RNs giving patient lab results.

PeakRN · Jun 28, 2019

3 hours ago, Jory said:
It did in this patient. She stopped the Synthroid and her TSH level was textbook normal when rechecked at 90 days and her final trimesters, and postpartum. This ended up being the first baby she carried to term.
So yes, this midwife absolutely understands the endocrine system very well. When you take Synthroid in the absence of hypothyroidism, in high enough does, it can absolutely drive the TSH level up.
My explanation wasn't backwards dear....you apparently have very limited practice in those with endocrine disorders.
By the way....if you contradict me to a patient without going through management or another provider, that is a write-up in my facility. Giving a diagnosis is out of your scope of practice. If you want to play APRN or an MD/DO...go back to school.

I don't think you are telling the truth. Never have I heard of someone having a TSH of 30 because they were on synthroid but otherwise had a normal thyroid. I looked in the literature and I can't find anything to support your idea of this phenomenon. None of the docs I work with (granted I only asked our ED docs and intensivisits, if I run into one of our high risk OB docs or endocrinologists I'll ask them too) have ever heard of this, nor did they think it would be appropriate to stop the synthroid or not perform a more thorough workup at that time.

Do you have any literature of any kind to back up your practice that you can share with us?

NurseBlaq · Jun 29, 2019

6 hours ago, Jory said:
It did in this patient. She stopped the Synthroid and her TSH level was textbook normal when rechecked at 90 days and her final trimesters, and postpartum. This ended up being the first baby she carried to term.
So yes, this midwife absolutely understands the endocrine system very well. When you take Synthroid in the absence of hypothyroidism, in high enough does, it can absolutely drive the TSH level up.
My explanation wasn't backwards dear....you apparently have very limited practice in those with endocrine disorders.
By the way....if you contradict me to a patient without going through management or another provider, that is a write-up in my facility. Giving a diagnosis is out of your scope of practice. If you want to play APRN or an MD/DO...go back to school.

Not to get in the middle of this but "textbook normal TSH" person here who was also misdiagnosed for years and actually had a multinodular goiter with a textbook normal TSH. TSH levels don't always tell the whole picture. I also had children, last one was high risk due to my thyroid disorder being undiagnosed for several years because they looked at the labs only and wrote it off. It was only diagnosed due to me getting my umpteenth doc because I knew something was wrong and all the other docs thought they knew better about my body than I did and were condescending because I'm only a lowly RN as though that exempts me knowing better, especially about my own health. They did a thyroid ultrasound and lo and behold, a massive goiter.

Each pregnancy made my thyroid disorder worse. Yes, I had a couple miscarriages along the way but it doesn't necessarily mean a miscarriage for every instance of hypothyroidism. Have you considered maybe the woman in your story was able to get pregnant because she was taking the neighbors Synthroid? Let me also add, Synthroid, levothyroxine, etc don't always work for everyone. I took them for years and still felt bad and didn't improve until I started taking Armour Thyroid.

Again, I'm not saying you're incompetent or trying to get in the middle of this. I'm saying none of us are above being wrong from time to time and in this instance, and as someone who went undiagnosed for years because people figured the labs were normal, it's still possible for the patient to have hypothyroidism. Don't write it off as a possible diagnosis.

We're all health professionals, there's no room for elitism when dealing with someone's life.

Jory, MSN, APRN, CNM · Jun 29, 2019

1 hour ago, NurseBlaq said:
Not to get in the middle of this but "textbook normal TSH" person here who was also misdiagnosed for years and actually had a multinodular goiter with a textbook normal TSH. TSH levels don't always tell the whole picture. I also had children, last one was high risk due to my thyroid disorder being undiagnosed for several years because they looked at the labs only and wrote it off. It was only diagnosed due to me getting my umpteenth doc because I knew something was wrong and all the other docs thought they knew better about my body than I did and were condescending because I'm only a lowly RN as though that exempts me knowing better, especially about my own health. They did a thyroid ultrasound and lo and behold, a massive goiter.
Each pregnancy made my thyroid disorder worse. Yes, I had a couple miscarriages along the way but it doesn't necessarily mean a miscarriage for every instance of hypothyroidism. Have you considered maybe the woman in your story was able to get pregnant because she was taking the neighbors Synthroid? Let me also add, Synthroid, levothyroxine, etc don't always work for everyone. I took them for years and still felt bad and didn't improve until I started taking Armour Thyroid.
Again, I'm not saying you're incompetent or trying to get in the middle of this. I'm saying none of us are above being wrong from time to time and in this instance, and as someone who went undiagnosed for years because people figured the labs were normal, it's still possible for the patient to have hypothyroidism. Don't write it off as a possible diagnosis.
We're all health professionals, there's no room for elitism when dealing with someone's life.

