Managing The Moderately Unstable Patient: The Challenge of Ambulatory Care Nursing

When a nurse educator makes the bold statement, “The moderately unstable patient is at the highest risk,” I’m interested in knowing why. I’ve thought about this statement ever since.

Wild Card by jparadisi

Wild Card by jparadisi

She explained that the task-oriented nature of ambulatory care units (ACU) is a contributing factor. While patients in the ACU are assessed by their physician or nurse practitioner for treatment readiness, and again assessed by the infusion RN during treatment, the primary goal of these appointments for patients and providers is to administer treatment, complete the appointment, and, for the providers, to move on to the next patient. The ACU patient then goes home to fend for his or herself until the next appointment.

If you spend only a small length of time at the triage nurse’s desk answering phones, the high risks faced by these moderately unstable patients are clear:

Pain
Chemotherapy-induced nausea and vomiting (CINV)
Blood clots
Febrile neutropenia
Depression
Herpes zoster shingles
Malnutrition
This list is not comprehensive. Individual risk factors such as living alone or comorbidities also play a role in overall risk factors.

Some risk factors that might occur during the ACU appointment:

Patient falls
Adverse drug reactions
Syncope
Patient and nurse are unaware that patient is unexpectedly unfit to drive after the appointment
The above factors often occur because the nurse caring for a particular patient is unfamiliar with that patient’s baseline functioning. This puts first-time patients, and nurses new to an established patient, at an increased risk for an unfortunate event.

So, how can ACU nurses protect patients and their nursing license in this fast paced, and rapidly expanding nursing specialty?

First, stop calling your place of work a clinic. The ACU is a specialty care area requiring its own unique set of nursing skills, and should be recognized as such.

Maintain a high level of suspicion. Asking the right question is more important than having all the answers. What you don’t know will harm your patient. One of the most common examples is explaining to a patient how to care for their back pain, only to later discover that the pain is shingles, which were missed because no one asked to see the patient’s back. Other important questions are: “When did you take your (fill in the blank) medication last?” If they haven’t recently, ask, “Why?” because the answer may surprise you. Asking the right questions is an essential part of a solid assessment.

Continuing education is critical to quality patient care. While ACU nursing may seem less demanding than inpatient nursing, it requires the same level of skill and vigilance.