Nursing medication errors can literally kill patients, and nurses are on the front lines and need to be vigilant in preventing them from happening!
5 Questions to Ask Before Calling the Doctor
As a nurse, sometimes it can be difficult to know just what your patient needs. When you don’t know – it can be nerve-wracking trying to decide your next action. Do you call the doctor immediately, do you just ignore it and hope for the best, or do you have to call an RRT?
When you’re unsure – it’s common to call the doctor or provider because that is a frequent solution as they often know what to do. However, not every patient issue needs to be called to the provider. Decreasing these unnecessary calls can increase your efficiency and problem-solving skills, but additionally will allow the providers to be more efficient as well. To help you with the decision-making process – these are 5 questions to ask yourself before you call the doctor.
1. Is the Patient Stable?
Learning to be a great nurse involves learning how to prioritize. Whenever there is a change in patient status or a reason to call the provider, always ask yourself – “Is the patient stable?”. This will oftentimes seem obvious but calling a Rapid Response can be nerve-wracking. What if you call one and everyone thinks you’re dumb because it wasn’t necessary? This is a common worry as a new graduate RN. As you gain experience in nursing – you will be able to more easily be able to identify the need for an RRT when it presents itself. However, in order to assess your patient’s stability – you really must do two things first (in this order!):
You must lay eyes on your patient. Let me repeat that – YOU MUST LAY EYES ON YOUR PATIENT. You may not even need to touch the patient and already acknowledge the need for immediate emergent intervention. If they are unresponsive and not breathing and/or don’t have a pulse – you can immediately activate an emergency response (CODE BLUE). However, it won’t always be so black and white – so the next step is to assess their vital signs.
Obtaining a new set of vital signs is imperative in order to assess the stability of a patient. “Is the patient stable” really just means “are their vital signs stable”. A patient who doesn’t have a pulse has a HR of 0 – so you don’t need to grab the Dynamap and grab a full set of vitals (spoiler – they won’t have any!). But it’s usually less clear. The patient may have increased lethargy, increased SOB (but not in acute respiratory failure), new chest pain, or any other changes of status. Getting these patient’s vital signs will determine whether or not they are stable. A patient who is SOB, in the tripod position, has an SPO2 of 80% on 4L NC, and RR of 48 – this patient needs an RRT or whatever emergency response team activated immediately. A patient with COPD who is moderately SOB, is 88% on 2L NC, and RR of 28 and mildly labored – this patient can likely be handled over the phone with changes in respiratory treatments and oxygen therapy.
If the patient has been deemed stable – you can move onto the next question.
2. Is there more information I need to know first?
This will obviously depend on the situation and will require some investigation. If the patient is SOB – what is their history? Do they have any related diseases such as Asthma, COPD, or CHF? If they have back pain – have they had this before? What do they usually take for it? It’s possible the same complaint or situation may have happened earlier in their hospital stay – what was done about it and how did the patient respond?
Investigating trends in their labs or vital signs is also important. If a patient’s blood pressure is 180/90 – what has their BP been running? The same holds true for hypotension. A patient whose BP is 90/40 but who’s baseline is 90s/40s is important to know. If you get a call for an elevated troponin or lactic acid level – what were their previous levels? Note all of this information for when you have to call the provider – so you can anticipate what they will ask and assist them in making the appropriate clinical decision.
The next important step is to check the orders that already exist.
3. Are there any PRN orders?
Many times patient’s will have “PRNs” or medications “as needed” that are already ordered by the provider. This means they have a medication or order which can be used for pre-established reasons that the provider must list. Look at their MAR and see if they have any PRN medications.
Some frequent PRN medications are as follows:
- Melatonin 3-9mg PRN for sleeping difficulty
- Acetaminophen 650mg Q4H PRN for Fever > 101.4 F
- Ondansetron 4mg IV PRN for nausea or vomiting
- Morphine 2mg IV Q4H PRN for severe pain
- Hydromorphone 0.5mg IV Q4H PRN for severe pain
- Ketorolac 15mg IV Q6H PRN for moderate pain
- Hydralazine 10mg IV Q6H PRN for SBP >160
- Ipratropium-Albuterol Inhl Q4H PRN for SOB or wheezing
Other Frequent PRN orders include:
- Oxygen via NC PRN – titrate SPO2 > 94%
- Heating pad PRN for back pain
- The patient may shower PRN
No matter the PRN order – it is your job as the nurse to look for which PRNs are available to you, and if you can utilize them accordingly. If your patient above who is mildly SOB and wheezing with a history of COPD – give them one of their Duonebs if it is appropriate. If they just received a treatment and still have not improved – then calling the provider is likely necessary.
4. Can I phone a friend?
Sometimes we may not know what to do with our patients, but we may also be unsure if we need to call the doctor for it. Asking a fellow nurse’s opinion on what needs to be done for your patient can improve your problem-solving and clinical judgment. Your nursing colleagues, especially those with more experience or even just more skill in a particular area – may be the perfect person to ask of their nursing opinion. Do they feel like its necessary to call the doctor – or is there a nursing intervention that can be tried first instead? Are you unsure of what EKG rhythm you are reading and think you might see a run of VTACH but aren’t sure – ask a nurse who is good at rhythm interpretation.
Now I am NOT saying that asking a fellow nurse is a replacement for calling the provider. However, sometimes bouncing ideas off of our colleagues can save us from having to make an unnecessary call. Even calling the nursing supervisor may be a resource which you can utilize if appropriate. However – for a new significant change in patient status or vital signs – the provider will need to be called regardless.
5. Am I calling the right person?
OK – so you know that you’ve exhausted your other options, you have the background information you need… now you just need to actually call the provider. But make sure you are calling the right provider. First – check to see who the attending physician is on record. Is there an in-house medical team such as a hospitalist group, house coverage, or medical resident team that covers that attending? If not – you may need to reach out directly to the attending physician’s service to speak with whoever is on call. This will be facility-specific, so you may not always know if you are new. This is where asking your colleagues for assistance can benefit you.
Reaching out to the medical team (listed above) is common and usually, they can help! However, sometimes they are not the right person to be notified in certain instances. Are there any specialists on board? If Infectious Disease is seeing a patient and there is a positive blood culture – it would be better to put a call out to them instead. If a patient who is on dialysis has uncontrolled high BP, placing a call to nephrology would be a better choice as well. You can reach out to the general medical team – but don’t be surprised if they ask you to place another call to the specialists instead.
Now you are fully prepared to make the phone call and accurately communicate what is going on with your patient, you will have investigated the background information, you will have obtained vital signs and done a quick assessment, and you will have recommendations for medications or orders at the ready (thanks to the other nurses you’ve asked!). As you can see – this perfectly sets you up to provide a great phone report to the provider! To learn more about giving a great phone report to a provider and steps to calling the doctor – you can read all about it here!
Calling the doctor doesn’t have to be scary. If you critically think your way through these important steps, and utilize my IMSBAR communication style – you WILL succeed and you will be amazed at how far a little preparation can go.
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Will Kelly, MSN, FNP-C
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