Unable to answer family questions about DVT.

allnurses Guide · Aug 21, 2012

Ah yes... it's been a long time since I worked in Med/Surge/Acute Care, but I

remember moments like what you described, quite well. When the family is

firing off all of those questions at you, it's hard to know how to respond. You

can't really say "The doctor is the best one to answer all of those questions for

you", whether it's true or not. Reason being, the doctor MAY NOT actually

sit down with the patient and family and discuss/explain everything. They may order

all of the treatments, meds, procedures, etc.. but will they actually do any of

the in depth explaining of what is going on? The MD may do that, or they

may not.

One thing that you can do with families is give them a starting point. You can

go over with them what is being done right NOW. "We're going to start with

IV fluids, IV Heparin, labs, and we'll go from there. I want to assure you that

your loved one is in very good hands and we are doing everything possible. We

will keep you updated." So, you don't really HAVE to go into a full legnth explanation

of a condition that you are not quite familiar with yet. Orient the family to

what is being done now for their loved one, and keep them reassured.

THEN, on your own time, spare time, whatever, educate yourself about

the various conditions such AS DVT, that you will come across.

brownbook · Aug 21, 2012

Sorry, I've been a RN too many years to count, and I would still would be kind of guessing, stumbling, at answers to the families questions along with you. But of course you don't want to look like an inept idiot in front of the family!

It is okay to say '"I don''t know the answers to all your questions.......the doctor has ordered all the appropriate tests and treatments.' Offer them paper and pen to write down their questions so they can remember to ask the doctor when they see him. Check with a co-worker or charge nurse (or a computer with Internet access) to see if you can get some quick answers to the questions.

The longer I have been a nurse the more comfortable I am with saying to patients or their family, "I don't know about that.....or.....I don't know what that drug is." Given the situation you can add......"but I will find out".....or....."your doctor will be here soon we will ask him.'

brillohead, ADN, RN · Aug 21, 2012

Every place I've been to has access to printable educational materials, as well... this is stuff that you can just print out and hand to the patient/family and they can read at their leisure.

Sun0408, ASN, RN · Aug 21, 2012

I love education material for just this. We can't know everything about everything but we should know where to find the answers :) I love pt guided material on things such as DVT's, basic procedures etc.. It really helps, also don't be afraid to ask your charge nurse, if she doesn't know, she/he can guide you in the right direction. I have called the MD for families before or arranged a meeting to answer all their questions.

nurseprnRN, BSN, RN · Aug 21, 2012

Personally, I hate hate hate it when a nurse says, "You'll have to ask the doctor about that," because it just makes the point that only the doctor knows anything and we poor benighted nurses are dumb as boxes of bricks and can only "follow doctor's orders." If that's what you want people to think about you and your chosen profession, be my guest...

... but maybe you could have said, "I am new here and I don't know, but I will find out for you," and get someone-- a nurse-- on the floor who is experienced enough to answer those questions. BTW, it is perfectly appropriate for a nurse to answer all of them.

" They were curious what the plan of action was," "A DVT is a clot in a big vein, in this case in your mother's leg. You can tell because it has a characteristic appearance, her leg is swollen and tender, and they did an ultrasound examination in the ER to look at the vein and saw the clot in there."

"... how long a DVT usually takes to resolve," "All clots eventually dissolve, and that can take different amounts of time for different people. What is important now is to do what we can to see that it doesn't get bigger, by giving her medications that make her blood clot less well. These are called "anticoagulants," because "coagulation" is the medical word for clotting. We will monitor her clotting by a blood test every day and adjust the medicine dose accordingly."

"... how did the Dr. know she had a DVT, and how was he treating it?" (See, we covered that already.)

For next time. Since you asked for advice, here's mine: every day at the end of your shift, pull out your textbook(s) and read something about at least one of the diagnoses and nursing care of something you saw that shift. You will have a better way to remember it than you ever did as a student. You should do this for the rest of your professional life. I have been out of school for smumblemumble years, and I still find there are things to learn. Different ones, but always something. Never stop learning.

