Nursing (RN) Challenges

Miscellaneous and Personal Stuff I Must Share
21

She’s gone.

Ditto on the confused old people–their strength is unnatural. It was the Dig, or was it? heh.

This is so interesting. We’d do the EKG and the enzymes (Troponins)–or I would, because I know my docs and they know me. Still, I shouldn’t do any of that without orders. Yes on the IV(we are covered by policy there)–good luck getting more than one access, though! We probably wouldn’t cath–our docs are Foley leery. We wouldn’t do the ABG or the Chem-7 or CXR. I have browbeat RTs into doing ABGs (nurses don’t do them in my hospital) but only when I fear the pt is going south–he still seems ok.

RNs here give MSO4 all the time! There is no need for doc–we have standing MI orders/protocols for such things (and they do include the labs, CXR etc as well as the morphine and nitro etc).

Can’t start steroids–need an order (remember, you’re a nurse!). You can elevate her HOB, give her O2, keep a close eye on her pulse ox, auscultate for wheezing and bug RT for a treatment while paging doc. (and do the kid reassurance thing).

Gah- we are separated by a common language! help! You’ve lost me on the labs–we measure BUN/Creat on different scales (much like we do BS). I agree we need more info re Ca++, albumin, Mg+ and AlkPhos. No idea what CRP is.

Yeah, I hedged a bit with the K+ on my HD lady. I’ve been out of stepdown for 8 months now–I’m amazed at how much is slipping away from me, already.

22

Ok, I wanna play, but I have to play from the other end, as I am from the Inscrutable Anathema (AKA The Lab). I don’t know nuthin’ 'bout no nursing.

Alternative scenario for pt #2: pre-Digibind, his dig level comes back as 2.6, yet he’s been on a maintenance dose for months. His accompanying pill bottle indicates he’s been compliant. Why is his dig level so high, and is it real?

Real scenario (I was part of this one), new pt: 16 yo female in a T-bone accident, has radical left nephrectomy, partial splenectomy. Surgeon says, in passing, “Oh, yeah, she got 10 units of O pos PBRCs on the table.” Who should you call, and why?

Another scenario, new pt: 55 yo male, obese, pitting (o)edema, CHF NY Class I. He’s taking Plendil (felopidine). He’s also on paroxetine. He says his doctor “gave him a death sentence” and he “got religion” and has just become a health food nut. His family has been sneaking in an odd cocktail he made up that contains, among other things, grapefruit juice and St John’s Wort “for the blues.” 24 hours later, he’s got bilateral railes, jugular distention, O[SUB]2[/SUB] sats around 93. What’s going on? At 48 hours, his family sees him again, and he casually mentions they brought “some herb called Chan-Su.” 6 hours later, his EKG is showing PR elongation and occasional runs of several seconds of V-tach. What happened?

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CRP = C reactive protein, a general inflammatory marker, more specific than a sed rate. It sounds like Irishgirl is describing a chem-12 as we run them on this side of the pond.

Vlad/Igor

24

Fantastic! But I think we better have people identify which scenario they’re answering–the nursing or the lab perspective.
I’ll take a stab at it.

Alternate scenario for pt #2: either his renal function is deteriorating or his lytes are out of whack (specifically, his K+ being low; which would happen if he were taking too much Furosemide, but he’s noncompliant and not taking his meds at home). Or it could be a false reading(?). Is the specimen hemolyzed?

MVA girl is ringing some dim bells in the back of my brain. I haven’t done a lot of trauma (mostly GSW), but isn’t there something with calcium and multiple blood transfusions? Doesn’t the pt need Ca++ replacement? Can’t find the textbook to look it up (and am not about to surf the net for it). Am I close? As for whom to call–is there a protocol re notifying Lifesource if you’ve depleted your store of O+ (I’m O+).? No idea. (should I know? I feel bad)
I don’t know specifics on the religious guy, but it’s got to be drug interactions causing symptoms. Grapefruit juice potentiates Felodipine, but there must be something else causing his symptoms(?). He’s obviously in heart failure–could not find a drug interaction between the Plendil and the Paxil, though. Never heard of Chan-su; but have heard that St John’s wort interacts with tons of stuff. Sorry I can’t be more specific, but I don’t work in lab!
:slight_smile:
I like this learning from each other.

