When to ship pt out to hospital? WWYD?

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My confidence has greatly improved now that I have a little experience under my belt, but had a rough shift last night and wanted some nurses opinions on two scenarios. I am a part time agency nurse and also work in a hospital part time so I do not 'know' all of my pt's well at this particular facility and have to go by what I see.

Pt #1 - CNA reports to me that pt is coughing up blood. I assess pt. He's SOB, coughing up a lot of bright red blood, very short of breath, RR is 24, and he's wheezing all over. I get from another CNA that he does this all the time and he makes himself sick on purpose. I know the guy takes a huge amount of lovenox and another nurse told me that yes usually he's got behaviors making himself sick etc, but that one time she did ship him out and he had a PE. So he gets shipped to ER for evaluation because the whole thing made me very uncomfortable. In the AM dayshift nurse tells me do not ship him out again. He does this whenever the regular nurse is away and the ER said to stop shipping him there. Now I'm honestly aggravated at this point because I do not like having to determine when someone is making himself sick or truly having an episode. He was definitely wheezing and definitely coughing up blood. I am so aggravated with this that I am not sure I want to go back to staff that facility.

Pt # 2 - Pt is on fall vitals. Check BP it's 200/100 at midnight. Call MD. Get order for lisinopril 10mg. Recheck BP in 2.5 hours it's still up at 195/95. Get second order for norvasc 5mg. Give this around 3am. Recheck BP at the end of my shift at 6am. Still up 210/102. Call doc again and doc is not super helpful asks me if I can get him into a doctor's appt today. I told him I wasn't sure when they'd be able to get him in as it's 6am. So we wind up shipping this guy out to the hospital too. I should add that looking at his history for the past few days from fall vitals his SBP was between 120-140 at the highest so this from what I could see was a deviation from his baseline. He was asymptomatic. Pupils reactive, smile symmetrical, nothing I could see that was different other than BP.

Now for whatever reason it's been bugging me all day if I made the wrong decisions on this. Ultimately the doc signed off on shipping both of them out, but I do feel they base a lot of this on nursing judgement. So with that, wondering would you have sent these people in for ER eval. I have not been doing nursing home work lately and have primarily been in the hospital, but just started doing it again and I almost think my hospital job is making me more jumpy. Would love some feedback.

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I'd be curious to hear other people's opinions. I'm a new grad and feel if I encountered either of these situations I would have done the same as you. Better to be jumpy and cautious than miss a potential huge issue right?

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The guy who bleeds on purpose, I would have waited it out a little, ignore him for 45 minutes then sneak look in the room to see what he's doing (half the time they are happy watching tv then the nurse walks in and they act half dead!) , if he stops then he was doing it on purpose. But then again in SNF/LTC I have 25 residents, and I don't have time for his antics, ship him out.

The guy with high fall BP, ship him out, I don't have time for that either. If the unit manager wants to take either guy over and deal with it for a couple of hours while I plug away with the other 23 residents then fine, they can stay, but "I ain't got no time for that!"

When in doubt ship them out.

Especially if they are full code!!

And if you do keep them, DOCUMENT DOCUMENT DOCUMENT! MD AWARE, MD STATED...MD,MD,MD

Good luck.

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The guy who bleeds on purpose, I would have waited it out a little, ignore him for 45 minutes then sneak look in the room to see what he's doing (half the time they are happy watching tv then the nurse walks in and they act half dead!) , if he stops then he was doing it on purpose. But then again in SNF/LTC I have 25 residents, and I don't have time for his antics, ship him out.

The guy with high fall BP, ship him out, I don't have time for that either. If the unit manager wants to take either guy over and deal with it for a couple of hours while I plug away with the other 23 residents then fine, they can stay, but "I ain't got no time for that!"

When in doubt ship them out.

Especially if they are full code!!

And if you do keep them, DOCUMENT DOCUMENT DOCUMENT! MD AWARE, MD STATED...MD,MD,MD

Good luck.

Thanks. If I'd have realized that someone could make themselves cough up blood I would have waited. Next time I go there I'd wait it out, but I really feel I should have got that in report.

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Not knowing either resident, or knowing just HOW somebody can wheeze and cough up blood at will, I'd send them out. ERs have capabilities that mere nurses do not. (Not that I'm calling anybody "mere" here lol)

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I don't care if an anti-coagulated patient is "making himself bleed" or not--he is at risk of bleeding out regardless of the "cause" of the bleeding. Send him out, because he is at high risk of rapid deterioration, which you can't assess or treat properly where you are.

High BPs are not to be played with either, especially when the patient is not normally hypertensive. He also earned a field trip to the ER.

You have been doing the right thing. At the end of the day, it's your license, and you should do whatever you believe is right and prudent.

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I don't care if an anti-coagulated patient is "making himself bleed" or not--he is at risk of bleeding out regardless of the "cause" of the bleeding. Send him out, because he is at high risk of rapid deterioration, which you can't assess or treat properly where you are.

High BPs are not to be played with either, especially when the patient is not normally hypertensive. He also earned a field trip to the ER.

You have been doing the right thing. At the end of the day, it's your license, and you should do whatever you believe is right and prudent.

Thanks for the vote of confidence. I think I'm going to shake that off as a bad night.

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I echo the above. i have about 20 years into LTC. I'd love for someone to tell me how you make yourself cough up blood?? Being that he was on Lovenox, I def would want the bleeding under control.

With the high BP, you tried to treat at the facility and it was ineffective. Without a DR present or close by and with a recent fall (any head injury??) I would have wanted further eval.

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Specializes in HH, Peds, Rehab, Clinical.

I never second guess myself for a decision to send someone to er for evaluation. It is always done with an md order, yes, based upon my assessment, but ultimately it is the decision of the on call md. Thankfully, the residents sent rarely have something seriously wrong, but I'm always glad to have sent them to find that out.

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I would have shipped both out. Good decisions on your part. Better safe than sorry!

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Specializes in Gerontology, Med surg, Home Health.

Hmmmm he made himself cough up blood? From what you said, I would have sent him. The second guy, I might have asked for nitro paste order... Old fashioned but it works to bring BP down quickly. I worked for a company that was all about keeping residents in the facility. They would call on Fridays and tell me they would give me $100 gift card if no one got sent out. I told them I would never second guess a nurse who was with the resident. I got several gift cards. I used them have pizza parties for the staff

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