER nurse does not admit patients so it's not up to us whether the patient goes to a specific floor or not. Of course the labs are going to be off, the patient had acute kidney injury so that's expected. One thing RN's that don't work in the ER do not understand is while they may have 5 medical patients, ER nurses (especially the ER I work in) usually have 4-5 patient's with at least 2-3 of those patients being a level 1 trauma patient waiting for an ICU bed or to be life flighted to another facility. You may not always get "easy" patients who only require vs q4hr. You may get overwhelmed at times which is normal, but in the end you are an RN so you are expected to know how to care for sick patients. Just saying..

Specializes in CVOR, CVICU/CTICU, CCRN.

We've had patients in our little bitty CAH that should have been shipped to an ICU, but d/t the physician's overestimation of our capabilities (over the nursing staff's objections), we're required to shift patient assignments mid-shift to provide the critical care needed. Not much fun, not even a little bit. Scary for the patient, and scary for the nurses.

+ Add a Comment