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Raising the Bar in Rehab

Clinical Judgment and Lab Values

Published October 22, 2009 7:52 AM by
Many times before a treatment session I will speak with the RN and discuss if the patient is appropriate for skilled therapy.  Literally 99 percent of the time, the RN will say "Oh yes, please go get the patient out of bed."  Occasionally a nurse will ask to hold the pt due to uncontrolled pain, fatigue, or unstable vital signs.

The problem occurs when I look at the chart and see a glucose of 345, or a hemoglobin/hematocrit reading of 7.1/23 percent.  Prothrombin time of 45 seconds. 

There is a fine line of discussing these cases respectfully with nurses or other health care providers without subtracting from their role as caregivers.  When I explain the patient is not appropriate for PT, many will respond with "If I can walk him to the bathroom, you can work with him from therapy."  Many nurses believe it is their responsibility to determine what impact lab values have on other treatments and have a difficult time accepting our opposing clinical judgment. 

It's always a compromise to say "I don't feel comfortable treating a patient with this current status.  Let me have my supervisor speak with you if you have any further questions." 

Educating our co-caregivers on risks of activity and importance of recovering from medical complications before strenuous activity is an important part of our job.   Have you ever dealt with this?  Where do you draw the line of acceptable lab values for a pt to work with therapy? 


Hey Lisa,

I had a situation like this the other day.  I had a patient on my schedule who had Hgb/Hct readings of 7.1/23.  On top of that, the patient's BUN was 119, which on our electronic documentation system gets TWO exclamation points to indicate a "panic" level!  Anyway, I talked to the RN about the patient and we both agreed the patient was not appropriate given these lab values.  

Then, over lunch, I got a page from the MD.  I called him back and he told me to see the patient regardless.  The doctor told me that the levels were a cause for alarm, but not a cause to cancel therapy.  He told me, "You shouldn't be scared off by those numbers!"  I was a little put off by his comments, but I added the patient back to my schedule for the end of the day.  It ended up that I wasn't able to see the patient due to other mitigating circumstances, but I still felt awkward about the whole situation.

Where would you stand your ground?  Would you tell the attending physician "no, I am not going to see that patient?"  It was an interesting situation.

Mike December 22, 2009 9:21 PM

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