Would you send this patient to the unit?

[Birdy2]

Patient gets sent to me after getting report and learning that she was dehydrated with acute kidney injury. Vitals stable, but labs were a little off.

Ok so the patients slow but she's a&o. Within 30 minutes new labs came back. BUN 112, Cr 11.7, Ca 6.6, K 2.4, Na 109, C02 13. I had orders to give her NS @ 100, 40 PO K, and really nothing else. The K, Ca, and Na were low before, but not that bad. I think Na was 120 in the ED. The patient had been in the ED since 5pm. She came to me at 10:30 pm. No consults had been called in that the ED dr had ordered when he saw the patient. There was a renal and cardio. So at 11:30 when the patients labs are called to me Im calling and waking up someone when they don't even know the patient. I got orders to transfer the patient to the SICU, but I had to fight with the supervisor for that bed. I don't understand why that patient was ever sent to my floor.

I get that we were out of beds and not enough nurses, but the paitient could have started having seizures and died while I was helping one of my other 5 patients. It just worries me that they're sending people to our floor like this and then we end up having to transfer patients all night. I just wonder if this is normal and happening other places. Sure is scary.

[icuRNmaggie, BSN, RN]

There isn't enough information to determine the cause such as a toxin, med overdose, contrast nephropathy, hypotension, obstruction etc. The chloride would be low in severe dehydration. We dont know the cause of the alkalosis. We don't know if the patient responded to fluid challenges or even if there was any urine output. We dont know if other organs were failing; if so, a MICU admission is entirely appropriate as those patients can deteriorate very quickly and it starts with a subtle change in mentation.

I think the OP did the right thing by advocating for her patient given the many unknowns and lack of any significant medical management.

Personally I suspect SIADH, but it could have been far more complex than that.

[annmariern]

I once got report from another unit for a transfer. 35 year old woman, came from the Er went unresponsive a couple of hours ago........what? Stop right there? She came in A/O x 3 and now shes unresponsive and your sending her to another med/surg floor because we have tele? I have had several ED pts come and immediately had to call to go to ICU. Several PACU pts come and found mysteriously their BP bottomed out on the ride up, their temps at 95, or hypoxic and needing to be vented. Not just your hospital. And yes, it is scary.

[MunoRN, RN]

Part of what I do as a rapid response nurse is help make sure patients are going to the right floor out of the ED. The biggest issue I would have had with this patient going to floor, even a monitored one, would have been the sodium. I would have asked that the ED send another set of labs prior to bed assignment, since that initial sodium of 120 is a borderline ICU-admission-required value. Far more important though is the trend. Getting a second set of labs does far more than just double the amount of data you have, it increases it exponentially since it adds something you didn't have before; trajectory. With a follow up sodium of 109 that's a pretty straightforward ICU/SD admission.

[0.adamantite]

With a follow up sodium of 109 that's a pretty straightforward ICU/SD admission.

I agree. This patient is at risk for seizures with a sodium that low. Also, a K of 2.4 is very low.

However, I work on an un-monitored floor so I have a few "dumb" questions.

How could the patient have a K of 2.4 with a Cr so high?

Of note, I have seen patients with a high Cr have bad reactions to meds built up in their system due to the inability of their kidneys to clear them.

[Anna Flaxis, BSN, RN]

Well I'm not sure but I get confused trying to make sense of the labs. Sodium would be high if she were dehydrated which she was. And yes, potassium would be high with renal failure.

Is she on diuretics, has she had diarrhea, or does she have some sort of intestinal malapsorbtion problem?

Couldn't the BUN/Cr be a result of dehydration?

The BUN/Cr ratio suggests an intrarenal cause, such as nephrotoxic medications or a systemic illness.

Is the patient on diuretics, SSRIs, antibiotics, or receiving cancer chemotherapy (tumor lysis syndrome)?

It could be that the fib/flutter isn't new for her.

As described, I agree with you this patient needs closer monitoring than can be realistically provided on the general medical unit.

Is there anything more to this picture that might have made a difference as far as bed placement decision? For example, what was her code status, and did she want aggressive intervention?

[NurseLexx]

Definitely!! You must work at my hospital. We get these types of patients on the floor often!

[Dazglue, ADN, BSN, MSN, RN]

We get these kind of patients on our floor and I work in a skilled nursing facility. I'm constantly fighting with our house supervisor and admission coordinator when we get patients like this.

[whofan, ADN, BSN, RN]

If the patient is alert and oriented and all vss are stable then no, but patient should definitely be on a step-down unit.

[rumwynnieRN]

To answer your question about ICU-type pts being sent to the floor, the answer is yes, we've had that problem. It's easier now to make sure we don't get them with EPIC. I have mixed feelings about the ER not even bothering to call report (we have a program now where we want the critical care and ER nurses to shadow the floor nurses for a shift because some of them where I work don't think we do anything) because they have sent us patients who are most definitely not appropriate for our floor. They assume we will have looked up the patient and send them -- room isn't ready and the nurse doesn't even know he/she's getting a patient.

Bed file has decided in the past that (I work on a med surg floor -- we are ENT/Eye/Urology mostly) we can take insane traumas because we deal with trachs and chest tubes. As in traumas that are by no means stable (BPs 60/40, insane blood loss, requires closer cardiac monitoring than what we can provide).

Last Saturday, they tried to send us a patient who was dx-ed with sepsis. It's a good thing I looked because the pt was definitely not hemodynamically stable (BP was trending down from 111/80 to 80/60 to 75/51), and no, the ER would not have called report.

We also don't have negative pressure rooms, and when they don't call report, we end up taking pts who have active TB or shingles or chickenpox. x.x; We have to notify the supervisor immediately and get them moved to a floor with negative pressure rooms.

[loveu123]

I think this patient is appropriate for a step down unit but I guess it will also depend on what type of hospital you work at. When I worked surgical unit in a busy, teaching hospital we did get this kind of patients on the floor. As an ER nurse, I would have definitely had the patient on a monitor and also asked for more potassium. I am also wanted to point to the fact that though patient arrived at a certain time, he may not have been by nurse till hours later. It's unfortunate that you have to care for him in addition to your other patients but that is becoming the reality these days. Your admitting doctor should not also have accepted the patient if it is not an appropriate admission for your unit. We sometimes have to have about 5 patients including intubated ICU patients and ambulances do come in non stop especially in Level 1 trauma centers and that is why we have to send the patients to the floor asap. This is the reason why most nurses are leaving the bedside. I understand how you feel because I have worked in different specialties but it is just unfortunate the way nursing is becoming these days.

[Twinmom06, ASN, APN]

I work step down and we are 5:1...I actually admitted a patient the other night with a Na+ of 112 - we just put up the seizure pads and had fluids running - by the time we transferred him to med surge he was up to 130.

The K+ of 2.4 would be more concerning (to me anyway) - especially since they only gave 40 mEQ of PO replacement. In my hospital that would buy you at least 4 K+ riders.

[MissM.RN, BSN, RN]

OP, you should be thanked for your advocacy and getting this pt to the unit where they belong. As a charge RN, I would simply not accept this patient to my unit, not assign a bed or nurse, and maybe even file a union "unsafe staffing" report.