Long-term care nurses are like traffic cops, managing data coming at them from multiple sources. Buried in the midst of vital signs, weights, meal percentages and overly detailed reports concerning bowel movements can also be found laboratory results. Nurses are typically gate-keepers who, before notifying the physician, assess these results in the context of the resident’s overall condition.
This task requires solid critical thinking skills and an understanding of the significance of the test results being reviewed. Below are listed various areas where the management of test results tends to be problematic:
Communication: Results phoned to the nurse from the lab, often stats or critical values should be read back in the same manner as physician’s orders. Make sure you’re aware of what your lab considers a critical result as those standards may not be appropriate for your facility’s population. Working with your medical director to define parameters for your facility and communicating them to your laboratory provider can prevent a serious delay in treatment. Regarding hard copy results, check the placement of the printer or fax machine where test results are received, making sure it’s accessible 24/7. (If kept in the DON’s office, which is locked on the weekend, bad things can and will happen.) When faxing rather than calling results to the physician don’t assume that no response means no action is required. The nurse’s ability to assess the results and assure appropriate follow-up is the cornerstone of this process.
Context: Certain test results “speak for themselves” such as a non-hemolysed potassium of 7.9 mEq/L. However, when evaluating most results its crucial to view them in the in light of the resident’s baseline values and clinical condition. For example, in a geriatric female a hematocrit of 32% may not be cause for alarm unless 2 days prior it was 38%. Similarly, a BUN of 85 mg/dL might lead clinicians to consider dehydration or renal disease unless they knew the test was obtained on a resident who was experiencing an acute GI bleed. Nurses must consider test results as part of the big clinical picture and make sure they provide enough information to the physician to do the same.
Misinterpretation: Perhaps no other test result is misinterpreted more often than the thyroid stimulating hormone (TSH). When used to monitor the treatment of hypothyroidism, a significantly elevated TSH suggests the need to increase the dose of the Levothyroxine while a dose reduction is indicated when the TSH is suppressed. This “inverse relationship” can confuse prescribers and result in inappropriate treatment of the disease. Nurses and consultant pharmacists should be vigilant in addressing this and other test related prescribing errors.
Test results are a valuable tool in the management of geriatric residents but carry risks of their own. By recognizing and addressing the above concerns you can prevent deficiencies, avoid lawsuits and most importantly provide exceptional care to your residents.
Bill Vaughan is the vice president of education and clinical affairs at Remedi SeniorCare Pharmacy.