Note: to get full impact of this message, it should display in Comic Sans, green. Thank you.

wanderlust99 · Aug 21, 2012

Typically the MD will write in the H&P or progress note the pt's problems and the plan. I always check that b/c in nursing report we tend to miss a lot of the important things unfortunetely. A lot of times they will number it like 1.DVT 2. Hypertension 3. etc... and they will write a plan like start heparin, CT of abd to rule out ...., and etc.. That will give you a better picture of the patient and the plan going forward.

I've been a nurse for awhile and have been stumped. Worse is when the families come in the morning and start firing off questions when I haven't had a chance to review the chart or really get to know the patient.

You'll find w/experience that a lot of the patients come in with similar things, DVT, PNA, etc.. and you will become more knowledgeable about these things. Next time you will be prepared to educate the pt and family on what a DVT is and the treatment I bet. Hang in there:)

PunkBenRN · Aug 22, 2012

Personally, I hate hate hate it when a nurse says, "You'll have to ask the doctor about that," because it just makes the point that only the doctor knows anything and we poor benighted nurses are dumb as boxes of bricks and can only "follow doctor's orders." If that's what you want people to think about you and your chosen profession, be my guest...

... but maybe you could have said, "I am new here and I don't know, but I will find out for you," and get someone-- a nurse-- on the floor who is experienced enough to answer those questions. BTW, it is perfectly appropriate for a nurse to answer all of them.
" They were curious what the plan of action was," "A DVT is a clot in a big vein, in this case in your mother's leg. You can tell because it has a characteristic appearance, her leg is swollen and tender, and they did an ultrasound examination in the ER to look at the vein and saw the clot in there."
"... how long a DVT usually takes to resolve," "All clots eventually dissolve, and that can take different amounts of time for different people. What is important now is to do what we can to see that it doesn't get bigger, by giving her medications that make her blood clot less well. These are called "anticoagulants," because "coagulation" is the medical word for clotting. We will monitor her clotting by a blood test every day and adjust the medicine dose accordingly."
"... how did the Dr. know she had a DVT, and how was he treating it?" (See, we covered that already.)

For next time. Since you asked for advice, here's mine: every day at the end of your shift, pull out your textbook(s) and read something about at least one of the diagnoses and nursing care of something you saw that shift. You will have a better way to remember it than you ever did as a student. You should do this for the rest of your professional life. I have been out of school for smumblemumble years, and I still find there are things to learn. Different ones, but always something. Never stop learning.
Note: to get full impact of this message, it should display in Comic Sans, green. Thank you.

This is your best answer.

When you don't know the answer, never try to bs the answer to the family; it is okay to say you don't know.

This is when you should go look it up, not just for your patient, but for your growth as a nurse. You should know what the plan is, because you are the one executing it - you are the pt advocate, you need to know if what you are doing is appropriate and working.

Essentially with DVTs, the plan is "don't throw the clot to the lung". Keep them off the leg, no massages, etc. Lovenox or heparin is usually used, as described above, not to 'dissolve' the clot but rather to keep it from getting bigger. Your body does the hard part, we are just there to prevent more from forming.

Dx can be performed with a number of different tests, typically it is clinical presentation confirmed by US to affected area. Sometimes you will see a D-Dimer which can suggest clots, however D-Dimer is not a concrete diagnostic tool as it can be elevated from other factors. Typically, the ultrasound is all you need.

Hope that helps.

brownbook · Aug 22, 2012

I agree "You will have to ask your doctor about that." Can be really annoying for a nurse to say. But there are certainly situations where it must be used.

What would you say to a patient who just had hernia surgery and asked you when he could ride his motorcycle? I wouldn't want to hazard a guess, I do know about driving a car instructions, and said, "You will have to ask your surgeon about that." Actually the surgeon was still in house so I called him.

I don't want the original poster to think that phrase should never be used. But I agree it grates on my ears when I hear nurses use it in many other situations.

nurseprnRN, BSN, RN · Aug 22, 2012

@brownbook: Perhaps in time you'll learn to say things like, "Since your foot will not have full range of motion until you've had several weeks of physical therapy, you won't be able to shift your bike safely. And those other fractures won't be healed enough to withstand any dumps, so you'll need to wait at least until your 6-week xray check to see if they're OK." Or, "I am pretty sure Dr. Green won't want you to put any strain on that abdominal incision after he took such great care to sew it up so neatly. ::with a smile:: I would plan on leaving the bike in the garage until he clears you for full activity, and that will probably be about six to eight weeks (or whatever)." And I would be good and sure the GF or parent hears that too. (This would NOT be a HIPAA violation !!)