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Which side of the pond are you? I should have known CRP–we call it that, too. It’s a bit harder out of context! (we call them basic metabolics or comprehensive metabolics, but chem-7 etc will get you where you need to go as well).

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I’m from the Kentucky side of the pond :slight_smile:

Pt#3: His high Lanoxin readings may be due to DLIF, an endogenous digoxin-like immunoreactive factor made in the arenal cortex in response to hypervolemic conditions. In the lab, most, if not all drugs are measured using antibodies. In the bad old days, the antibodies used were promiscuous, meaning that they did not bind to just digoxin, and we would sometime post a result that didn’t make sense given the patient’s medication history. The antibodies used are more specifc (i.e. they aren’t sluts), but they can still cross react in rare cases. The other reason for a high dig reading w/o toxic sogns could be related to the health nut below.

New case: Yes, the rule of thumb is (or was 8 years ago when I last worked in a blood bank) one unit of FFP for every 6 units of PRBCs given, as the citrate preservative binds Ca2+. In this case, the patient was O neg (hence the rushed surgeon’s cryptic comment), and when we exhausted our 6 O neg units, we had to switch over to O pos. She also got some A pos, for a total of 23 units. She needed Rhogam (50 units IIRC) to try to hide enough of the Rh+ cells from her immune system so that she didn’t make antibodies against the Rh protein and run the risk of HDN with her first Rh+ child. Either that or marry a guy who was Rh-. So, you would have called the Blood Bank and asked what was up with the patient, and give them a heads up for a large Rhogam order (again, IIRC, we had to special order a 50 unit dose directly from Ortho).

Grapefruit and St. John’s wort both inhibit CYP3A4, the enzyme responsible for metabolizing parent compounds to an inactive metabolite. Plendil and paroxetine are both 3A4 substrates, so in the presence of grapefruit and St. John’s Wort, the parent compounds are metabolized more slowly, increasing the risk of an overdose with a normal dosing regimen. The grapefruit counteracted the beneficial effects of Plendil, and the patient’s CHF worsened [On review I screwed that one up - you are right that Plendil would be potentiated, NOT sending the pt further down the CHF drain]. The Plendil could be substituted with Verapamil, which is not a 3A4 substrate.

Chan-Su is a Chinese herbal concoction that contains bufadienolides (harvested from chinese toad skin scrapings), i.e. cardenolides. There is no way to know how much bufa is in the given herbal prep without specialized measurments, so cardiotoxicity from its use is not uncommon. The Chan-Su precipitated a cardiotoxic event in the patient.

Vlad/Igor

27

Ah. thanks! But we didn’t know the blood type of the girl. :confused: If she got 10 units of O+ PRBCs and she’s O-, I’d say we have a HUGE problem, beyond her need for Rhogam! (like sentinel event time)

Cool beans on the OTC herb stuff–we’re going to see more and more of that (I would hate to have to take nursing pharmacology now!).

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Paroxetine is a 2D6 substrate that is also a powerful 2D6 inhibitor. I would now expect to see levels of other 2D6 substrate drugs rising to dangerous levels.

SJW is an inducer of 3A4, which can be expected to cause lower blood concentrations of other 3A4 substrates which then could drop to subtherapeutic levels.

The grapefruit juice will inhibit some of the extra 3A4 enzymes, just to make the calculations more complicated.

Then, I’d remember I’m there to do a psychiatric consult on the nice lady in the next unit, and hurry on. I hope you’re all on duty the night when something bad happens to me! :slight_smile:

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Well, as a total non-medical personnel type who’s bothered to read the owner’s manual I’m amazed at the complexity of what y’all have to deal with on a regular basis and I’m completely banjaxed that I’m almost able to follow about 60% of what you’re saying! It’s totally fascinating, though, I hope y’all keep it going. I’m learning all kindsa cool stuff. It’s really fascinating to see the differences in terminology and practice between countries–I guess I’d always assumed that medicine was a universal language.

Do we have any MDs who want to chime in on this? Where’s Qadgop’s weird penis guy when we really need him?