When someone answers in a snide manner...they should expect the same back.

I work very closely with an endocrinologist and co-manage many patients with thyroid disorders in pregnancy. TSH levels for childbearing women, per ASRM, should be lower than what most labs have as their normal range. I am well-versed in how to diagnose thyroid disorders as well as collaborate with our endocrinologist on achieving trimester specific ranges for our patients. I also encourage patients to return six months postpartum for a thyroid re-check because you can develop pregnancy-induced hypothyroidism that doesn't show up until several months later in the postpartum period. You'll be hard pressed to find many providers that offer that service.

Yes, I understand TSH levels don't tell the entire picture. I presented a quick case study. I draw the entire thyroid panel along with TPO.

She was taking the Synthroid with her previous pregnancies, all lost in the first trimester. She was seeing another provider at that time that didn't think baseline thyroid panels were important. The only reason I even ended up with the patient is that she came through the ER. Her entire TPO axis was off and her periods very irregular because of it. She rarely knew how far long she was in her pregnancies and we had to rely on ultrasound to date them.

It is very unfortunate a massive goiter was missed in your case. I palpate thyroids during my regular physical exam and can generally pick up even small nodules, so I don't understand how one progresses that far if a provider is doing a complete exam.

It's not a matter of Synthroid working or Armour working...it depends on what you are trying to correct. I never stated that I only prescribed Synthroid, there is Armour, NP thyroid, Nature-Throid, and others. Armour comes from pigs...there are some religious groups that will not take a prescription of Armour.

It's not about being elitist...this is a topic about RNs giving lab results and some RNs are very elitist about giving them out no matter what. Maybe there is nothing wrong with telling someone what their sodium or potassium level is, but questions on lab values generally never end that simply, it's always, "Well, what does that mean? Some things like glucose levels or bilirubin..may be easy enough but other labs may fluctuate in accordance with their disease process, medication, or have an inverse relationship with another.

When a patient receives too many different explanations from too many different people during the course of their stay, it causes them to not have confidence in the level of care they are receiving.

canadianedmurse · Jun 29, 2019

I understand where you are coming from, however I think it is the elitist "Provider" role who insists on being the sole provider of information that is often the issue. We are in an age of technology and freedom of information. People are likely to google their symptoms and abnormal lab values to self diagnose themselves.

I hope the RNs you work with don't interprete lab values matter of factly and state their findings to the patient, unless the cause is obvious. I don't think anyone here is saying that RNs can and should state what is causing the abmormal value. I think providing simple explanations for results is completely fine. Especially when you discuss things in a manner using terms such as "It often indicates" "it can indicate" "it could be from" and end your discussion with the caveat that "Your provider will be back in to discuss the findings and their cause in greater detail" ect.

canadianedmurse · Jun 29, 2019

I think it's important to make the distinction that we aren't really talking about these massively complex disease processes and giving patients matter-of-fact information on our internal med consult patients. We're talking about giving simple lab values simple potenti answers, with the caveat that the MD will be in to clarify and explain in further detail. If any nurse is going around telling patients their labs are x because of y and z then we would all agree that is wrong.

Jory, MSN, APRN, CNM · Jun 29, 2019

4 hours ago, PeakRN said:
I don't think you are telling the truth. Never have I heard of someone having a TSH of 30 because they were on synthroid but otherwise had a normal thyroid. I looked in the literature and I can't find anything to support your idea of this phenomenon. None of the docs I work with (granted I only asked our ED docs and intensivisits, if I run into one of our high risk OB docs or endocrinologists I'll ask them too) have ever heard of this, nor did they think it would be appropriate to stop the synthroid or not perform a more thorough workup at that time.
Do you have any literature of any kind to back up your practice that you can share with us?

I can't help it if you have never heard of it.....literature is going to be limited because how many studies are going to be out there where someone has normal thyroid panel and the study gives them a whopping dose of Synthroid? It would never get past an IRB review. How many patients do you run into in the ER that takes a large amount of thyroid medication from their neighbor that has NEVER been diagnosed with any thyroid condition?

