Unable to answer family questions about DVT.

[arallenrn11]

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.

She had arrived on the floor shortly before shift change. She had 3 family members in the room who had questions for me as soon as report was finished. They were curious what the plan of action was, how long a DVT usually takes to resolve, how did the Dr. know she had a DVT, and how was he treating it? Seems to me this should have been addressed by someone already, but it wasn't, so they asked me, the nurse.

Of course. It's my job to answer questions right? Except, I didn't know the answers. I responded initially by stating that I needed to review the pt's chart before I could answer their questions. I did so and found that an abdominal/pelvic CT had been ordered but not done bc the pt was uncooperative (pt had dementia). I don't even know what it was ordered for.

The DVT was in the lower extremity. Were they trying to rule out others or was this test unrelated? There were no other procedures ordered. There were some labs but I can't remember what they were now, and the pt's leg was warm and swollen.

I felt at a loss trying to answer the family's questions for several reasons.

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.

2) I have no idea the average length of time a DVT takes to resolve and couldn't just call the Dr. to ask.

3) I don't know how they monitor progress in a DVT pt. Basically, I need a refresher on DVT's I guess. But I seem to be in this situation a lot where I just don't have the answers and I feel like I should. Any advice?

I just feel like there is so much I don't know! I did well in school but feel I have forgotten everything. Probably the 11 months in LTC prior to Med/Surg.

[PinkCupcake]

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.

I just have to say I love this idea! I'll be doing the same thing when I'm done with school. Thanks for the idea :)

[maelstrom143]

I agree w/everyone here. We don't have all the answers. It is ok to say I don't know, but I will find out for you. Most hospitals have internet access and/or resources where you can print out patient education (ours have resources and sign off sheets to prove we gave the family the information...lol). Offer them paper and pen to write down their questions for when doctors round.

Whenever you come across a dx you are unfamiliar with, take notes, do the research after work and review the doc notes to see why things are ordered. Often, patients tell doc one thing and nurse another (doc, my stomach hurts...nurse, no I am fine!) so reviewing progress notes really helps (even better if computerized for easier reading )

It gets easier as you do it more and become more familiar with the recurring themes on your floor. Good luck :)

[brownbook]

Sheesh, GrnTea.... I am bending over backwards to agree with you.....I do hate, "I can't tell you that you will have to ask your doctor." All I'm saying is there is rarely, occasionally, maybe once or twice a year, a time when it does need to be said!

Not driving a car after hernia surgery has to do with using your feet to push on the gas and brake pedals, which of course impacts the abdominal muscles. Especially a concern if there is a sudden need to slam on the brakes. That is a large part of no driving for (it varies) 7 days to 2 weeks after surgery.

I am not a motorcycle rider, I thought most of the activity was with the handlebars, not so much with pushing with your feet.

With out patient surgery patients are much quicker, with the surgeons approval, to get back to normal activities of daily living.

Why would I want to guess about motorcycle riding?

[Jory, MSN, APRN, CNM]

It is not you job to diagnose the patient, but it is your job to read the chart and find out what has been done so far.

I never, ever, answer any questions on a patient whose chart I don't have and family members can be very damanding..but this is where you develop a backbone.

Just ignore their questions as you get you admit the patient, "If you can give me just a few to get your family member admitted and review her chart, I'll be happy to answer any questions you have." If they keep pressing KEEP REPEATING A VARIATION of the same sentence, trust me....they eventually shut up.

Then as you read the chart...in this case, for example, what you are looking for is a PHYSICIAN DIAGNOSIS OF A DVT OR A TEST TO RULE OUT ONE.

Anytime a scan is ordered, a reason for it is always listed, so they know what they are supposed to be looking for.

So, let's say a scan was ordered, a DVT was suspected, but not confirmed, here is what you say.

"Well, it is my understanding that the doctor ordered a CT scan to rule out or confirm the presence of a DVT...since we don't have a diagnosis yet, why don't we just wait until the scan and we know exactly what we are dealing with and at that time...the doctor will be happy to advise you at that time. At this time, it is pure speculation and I would hate for you folks to get upset when it may be something else we are dealing with"....say this NO MATTER HOW OBVIOUS IT IS THAT SHE HAS ONE.

They will try to get you to give them answers, just keep saying, "It would be inappropriate for me to give you advice on what we do for a condition that she may or may not have....if we can just wait until she has the scan." Repeat. Repeat.

Now, on the off chance a diagnosis is already made...ask them, "Have you spoken with the physician yet?". The answer will almost always be no. Then you say, "Well, I don't know what Dr. Smith's plan is yet because we just got your mother admitted, but as soon as he gets here and writes orders, he will be happy to go over everything with you at that time."