I just got done watching Tony Bourdain explain restaurant terminology and procedures and this thread is weirdly similar in character to to that–it’s so cool watching pro’s work. :stuck_out_tongue:

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On the Blood Bank issue-not necessarily. Banks don’t usually have a lot of o neg units lying around since they’re in such hot demand for traumas and such so it’s not unheard of to switch over to o pos when massive transfusion is called for. You would, of course, have already screened the patient for existing antibodies and gotten the approval of the Blood Bank Director for the change. I’ve done it a few times when working on G I bleeds and AAAs. Ideally you’d want to try and avoid Rh switching with a young female patient but it isn’t always pratical and is lots better than bleeding out.

31

My first thought on who to call with the chick with 6 units of PRBC:

Renal consult!

I’d really like to see a 12-lead on #2 and #4. I thought I had the answer with that, until I got back down to #1. For her, I’d like an order for a (repeat?) chest x-ray.

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I can’t play the game as it’s intended, but I’ll be watching this and similar threads with interest (thanks eleanorigby) because I’m premed and working in a hospital. Sometimes I get sneaky suspicions about what’s going on with people, but I don’t have a good idea based on lab results etc.

Watching how people think these things out is really educational.

EDIT: But now reading this on preview (now that I’m not trying to play) I still would have pegged the Hispanic gentleman as the person most likely to go south - undetermined source of pain could be a bunch of things.

33

That was exactly the situation we had. She was bleeding out as fast as they were (quite literally) squeezing the units in through large bore IVs. The surgeon later said he’d never seen anything like it. We broke all sorts of AABB rules, but we saved her, and I’m going to guess that she was fairly well protected by the Rhogam. I wonder how she’s doing now…

Vlad/Igor

34

So…I’ve got a question that’s been niggling at me overnight. And perhaps this is hopelessly naive, so go ahead and settle back into your comfy chair and prepare to have a good gigglesnort at the noob…

As some of you probably know, I was trained in alt. medicine, where it was pounded into us for legal reasons that ONLY an MD (or chiro or dentist or ND, but a ‘doctor’) is allowed to diagnose and prescribe. So, to cover our asses and that of our school, it was emphasized that we saw clients, not patients. We interviewed, we did not diagnose, and we counseled, we did not prescribe herbs or supplements. Now, a lot of this is just plain doublespeak, to be sure. But just like that bottle of echinacea extract carefully and deliberately says, “To maintain a healthy immune system” instead of “Cures the common cold!” we could risk our livelihood if we used language that made it seem like we were practicing medicine without a license.

But it seems from what I’m reading here that nurses are, in fact, expected to diagnose their patients quite a bit. They’re expected to figure out what’s wrong and the best way to treat it, and to start that treatment and even to order tests in *anticipation *of what their doc will want to see.

So how does that jibe with the nursing scope of practice? Is it that there are some diagnoses within the nursing scope and some outside? Is it that you can legally make a temporary diagnosis but it must be verified or adjusted by an MD within X number of hours? Is it just that you have to get the job done because the patient in bed 2 needs help now, dammit, and the law can get fucked because there’s no doc to do it?

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… And WhyNot opens the 400 pound can of worms! Look at my scenarios carefully. I give you the admitting diagnosis (dx), but then I ONLY describe signs, symptoms and labs. I do NOT say, this woman has pneumonia–I say, this woman is coughing up “yucky stuff” and has a temp or a sharp pain upon inhalation (actually she has pleurisy–oops!).

Nursing has its own diagnoses. Gah-this is so involved and convoluted. I doubt I could do justice to it by posting. There are some nursing profs who will insist that nursing is a SEPARATE profession, independent of medicine. To that I say: :confused: because I, as an RN, cannot act unless I’m under an MD’s order–for SOME things. For most things. Technically, legally, I cannot even change a pt’s diet w/o an order. Or get a pt out of bed into a chair, if bedrest has been ordered.

It gets very tricky. I think everyone knows that a nurse can’t just go get a pt some Tylenol for the complaint of (c/o) a HA (headache)–that’s unlawful diagnosing, prescribing and dispensing (in the hospital setting)–but most don’t realize it holds true for most everything else as well.