I'm going to ask any patient to stop ANY medication she has:

1. Not been prescribed

2. For a condition she has never been diagnosed.

If you had a patient in the ER with blood pressure bottoming out that had been taking her neighbor's labetalol because she "thought" her BP was high but didn't even own a BP cuff....are you going to tell her to keep taking her neighbor's medication?

Patients that come into the hospital with an incidental pregnancy finding is not going to get the $100K workup. If you knew anything about thyroid lab values at all they adjust slowly. What workup would you suggest? The patient was followed and endo was consulted after her first clinic visit and they also agreed with the discontinuation and she received the appropriate testing. She didn't have anything wrong with her thyroid. It was not a medical emergency.

This patient was a little bit of a zebra...you aren't going to find too many patients that have access to thyroid meds on a regular basis, at a high dose, that don't need them. If you can find a study that reviews that scenario to prove me wrong, I would be interested in reading it.

You can ask anyone you wish....but you are looking at this from a very limited viewpoint. I trust our endo team that we have been working with for years.

NurseBlaq · Jun 29, 2019

4 hours ago, Jory said:
When someone answers in a snide manner...they should expect the same back.
I work very closely with an endocrinologist and co-manage many patients with thyroid disorders in pregnancy. TSH levels for childbearing women, per ASRM, should be lower than what most labs have as their normal range. I am well-versed in how to diagnose thyroid disorders as well as collaborate with our endocrinologist on achieving trimester specific ranges for our patients. I also encourage patients to return six months postpartum for a thyroid re-check because you can develop pregnancy-induced hypothyroidism that doesn't show up until several months later in the postpartum period. You'll be hard pressed to find many providers that offer that service.
Yes, I understand TSH levels don't tell the entire picture. I presented a quick case study. I draw the entire thyroid panel along with TPO.
It is very unfortunate a massive goiter was missed in your case. I palpate thyroids during my regular physical exam and can generally pick up even small nodules, so I don't understand how one progresses that far if a provider is doing a complete exam.
It's not a matter of Synthroid working or Armour working...it depends on what you are trying to correct. I never stated that I only prescribed Synthroid, there is Armour, NP thyroid, Nature-Throid, and others. Armour comes from pigs...there are some religious groups that will not take a prescription of Armour.
It's not about being elitist...this is a topic about RNs giving lab results and some RNs are very elitist about giving them out no matter what. Maybe there is nothing wrong with telling someone what their sodium or potassium level is, but questions on lab values generally never end that simply, it's always, "Well, what does that mean? Some things like glucose levels or bilirubin..may be easy enough but other labs may fluctuate in accordance with their disease process, medication, or have an inverse relationship with another.
When a patient receives too many different explanations from too many different people during the course of their stay, it causes them to not have confidence in the level of care they are receiving.

This whole post is an example of what I'm talking about. You are arguing several things that weren't said, including the assumption my thyroid wasn't palpated and still missed. Also, my thyroid disorder predated having children. It wasn't caught until pregnancy until the third child and after umpteen doctors. Were they all incompetent and you're superb?

Also, I didn't state YOU prescribed anything, I said I was given Synthroid and it didn't do anything and I still felt bad until Armour Thyroid, so yes, it does matter because there are several instances of people saying they noticed a difference in the two meds. Again, you're presuming people are so incompetent they can't tell a difference, even when it's their health. Not what I was stating at all but here you are arguing what wasn't the point.

Yes, you are being elitist, evidenced by this entire post. I shared my experience and you took the time to write a whole narrative arguing what wasn't the point at all, not to mention, being condescending throughout. Maybe take your own advice about being snide. No one is arguing giving lab results and undermining providers, you just seem to have the opinion of everyone being too simple minded to give out basic lab results. No one said they'd interpret or give medical diagnoses, you took it there with this high horse you're sitting atop.

Nurses giving lab values does NOT equate explanation. If your patients "don't have confidence in the level of care they're receiving" maybe it's something you're doing and not the RNs. For example, when the patient is explaining their health to you, don't assume they're only a patient and don't know better and that you know more than they do because you've interpreted some labs, reviewed some tests, or work with endo or whomever, which was the point of my story in case you missed it. Patients know their body better than anyone else despite the lab values you're looking at, or whomever you work with. Based upon your perceived slight in this thread, I'm sure you're guilty of this because you refuse to take anyone's POV into account except your own. NONE of us are above being wrong at any time, including you.