Don't be bullied into giving information too early.

[celtchick68]

I have been a nurse for the same time period (2.5 months) and frequently come across these issues. While I may be familiar with the answers to a particular diagnosis I'm somewhat hesitant to discuss it with patients because I'm uncertain exactly what the doctor has already told them or if he's even discussed their diagnosis with them yet. I recall from school that it's not the job of the RN to inform them of their diagnosis but to reinforce education etc. I work in the ER so it's a little different than on med surg in that once they get up to the floor they usually already have their dx vs a new discovery in the ER. I'm never too proud to say "I don't know" but I always follow up with "...but I'll find out." I find that I appreciate the questioning because it forces me to find the answers which helps commit it to memory.

[Ruby Vee, BSN]

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.

I don't understand why you cannot say "The doctor is the best one to answer all of these questions" and then go get (or call) the doctor. Even if you answer all of the questions, they're still going to want to talk to the doctor.

[celtchick68]

Ruby,

I believe the idea is that we're nurses. We're educated. We should be capable of answering basic questions about disease processes when asked. We deal with doctors who explain a patient's dx with them and their family and the family still has questions that may have gone unanswered or that they may have thought of after the fact. We should be able to reinforce their knowledge without running to the doctor to save us from having to know something on our own. To defer to the doctor for everything tells the patient that we are not confident with our own knowledge base.

[Sun0408, ASN, RN]

There are many questions I can answer and many I can't or shouldn't. If tests are back and the PCP has not talked to the family "we" can not say a word, so yes there are times when calling the Dr. is the best thing to do. We can only reinforce what the doc has already stated and many times reading the progress notes do not give a clear picture about what has been said. Many times the families want more information than basic answers. In the ICU, I can't tell you the number of questions I have been asked re: treatments, surgery options, survival rates etc and yes, those type questions are more than basic and I will refer them to the doc.

[Jory, MSN, APRN, CNM]

I don't understand why you cannot say "The doctor is the best one to answer all of these questions" and then go get (or call) the doctor. Even if you answer all of the questions, they're still going to want to talk to the doctor.

I worked in a critical care pediatric unit where the parents would often come on the night shift when only one resident would be there and may have just learned what the diagnosis is, but doesn't know the patient's history like we did.

Therefore, if I knew what the diagnosis was and it was a routine issue in the unit, I was 100% comfortable giving the family member the doctor's diagnosis and the plan of care, medications, future testing, etc.

However, for very serious, potentially fatal diagnosis...no way would I touch that. That is why they get paid the big bucks.

[Ruby Vee, BSN]

Ruby,

I believe the idea is that we're nurses. We're educated. We should be capable of answering basic questions about disease processes when asked. We deal with doctors who explain a patient's dx with them and their family and the family still has questions that may have gone unanswered or that they may have thought of after the fact. We should be able to reinforce their knowledge without running to the doctor to save us from having to know something on our own. To defer to the doctor for everything tells the patient that we are not confident with our own knowledge base.

I forget that not everyone has hot and cold running providers sitting around the unit 24/7 shopping on-line or Sporcleing. Yes, we're educated and we're capable of answering questions about meds, labs and disease processes when asked. If the family is pestering me with questions that the doctor should have answered and hasn't, I see no problem with getting said doctor off his or her rear to deal with the family. If the doctor has not yet discussed the patient's disease process with the patient and family AT ALL, that's definitely their job. If I have things to do and the doctor's biggest concern is the capitol of North Dakota, let the doctor deal with the family's questions. I have the luxury of doctors just sitting around our unit doing nothing. Not everyone has that.

[Ruby Vee, BSN]

There are many questions I can answer and many I can't or shouldn't. If tests are back and the PCP has not talked to the family "we" can not say a word, so yes there are times when calling the Dr. is the best thing to do. We can only reinforce what the doc has already stated and many times reading the progress notes do not give a clear picture about what has been said. Many times the families want more information than basic answers. In the ICU, I can't tell you the number of questions I have been asked re: treatments, surgery options, survival rates etc and yes, those type questions are more than basic and I will refer them to the doc.

What she said.

[arallenrn11]

Ruby - I personally see nothing wrong with referring a patient or family member to the Dr. if necessary. However, working nights, I don't always have that option. Quite often a pt comes up from ER and isn't seen by the attending until the next morning. I wouldn't want to leave a patient and their family waiting that length of time if there's something that I can answer for them. It's very frustrating because I wish everyone could be seen by the attending right off the bat. Then these types of situations would be minimized, but that's just now how it goes.