Anyone with ideas/secrets to share? Please
Sometimes you just have a situation when something is wrong and you can't quite put your finger on it, but you just know that trouble is coming.
you get a little knee ache when a twisters a' comin too?
"Somethings wrong but you can't quite put your finger on it" isn't a lot of help. If everything is normal (VS, UOP no complaints) but you've got a "feeling" chances are the Dr ain't gonna be able to discern what the problem is based upon your description of the type of knot in your stomach. If trouble is coming give me a call when it gets here, I don't like to wait.
So what are you supposed to do if an order for a med expires at an inconvenient time and the pt needs it? I know what I would do...I'd just write a telephone order, but technically, that's not legal since I didn't actualy get a telephone order. It would also depend on what the drug was; I wouldn't do that for abx, cardiac meds, narcs etc.
For the record, I have also used the "pt doesn't look right" line myself, but I always have vs, labs, etc. in addition.
Not to be sarcastic, but do you think I would be insane enough to call a doctor and just say, "Uh this pt doesn't look good" and have no vitals, no recent labs, not listened to his heart, lungs, etc.? Really? Honestly?
It does seem like most of the complaints from folks here revolve around being paged for housekeeping issues in the middle of the night. Anyone here ever actually get a page for, "The patient doesn't look right" with no supporting data? Honestly, that would suprise me a little.
Anyone here ever actually get a page for, "The patient doesn't look right" with no supporting data?
Absolutely.
Not to be sarcastic, but do you think I would be insane enough to call a doctor and just say, "Uh this pt doesn't look good" and have no vitals, no recent labs, not listened to his heart, lungs, etc.?
Really? .
Honestly? .
I tend to agree with what Dr. Cox said. Sometimes you pick up on subtle changes that you've seen in the past right before everything goes down the chute. It sticks in the back of your mind, and though you may not be thinking of that specific incident, there's that little alarm that goes off in the back of your head.
Really? So you've never noted a patient who "looks ill/toxic/worse than last time seen on rounds, etc."?
I think you underestimate the value of just looking at the patient and knowing they look ill. This has nothing to do with doctors vs nurses except when physicians insist that they are right over evidence which tells us that patients can and do appear ill before there are systemic signs.
Yes
Yes
ummmm...yes.
Fantastic, outstanding, really....meanwhile, just let me know what reliable indicator signifies a downward spiral. If the HR is 35 you don't need to tell me the patient doesn't look right. So if you HAVE the facts...just tell them to me. Here's a little exercise..pick the part out of this sentance that doesn't need to be said:
"Mr. X just doesn't look right, and he's having crushing substernal chest pain"
I'm glad we're all for gestalt and we can all join hands and dance circles around the old wise nurses (and I'm sure they have a much better handle on what to do than me)...but lets be real, if a Dr. put down "doesn't look right" in the subjective portion of his note...he'd be laughed at.
Telling me he doesn't look right isn't very descriptive but it doesn't necessarily mean that there isn't anything wrong with the patient.
What I objected to was the response that assumes that such a call is totally bogus and needs no response. If you feel you must clarify what "he doesn't look right" - go ahead; I'd prefer to ask and still go and see the patient myself. The resident that stays in bed is the resident who finds themselves in trouble, IMHO.
There is a lot of bravado here about unnecessary pages and resident abuse; I've been part of it as well. But lets not forget that residents and attending physicians are aprt of the problem. If you don't educate someone on what an inappropriate call is, you can expect to get another one. And if you don't go see a patient when there is potentially a problem, its only your arse which is going to pay for it, not the nurse who has paged you to tell you of the problem.
Never mind. Clearly, you've missed the point. Such a shame that you haven't yet learned that there's more to treating pts than just numbers. Disregard such comments at your own peril (or your pts' peril, really).
As a graduating med student, I've worked with expert nurses that I would have died without.
Disclaimer: I will only be an MSI this summer.
I completely understand not wanting to be awoken in the middle of a very precious nap...Take it for what its worth.
Yeah, there is also anecdotal evidence and gestalt apparently. If you'd like to reduce this too numbers to shield your ego that's just dandy with me...you've allready decided to stick with the not looking right as an adequate reason to call for help. However, for others reading, I would encourage them to try to improve their descriptive vocabulary, exam technique and attention to detail so they can perhaps more fluently discern what it is thats...not right...before reaching for the phone. One options easy, ones hard...I know which one most people will choose.
My patients are in no peril...despite my sarcastic attitude I'll trudge my a$$ down there to see the patient despite your feeble attempt at discerning the problem...however, eventually you'll run into the few residents that won't respond...then your patients will be in danger because you failed to properly and clearly convey the need for a physicians attention. Don't worry though its not your responsability right?
"Mr. X just doesn't look right, and I am completely incapable of providing more information (which was the anecdote that started this discussion)"
I completely understand not wanting to be awoken in the middle of a very precious nap- I value my sleep as well ... There was one particular night where it was so severe I could not sit, sleep or do anything but writhe in pain. ... I basically was told that, yes she should have called for the order but that specific nurse was berated on an earlier shift for calling an attending ( or resident, I dont recall ) at nite for what said doctor thought was trivial.
I'm sorry you had that experience Jjeton. Pts. should never have to suffer in pain because of something like that; unfortunately, it happens all too frequently. Here's where you can take that experience and try to promise to yourself that you won't become that intern/resident/attending that bullies staff and makes them so fearful that pt care gets compromised.