Having said that, I'm not going back and forth with you. All of my providers are NPs but if they were dismissive and elitist like you I'd definitely get a new provider, especially if they didn't listen to me as a patient because what I said didn't match their lab values. And FYI, undiagnosed patient here again, working closely with endo doesn't equate a missed diagnosis or assumption of unprescribed Synthroid causing miscarriages.

Also. I'm lost here:

Quote
She was taking the Synthroid with her previous pregnancies, all lost in the first trimester. She was seeing another provider at that time that didn't think baseline thyroid panels were important. The only reason I even ended up with the patient is that she came through the ER. Her entire TPO axis was off and her periods very irregular because of it. She rarely knew how far long she was in her pregnancies and we had to rely on ultrasound to date them.

You state she was seeing another provider and you saw her via ER then go on to say she had multiple pregnancies which all had to rely on ultrasound to date them. What does that mean? Did you see her each pregnancy? Did you not know about the Synthroid with the previous pregnancies? Since there were more, and you knew her periodss were irregular, were you seeing her on an outpatient basis too? I have many questions based upon this paragraph so I separated it.

canadianedmurse · Jun 29, 2019

30 minutes ago, NurseBlaq said:
This whole post is an example of what I'm talking about. You are arguing several things that weren't said, including the assumption my thyroid wasn't palpated and still missed. Also, my thyroid disorder predated having children. It wasn't caught until pregnancy until the third child and after umpteen doctors. Were they all incompetent and you're superb?
Also, I didn't state YOU prescribed anything, I said I was given Synthroid and it didn't do anything and I still felt bad until Armour Thyroid, so yes, it does matter because there are several instances of people saying they noticed a difference in the two meds. Again, you're presuming people are so incompetent they can't tell a difference, even when it's their health. Not what I was stating at all but here you are arguing what wasn't the point.
Yes, you are being elitist, evidenced by this entire post. I shared my experience and you took the time to write a whole narrative arguing what wasn't the point at all, not to mention, being condescending throughout. Maybe take your own advice about being snide. No one is arguing giving lab results and undermining providers, you just seem to have the opinion of everyone being too simple minded to give out basic lab results. No one said they'd interpret or give medical diagnoses, you took it there with this high horse you're sitting atop.
Nurses giving lab values does NOT equate explanation. If your patients "don't have confidence in the level of care they're receiving" maybe it's something you're doing and not the RNs. For example, when the patient is explaining their health to you, don't assume they're only a patient and don't know better and that you know more than they do because you've interpreted some labs, reviewed some tests, or work with endo or whomever, which was the point of my story in case you missed it. Patients know their body better than anyone else despite the lab values you're looking at, or whomever you work with. Based upon your perceived slight in this thread, I'm sure you're guilty of this because you refuse to take anyone's POV into account except your own. NONE of us are above being wrong at any time, including you.
Having said that, I'm not going back and forth with you. All of my providers are NPs but if they were dismissive and elitist like you I'd definitely get a new provider, especially if they didn't listen to me as a patient because what I said didn't match their lab values. And FYI, undiagnosed patient here again, working closely with endo doesn't equate a missed diagnosis or assumption of unprescribed Synthroid causing miscarriages.
Also. I'm lost here:
You state she was seeing another provider and you saw her via ER then go on to say she had multiple pregnancies which all had to rely on ultrasound to date them. What does that mean? Did you see her each pregnancy? Did you not know about the Synthroid with the previous pregnancies? Since there were more, and you knew her periodss were irregular, were you seeing her on an outpatient basis too? I have many questions based upon this paragraph so I separated it.

Jory also said that by giving lab values with an explanation that we are playing APRN, MD/DO. Talk about elitist attitude and gateway of information... and she's an NP!

NurseBlaq · Jun 29, 2019

7 minutes ago, canadianedmurse said:
Jory also said that by giving lab values with an explanation that we are playing APRN, MD/DO. Talk about elitist attitude and gateway of information... and she's an NP!

If a patient ask what a test is, it's not wrong for a nurse to explain that test. If they ask why a test was ordered, we'd still explain what the test is and refer them to the provider to explain why they ordered that test. If a patient states the provider explained it and that they still don't understand, then we'd explain, on the patient's level of understanding, what the provider said.