This is where standing orders and protocols come into play. They can (and do) save lives. No doctor, not even Marcus Welby or our own dear QtM, can be everywhere at once or answer every. single. page. night. and. day. Truly GOOD docs write pro-active orders. Their admission orders already anticipate discharge (as much as one can plan for the future) to some degree. They will give the nurse’s parameters in which to work. Excellent communication skills are vital to nursing. And the RN must be assertive and not easily intimidated (or not at all intimidated). If you keep the welfare of your pts foremost in your mind, all else falls into place, usually.

What I have described in some of my asides is indeed my practice. I have known most of these docs for almost 20 years. I trust them and they trust me. This is VERY different from new nurse talking to doctor X or RN new to this hospital( but experienced) talking to Dr X.
I worked one day of agency nursing in my life–at a different hospital. I asked for orders on everything that was not already covered. I did NOT just go and do stuff like I did in my staff job. (I quit the agency after one day–I saw liability issues that I was not comfortable with. YMMV). I do not recommend that anyone just “go and do”. I also do not recommend that you take a verbal order from any doc, unless it’s in a code situation, UNLESS you know and trust that doc, and s/he you. Even then… it can get dicey.

It’s long and complicated, WhyNot–in some areas of nursing, we are indeed independent practitioners and practice the complex wordplay that you are familiar with. In others, we are directly dependent upon a doctor’s orders and it behooves us to not forget it–for our license’s sake. Does that make sense?

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Sorry, I’m good at that! :smiley:

Right, absolutely. I see how you worded everything as signs and symptoms, and that doesn’t surprise me. It’s in the following discussion that I see what look like diagnoses made on the nursing level (“renal failure”, “dig toxicity”, “could be aneurysm”, “lytes are out of whack”).

So can (and should) a doctor write an order on admission like “400 mg Tylenol for general pain or headache should the patient complain of such a thing and the nurse think it’s not worth paging me on the golf course,”? In medi-speak, of course. :wink: (Which I think would be that handy little “prn” abbreviation, right?)

“Standing orders” come from a doctor, and “protocol” comes from hospital administration, yes? Must suck when the two conflict…

I think it makes as much sense as it can until I get there myself. And it sounds like it will change with every new place I work, and even with different doctors within the same place.

Thanks again for letting me tag along in this thread. I feel a bit like the little yappy dog running alongside the big busy pack, but I’m having a great time!

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Answers:

  1. #2, #4, and #1 ALL need IV access. What you say? That wasn’t already done? In RL, it would have been, but I wanted you all to think and notice what was missing. Irishgirl mentioned it with her post. (btw, what is LRTI?). nursing instructors love to be sneaky like that. Word to the wise.

  2. What to do for #2 specifically? You can go over him with a fine tooth comb. I mean thorough head to toe assessment (what docs call a physical exam). I would trend some vitals and look at his labs. I would look to see how his VS trended with his meds.
    I would also TALK to him–try to find out why he is so sure he is going to die. (this may be apocryphal, but I have had too many ICU pts call for Mama or say they’re going upstairs etc and then die to not pay attention to this guy). Something is going on–either his ACE inhibitor needs tweaking or he needs to come off Dig(or both).
    The runs of bigeminy are another sign of Dig toxicity–there is no order (did you notice?), but an RN can go ahead and HOLD HIS DIGOXIN (and s/he should have). When I call the doctor, I’m going to update him on the status, but now I’ll start pressing him/her–does s/he want a 2-D echo? How often does he want enzymes (note the subtle difference between “do you want labs drawn?” and “what frequency would like the labs drawn?”. Does he want a consult with the CHF nurse? Has he spoken to the pt and the family about DNR?

  3. Priorities:
    This guy needs fluid. We are not told how much IVF he got in ER, but his H&H is low and probably will continue to drop a bit (there’s a lag time). He needs at least one good IV access (18 gauge in a large vein), 2 would be better. (you have a hospital policy re IV access. Also, ER already did this-make sure the ER IV accesses work. Yes, I’m serious).

He will need to be transfused (we transfuse under 8) most likely, so we need a blood transfusion consent. Is he a Jehovah’s Witness or similar? Find out. Once he is rehydrated, his H&H will drop (dilutional). Type and screen him.(yes, you need an order for that). I’d be amazed if ER hadn’t already TxS’ed him, though.