Surely everyone here recognizes the difference between a 2am call that says:
"Mr. X's pain control is inadequate. His pain is so bad that he cannot sleep."
and...
"Mr. X just doesn't look right, and I am completely incapable of providing more information (which was the anecdote that started this discussion)"
And while you're busy cheerleading, please keep in mind that I've actually been on services where the housestaff REFUSED to leave a standing PRN order for Tylenol for the nurses. Why? Because they could not trust the nurses to actually inform in the physician when the patient had a fever so that a work-up could be done. They were afraid they would just give the Tylenol and be done with it; meanwhile some infection continues to brew.
So, yeah, we may all be on the same team, but we're not always using the same playbook.
I'm sorry you had that experience Jjeton. Pts. should never have to suffer in pain because of something like that; unfortunately, it happens all too frequently. Here's where you can take that experience and try to promise to yourself that you won't become that intern/resident/attending that bullies staff and makes them so fearful that pt care gets compromised.
Good luck to you!
The Tylenol example above is classic; too often we are asked for prn, RTC meds or treatments and these are given without thought to why the patient needs them. I do not want my gastric bypass patient to simply get Tylenol for a fever on pod #1 nor do I want the staff to wait until the HR is >120 before calling.
Thanks and don't worry. My wife would kick my A@@ if I did!
I find it interesting to read all these threads by med students and intern/residents complaining about ' stupid ' nurses and such. I have yet to meet one attending online or in real life that complains like this ( and before anyone says that they wouldn't complain to a patient, believe me its not true). They might complain about a specific incompetent nurse but never to the extent you read here from students and residents. Heck even the more experienced residents on this forum dont have these complaints. Just a thought.
You know, its true that many nurses dont realize the stresses residents are under but it seems that many on our side are guilty of the same. Until my wife started nursing school, I didnt fully understand it. A typical day for my wife of clinicals at one of the hospitals , who is still a student mind you, starts off by her walking onto the floor at 8 am and being handed a list of 5 patients with a list of their meds and charts. The only instructions are
" Here are your patients. See you at 8. " There very rarely is someone with enough free time to answer her questions or go over her work during the shift. She usually gets 10 or 15 minutes of her 1 hour lunch break ( the regulars at least get 1 hr + 2 15 minute breaks which they dont ever give up at least). Most of the patients dont speak English and half the notes ( which in this NYC hospital are not yet computarized ) are illegible. Meds are rarely given on time since they often dont get them from the pharmacy until a few hours after they are supposed to be administered. Oh and this is med-surg floor with most patients having complicated dx's and multiple conditions. Now she is a student so she isnt given more than 5 or 6 patients but the RN's on staff usually have at least 12 patients ( regulations be damned, this is real life...)
I thought the OP started a great thread, and I was really hoping for more specifics...what are your favorite remedies for constipation? pain? what little things should we avoid in treating common problems that might cause bigger problems?
If you are allowed and feel comfortable, try and be as liberal with your PRN orders as you can. Include antidotes if appropriate (glucagon, D50, protamine sulfate, narcan etc...),
Anyone with ideas/secrets to share? Please
as a student nurse here are some obvious, but still relevant tips that can help you avoid calls from the nurses:
If you don't have computer charting, please write legibly and don't use confusing abbreviations (PE has been used for so many things....)
please check allergies before you write orders. If we see an order for ibuprofen for mild pain and patient has NSAID listed in the allergy section and you haven't given me any other pain options you might get a call (if it is relevant at the time). This sometimes isn't your fault though, because I have seen NKDA written in the front of the chart and then later on in the assessment notes low and behold there are allergies listed there. So we all should be double-checking.
If you are allowed and feel comfortable, try and be as liberal with your PRN orders as you can. Include antidotes if appropriate (glucagon, D50, protamine sulfate, narcan etc...), mild pain meds, more aggressive pain meds if the situation might warrant it, tylenol and put a value on what fevers you wish to be called for. stool softeners, antacids/gastric pump inhibitors, benadryl, potassium. -basically just be as complete in your orders as possible.
Make sure any restraint orders are complete and include times and dates. One nurse might not notice an incorrect restraint order and then the night shift nurse might come and realize that it is incorrect and it technically should be fixed "immediately" and she/he would have to call to get a new order.
I have to say that as a student nurse most of my experiences with physicians and medical students have been positive. I agree with whoever said educate the staff on what warrants a call and what doesn't. I can say that we are going over what is critical to report, what can wait, what info to have ready if you have called a doc etc...
While I agree with good PRN orders, if you think you need to give glucagon, protamine, narcan etc, I want to know and see the patient before anything is given, unless the patient is actively dying. Moreover, while PRNs stop us from getting bothered, they do encourage polypharmacy. Given the age group that generally comes into the hospital, less is more. Before adding a medication to combat a side effect, I want to see if I can reduce something esle.
Even "benign" drugs, like diphenhydramine, can have significant side effects in the elderly. And then sometimes you can get carried away. I once saw a resident who wrote "1 g Ceftriaxone IV Q12h prn temp >37.9." Fortunately the pharmacy nixed that one.
So while I have to agree that PRN orders are good, one must not be too liberal and should only cover very common problems and must be tailored to the individual.