At the same time, providing basic lab results and/or explaining a test isn't the same as interpretation of the test nor a diagnosis which is what the remixed argument has for whatever reason become. I get the impression Jory just doesn't want to believe nurses have any mental capacity at all as they're the almighty provider and we're just lowly minions. I don't believe providers feel this way, but based on this thread Jory definitely does.

JKL33 · Jun 29, 2019

8 hours ago, Jory said:
This patient was a little bit of a zebra...you aren't going to find too many patients that have access to thyroid meds on a regular basis, at a high dose, that don't need them. If you can find a study that reviews that scenario to prove me wrong, I would be interested in reading it.

If all of that is the case, it really isn’t a legitimate example of why RNs wouldn’t be allowed to deliver basic information and results. From the sounds of it, complete fluke is an even better descriptor than zebra.

Helping a patient understand their medical situation has been an expected part of the job for all of my time as a nurse. The move away from expert nursing toward simply having us work on billing and documentation while every other entity is an expert of some sort who can help the patient is a more recent and inexplicable development. We should and do have information and expertise to share, and those RNs who don’t either didn’t learn what was presented to them or else received training focused on the needs and processes of employers rather than the needs of patients and processes of proper nursing care. ??‍♂️

FWIW I agree that I don’t like to overhear RNs throwing out guesses or wrong information that doesn’t apply in the particular case rather than just saying, “we will make sure to get that answered when your doctor/provider comes around” (or similar) - but I guess the difference is that I believe these problems are educable for the most part, if anyone still cared to take that kind of time to build strong and knowledgeable RNs. But, it looks like we would rather limit everyone to the capabilities of the weak links. The problem is, in doing that the entire role slowly morphs into that lesser thing.

**CommunityRNBSN, BSN, RN** · Jun 29, 2019

This is not related to the OP question, but on the subject of giving results generally. I am a new nurse, and nurses are not supposed to give any lab results at our community health clinic. In fact, the providers are supposed to give all lab results IN PERSON at a follow-up visit. Not over the phone.

Last week I had this conversation via phone with a patient.

Pt: Hi, I am calling to find out the results of my recent HIV test.

Me: (looking through his chart and seeing a negative HIV) Well, I see that you have a doctor’s appointment scheduled to “get lab results” in six weeks. The doctor will give you the results then.

Pt: Okay... I’m assuming that if there was anything bad in those results, he’d probably call to tell me that sooner than six weeks, right?

Me: That seems like a pretty safe assumption.

MunoRN, RN · Jun 29, 2019

20 hours ago, Jory said:
It did in this patient. She stopped the Synthroid and her TSH level was textbook normal when rechecked at 90 days and her final trimesters, and postpartum. This ended up being the first baby she carried to term.
So yes, this midwife absolutely understands the endocrine system very well. When you take Synthroid in the absence of hypothyroidism, in high enough does, it can absolutely drive the TSH level up.
My explanation wasn't backwards dear....you apparently have very limited practice in those with endocrine disorders.
By the way....if you contradict me to a patient without going through management or another provider, that is a write-up in my facility. Giving a diagnosis is out of your scope of practice. If you want to play APRN or an MD/DO...go back to school.

Not to keep sticking my head in the Lion's mouth here as I'm really not trying to be snarky, but clearly our understandings of the relationship between thyroid levels and TSH diverges at some point, so here's a simplistic description of the thyroid level / TSH relationship, maybe we can pinpoint where that divergence occurs.

According to every available source, including AACE, when thyroid levels decrease the body responds by increasing TSH levels, and vice versa. It's a well understood relationship as it's the basis for thyroid replacement dosage adjustments; High TSH level = needs more thyroid replacement, low TSH level = needs less thyroid replacement. So I'm not clear how it seemed apparent to you that an extremely elevated TSH level was explained by the patient taking their neighbor's Synthroid, that would be a paradoxical response to exogenous hyperthyroidism, not the expected response.

20 hours ago, Jory said:
If you had a patient in the ER with blood pressure bottoming out that had been taking her neighbor's labetalol because she "thought" her BP was high but didn't even own a BP cuff....are you going to tell her to keep taking her neighbor's medication?

If her BP was 180/100 despite taking her neighbor's labetolol, and the provider said "that's because you're taking someone else's labetolol, labetolol increases blood pressure" and just sent them on their way then yes, I would voice concern, that's my professional responsibility and my job.

And I'm still not clear why you think explaining to a patient the basic physiologic mechanisms that a test is assessing is out of a nurse's scope.