Would you send this patient to the unit?

  1. 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.
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    Joined: Nov '14; Posts: 125; Likes: 109

    46 Comments

  3. by   kerleigh722
    Yes, I would have sent her to the unit. I understand your frustration of getting icu type patients on the floor... It's rough. Luckily we have great resource nurses who typically have our backs and fight for us when it comes to something like this... If not the unit, then I might get a 1:1 RN.
  4. by   EmergencyRN22
    Well, just my experience. Our ER docs don't assign consults to admitted pts, that's left up to the admitting doc to who they prefer. Just because the pt arrived at 1700- doesn't mean they are admitting right away. It's usually At least 90 min from arrival to admitted if lucky ...many times its 4-5 hours after arrival when they are finally admitted d/t pending scan results.

    Personally, those labs are critical but I wouldn't be sweating bullets if I had that pt with 4 other (poss high acuity pt) boarding in the ER. Esp with the pt a&ox3 and stable vitals.

    Im assuming you're on a Step down/monitored care floor.



    Quote from Birdy2
    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.
  5. by   amzyRN
    I probably would have asked if we could give her more K and some Ca although maybe they didn't want to give her the K because the Cr is elevated. I don't know the nuances of electrolyte imbalances the way a physician does. If the patient was running SR on the monitor (she should be monitored) and her VSS and she was asymptomatic I don't think she would need to go to the unit. Perhaps a tele floor or step down, but nothing higher at this time. The patients I've sent to the unit were usually more unstable than that, showing symptoms and had unstable vitals. But I might be overlooking something and I would definitely consult my charge nurse on that one.
  6. by   calivianya
    I would say she is a stepdown patient. The labs are critical but if the patient is A&O with a good BP, I wouldn't classify her as unstable.
  7. by   NobleLeo
    We get patients like these all the time on my med-surg floor. I would have just called the doctor and gotten some K+ bumps and calcium ordered and had an increase in IV fluids. As long as the vital signs remain stable, I would just wait for lab work in the morning. I've spent many nights correcting people's electrolyte balance either because it wasn't done in the ED or was never addressed by the physician.
  8. by   Birdy2
    Well I'm just wondering if that's acceptable? Some people said that it should have been done in the ER before she came to our floor. What concerned me the most was her potassium and sodium. I think it was a good decision for her to be monitored more closely and I couldn't do that with 5 others. She was running fib/flutter on the monitor and they didn't even have one on her in the ER. I put one on as soon as she got to our floor and when I first looked it was normal sinus with occasional PVCs then changed a little later
  9. by   NobleLeo
    Is it acceptable? No, however it is the reality. I work in a small hospital with our only doctor being in the ED overnight and we often get patients who should be monitored but aren't. I know that I just keep that extra eye on a patient I'm concerned about even if it means doing my charting near the room. If I notice a patient starting to decline, I call right away.
  10. by   EmergencyRN22
    Personally, I'd ask the dr to reorder the blood work and send down a new sample. If she was a&ox3 with normal vitals. I'd almost question the original blood work. I *know* people who draw off ems iv lines which potentially dilute the samples or staff that straight stick the vein above the existing iv WITH fluids running. It happens.

    personally, I would have the dr reorder the labs and I would personally redraw them myself before I'd do too much.

    Plus, with ARF wouldn't the K+ be high(er)?
  11. by   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. Couldn't the BUN/Cr be a result of dehydration? I guess that would have been a good idea to do a redraw, but the lab tech doing it did a good job. I was actually in the room when she did it.
  12. by   EmergencyRN22
    Other things like infection and meds can cause acute kidney injury, not just dehydration.
  13. by   Here.I.Stand
    I'm with calivianya, and think stepdown would have been appropriate. I'm not seeing anything that screams "she needs an ICU bed," but SD could keep a closer eye on her than is possible on the floor. Where I work anyway, the SD units have 3 pts to 1 RN. The medical one takes DKA pts who are on insulin gtt with q 1 hr fingersticks, q 4 hr labs with K+ replacements (usually with every lab draw, since all that insulin lowers the K+); they take post-cath lab pts; and other such pts who are high acuity but not unstable to the level of needing ICU care.
  14. by   icuRNmaggie
    There isn't enough information to determine the cause such as a toxin, med overdose, contrast nephropathy, hypotension, obstruction etc. The chloride would be low in severe dehydration. We dont know the cause of the alkalosis. We don't know if the patient responded to fluid challenges or even if there was any urine output. We dont know if other organs were failing; if so, a MICU admission is entirely appropriate as those patients can deteriorate very quickly and it starts with a subtle change in mentation.

    I think the OP did the right thing by advocating for her patient given the many unknowns and lack of any significant medical management.
    Personally I suspect SIADH, but it could have been far more complex than that.
    Last edit by icuRNmaggie on Apr 6, '15

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