When was the last time he had ETOH? He may go into DT’s. He’s NPO, but Librium can be given IV. Also, you can anticipate some of his needs and let him know that he will most likely be passing black stool (some pts freak out), and let him know to call the RN if he starts vomitting or has abd pain. Explain the NPO to him. Do not sound apologetic; sound sympathetic. If he gets ornery, get tough by asking him a question: does he want to go through what he went through in the ER again? No? Good-that’s why he’s not eating–to prevent that. You may have to repeat yourself.
Last one: not a true emergency, but doc needs to know. First do a thorough assessment on her-auscultate her lung sounds, get new VS. Get details–when did this start, what makes it worse or better, is the pain constant, does it change location etc. THEN call the doctor.

I have to go do my other job now–librarian student “clinical”. Ciao!

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Some are (renal failure), some aren’t (dig toxicity). Also, we (RNs) never, never tell the pt or family that they have “renal failure”. I tend to say “your kidneys aren’t working well (or just not working)”; doctor has ordered/put you on X etc. “Could be aneursym” is anyone’s guess–again, you do NOT say this to the family or pt. Never speculate in this way to them–speculate at the nurse’s station and/or with the doc (best phrase it as a question).

prn=pro re nata, Latin for as required. I live my entire life, prn! :wink: Yes. A good doc will try to cover these little contingencies so that they are not called at 0300 for Tylenol.

BINGBINGBINGBING!!! And WhyNot takes home a prize! Note: if the contest comes between protocol and actual orders written by the doc (not “standing”)–his take precedence. (unless the med ordered is non-formulary. Unless the treatment is outmoded such as Betadine in wounds. Unless–my head hurts now)

It’s many layered and most of the layers don’t change too much between hospital to hosp.

You’re very welcome!

39

I will post one last scenario later today.

40

In case anyone doesn’t know- I’m a doctor, but a baby doctor (F2/first year resident/first year SHO) and I’m chiming in because I can always learn more!

For the asthmatic girl- anyone who has asthma requiring hospital admission here will be prescribed steroids, they will get magsulph in the A&E, and I will prescribe PRN nebs, 100% oxygen and an antibiotic to be given if temp spikes or there is a cough productive of sputum (that’s what is on our asthma protocol here), they’ll also get saline nebs, chest physio and a peak flow meter.

Mostly the JHOS (interns/F1 doctors/newbies) write the medicine kardexes on admission, and they are well trained to put everyone on some sort of painkiller, laxative, antiemetic and indigestion medication PRN and to write anyone bed bound up for a bloodthinner and some TED stockings. I just come along and stop and start things as seems appropriate, or as my consultant tells me (and their word is law).

As a doctor, I can tell you absolutely nothing is as heartsinking as answering a bleep to be told “Could you come and see Mr X, I just don’t like the look of him”.
That is usually a bad sign of things to come, and the conversation usually goes something like this:

  1. “Who the &$%@ is Mr X?”
    I have 70 patients under my care, I’ve been off all weekend, and busy admitting people in the A&E department all day so I don’t know most of them yet.
  2. “Can you tell me in exact terms why you don’t like the look of him?”
    Angry blistering Rash? Pale and bleeding from a wound? Swigging from a bottle of whiskey and cursing? Making annoying faces at you? Not breathing? Specifics please.
  3. “What are his obs?”
    …oh you haven’t done any since lunch…could you do some now, please?
  4. “Right, what medications is he on? Well, could you get the chart and find out please?”

At which point, just before my head exploded, I discovered that he’s got chest pain and a BP in his boots and had his aspirin stopped yesterday in preparation for his cardiac bypass operation, but a whole load of new antihypertensives started.

At this point, I’ll ask for IV access, an ECG and bloods to be done while I get to the ward (which, if it is a big hospital or I’ve got another sickie could be 5 or 10 mins), and for someone to call the radiographer for a portable chest Xray and to stick a sticker on an Xray form so all I have to do is sign it when I arrive.

There’s recognising a sick person, (which is a vital skill for all health care workers) and then there’s realising someone is sick and doing the things you can do and doing them well while you wait for other members of the team to arrive and help out. That is also a skill, but it is much harder to do well.

If I have good nurses, a really sick peson can be sorted out quickly, efficiently and easily. If not…well, my life can get a lot harder.