What do you think, or what would you do?

Dealing outside an acute care facility is often frustrating. I think you are on the money about the UTI. We know that any stress like an infection will raise the INR so the bleeding could be related. Was the cyanosis of the toes new? How old is she? Need more complete history to be of much help about the specifics. Full code status should not make any difference except for end of life. We still treat illness and infection, don't we?

I hope the PCP is approachable. Ask the PCP the questions you have in a polite way. Explain that you want to understand the reasoning not to treat based on prelim lab data while awaiting a full C&S. There must of been some thought involved with the changes in meds so it is not like a duck and run visit. Many doctors will teach if they think it will prevent unnecessary phone calls. Most PCP really want the nurses on their side rather than in an advisarial role.

Go to your supervisor if you really have concerns about the care this resident is receiving. Again, be polite and ask how to approach the PCP to get this resident more assistance.

Hugs, I feel your frustration.

To answer your questions, she is an 80 year old female. Hx of DVT, pneumonia, and deconditioning. Continued on coumadin for preventing the DVT. New Dx of A-fib in the last month and has been on dig Tx. Cyanosis of the toes was fairly new, had occurred over the past week. Toes used to be red in color, as well as the feet, but had progressively turned cyanotic. She also c/o numbness and tingling in her feet x 2 days. Her pain was intense enough that the vicodin did not touch her pain.

Ohh the frustration. We'll see what happened when I go into work in a couple hrs.

I'm just curious, as I have never worked in a LTC, but is there ever a time where you just use your judgement and decide to send the pt to the hospital, regardless of what the doc says?

Yes, you can use judgement and bypass the doc's decision! In LTC, 911 can and will bypass the doc!

Yes, you can use judgement and bypass the doc's decision! In LTC, 911 can and will bypass the doc!

Ok good, because I was thinking in this case, I would have just sent the pt to the hospital, as increasing cyanosis of a limb and knowing that the pt has hx of DVT seems like a medical emergency to me!

From what I learned this week, the resident had pneumonia, MRSA in her urine, and an elevated INR. She still had not come back as of Sat. morning. Hope she's doing okay, she's one that I actually LIKE on my floor. :)

A little trick I've learned: If I feel the MD will fight me wanting to send someone in, and I really think they need to go, I call the family first and get their approval for send in. When a MD hears, "The family wants her to be seen in the ER", they will always appease the family and give the order. EVERY TIME!! It's irritates the crap out of some of them, but I'm not trying to make them happy, I'm trying to take care of my resident.

Yep...."family wants xyz" that gets them going.

I love to document out the but on cases like this too. I bet it was the age factor in the PCP delaying tx.

I find this really frustrating with a lot of GPs in aged care. My great auntie is 84 with an Hx of 1 previous MI, AF, CAD, COPD and CCF. Last Monday her toes were purple, her feet blue and her legs severely edematous to the knees. She was dyspneic at rest, significantly more so on exertion, majorly increased RR, orthopoenic, hadn't slept due to SOB, hadn't eaten for same reason etc. GP says, "oh, just increase her lasix by 20mg (she's already on 40mg), it's probably pulmonary oedema."

By Thursday night all symptoms were so severe she hadn't eaten, showered, changed her clothes or even been able to walk to her bed from her chair in the lounge. I had her in the ER where they panicked and sent her straight to ICU. Turns out her dig wasn't (and never had been at) a therapeutic level (failure of PCP to monitor), her AF was uncontrolled and she was now in left AND right sided HF as opposed to just right. It was pulmonary oedema - and it's taken three days in ICU on well monitored doses of heavy IV lasix amongst other things, including BiPAP to reduce her WOB and clear the fluid. Her feet now fit in her shoes and she's in an monitored bed in CCU where they've now discovered a tricusipid and mitiral vavle leak.

I was appalled at the lack of concern and regard for her welfare, simply because she was old and probably going to die anyway.

A little trick I've learned: If I feel the MD will fight me wanting to send someone in, and I really think they need to go, I call the family first and get their approval for send in. When a MD hears, "The family wants her to be seen in the ER", they will always appease the family and give the order. EVERY TIME!! It's irritates the crap out of some of them, but I'm not trying to make them happy, I'm trying to take care of my resident.

I have done something similar...if the patient is their own responsible party, their request to go 911 trumps MD's refusal to give an order!