Note: for full impact of this message, it should display in Comic Sans, green. Thank you.

Christy1019, ASN, RN · Aug 22, 2012

I'm an RN with 2 1/2 months experience in Med/Surg following 11 months in LTC. I work 7p to 7a. Recently I had an elderly female pt. admitted for DVT - my first DVT pt.
1) I wasn't sure of the diagnostic criteria for DVT and because I'm an RN not an MD I didn't want to get into how the pt was diagnosed because that's not my job.

That statement kinda bugs me honestly.. I understand that this was unfamiliar to you, but I have never come across any policy stating that as a R.N. it is not my job to explain to patients and family how they came to the diagnosis that they are now being treated for. I mean, there is no way I would accept medications or have procedures done as a patient, if noone told me why they came to the current diagnosis and what my test results mean. Even though the diagnosis was made prior to your arrival, the pt's chart as well as any electronic medical record of radiology/lab studies recorded, will give you the information needed to answer their question.

Your response that you had to read the chart first was completely appropriate so that you can give them accurate information, as well as it buys you some time to utilize resources and get a quick refresher on the aspects you are unfamiliar with. My only guess as to the purpose of abd/pelvic CT without any additional pt data would be if they were checking for additional DVTs in the pelvis, or there was history of possible trauma i.e. fall and they wanted to rule out pelvic fx's, or perhaps she was just complaining of low abd pain at that time, it's really hard to say.

Working in med-surg you will frequently encounter DVTs in one form or another, whether it's Prevention, by use of SCDs and SubQ heparin injections, Management of pts presenting with DVTs and/or Pulmonary embolism with heparin infusions/lovenox injections/coumadin teaching, in addition to other appropriate nursing assessments/interventions for those patients, and throughout all of this you will do lots of patient teaching, as that is an integral part of nursing.

Things that you should definately educate the patient about include significant modifiable risk factors for DVT development (sedentary lifestyle, obesity, smoking, prolonged periods of limited mobility i.e. hospitalization, injury/trauma/surgery) as well as non-modifiable risks (family history of DVT/PE, coagulopathy, atrial fib/CHF/CAD/coronary valve disease, cancer). They should be aware of the inherent dangers of DVTs and the increased risk that they can break off and travel to the heart, causing a M.I., or to the pulmonary vessels causing a PE, both complications can certainly result in sudden death in some cases.

They should also be educated on what symptoms they should look for in cases of DVT: pain, swelling and redness to one leg that also feels warmer to touch than non-effected leg, and to seek immediate care if any symptoms of PE develop: unexplained, sudden onset of severe shortness of breath, chest pain that worsens w/deep breath or cough, coughing up blood, passing out or feeling faint, diaphoresis, or feeling anxious/panicked with no obvious cause.

Last, you should talk to your pts and/or family about the importance of being compliant with follow up care and medication therapy, as well as strategies to reduce some of their modifiable risk factors i.e. exercise/stop smoking etc. Unfortunately, you will come across many patients who could care less about what you are trying to teach them and have no intentions of changing their lifestyle, which will definately be frustrating, but the personal satisfaction comes with helping pts to feel better and giving them the tools they need to be successful in making positive changes in their life, or at least it does for me.

:twocents: :nurse:

arallenrn11 · Aug 22, 2012

Christy1019 - I think it came across wrong when I said it wasn't my job to explain the process of diagnosing DVT. What I meant by that is that I didn't want to overstep my bounds professionally, and, as I stated, I wasn't 100% clear on the diagnostic criteria. I was confused upon reviewing the chart bc no ultrasound was performed and lab values are my weakness, so while I assumed the diagnosis was based on the lab findings and the clinical s/s, I wasn't sure which lab values were relevant. Interestingly, the next day I did research and found many articles which recommended the use of a rapid result d-dimer in combo with clinical s/s as a more cost-effective and slightly more accurate way to diagnose DVT vs ultrasound. I'm glad I looked it up. Thank you for all your responses. They were all very helpful :)