My patient coded the other night

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    Right in front of my eyes. Thank goodness I had my charge nurse there and a tech. I don't know if I would have realized he was going downhill so fast. The other nurse knew that the RAP team need to be called, then maybe two minutes after the RAP team got in the room I called a code. Once the patient was stabilized he was transferred to the unit. I believe he will be fine.

    Some of my patients are so sick from the time I get them from another nurse. Their vitals can be poor even from the time I get them. Looking back through the day, they look the same. Experienced nurses say it will come with time, that you can just tell by looking at them with experience.

    Any tips from experienced nurse how you "just know"?

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  2. 15 Comments...

  3. 0
    Wow! Sounds like a busy night! Sorry, I don't have any tips, but with just the 3 years that I have under my belt, I've noticed I've picked up some of whatever that "it" is. I am more able to pick a pt who is more likely to go bad when I lay eyes on him/her.
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    I always am looking at a patient's color. They look differently just before they code. Some get much paler, others turn a funny mask-like gray color. Their behavior isn't always quite right either. A lot of them get lethargic and kind of faraway and detached from conversations. I think the real clincher is that when a person codes their face and limbs become relaxed and slack because they are literally dead. Sometimes you just don't know. I had a lady once who I helped to the bathroom. As I got her settled back in bed, she died (she was a cancer patient). If the patient is on telemetry you can sometimes see a change in their heart rhythm before they code. Vital signs may be poor, but I've seen patients sustain low B/Ps for many hours without coding. I think the sentinel event for a code is that the heart fails to perfuse blood throughout the body, particularly the brain.

    Learn to find that carotid pulse so you can quickly assess if there is cardiac perfusion. When people code, they usually pass out because the heart is no longer pumping any blood into the brain. Now, the cardiac nurses will tell you that people can also code and remain conscious. That is not standard, however. It is better to call a code and turn the code team away if you've erred than to stand around for 2 or 3 precious minutes trying to figure out if you've got a dead patient on your hands.
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    I had a similar experience recently with an 80-plus-year old who went from resting in bed to purple from the nipple-line up in minutes...I had felt bad about her all night, but had no obvious data or physical factors to back up my intuition. Ultimately, the code team believe it was a PE. It was a rapidly deteriorating and sad experience. I had just returned from hanging some iv meds, checked on everyone, and was starting to try to catch up on my charting. My coworkers and I were in the nurses' station, everyone was talking, and I said, "do you hear that? it sounds like someone yelling for help?" My coworker nearest the door went to check, I closed my book, went to follow, when someone rushed in to get me. We found my patient thrashing in bed, yelling that she was nauseous, that she "had to get up," and was turning blue.....FAST. At the same time I said "hit the code light," she tensed, and it was all a blur from there.

    It's one thing to participate in a high-drama, challenging situation as a support person, but I couldn't help feeling that, as her primary nurse, I had failed her somehow, and I still do. As a new nurse, I still feel like I have so much to learn and relearn. All that stuff we did in four years of nursing school was just the icing on the cake.
  6. 0
    Quote from jenrninmi

    Some of my patients are so sick from the time I get them from another nurse. Their vitals can be poor even from the time I get them. Looking back through the day, they look the same. Experienced nurses say it will come with time, that you can just tell by looking at them with experience.

    Any tips from experienced nurse how you "just know"?
    I believe that there's not any "one" symptom that tells you a pt is going to code, but there's just a combination of signs one gets when a pt is about to go bad. Like you said, that will come with experience. The other symptoms I've heard mentioned in this forum (gray, putty-like mask, faraway look) sound very common. You will eventually put these together with time (and then notice your own) and experience.

    I'm glad that your pt will be OK.
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    I do have a "funny" story about this topic. I work in the CVICU and had a patient who was a pulmonary nightmare so went panicky with breathing difficulty. He also had a hx of Ativan at home (giving a clearer picture here). Out of nowhere, he's panicked and restless. I go over to him noting he has not received any PRN ativan all day and calmly ask him what the matter is while checking out the vitals, EKG, O2 and the patient himself. He needs to have his wife sign the papers. "What papers?" I ask. "The papers, the PAPERS!!! NOW!!! I need my wife." I notice he is sweating and I continue to watch the monitor for any signs of cardiac involvement or O2 desat. I tell him that I need to know exactly what he is "Feeling" before I can go and get her. "Something is terribly wrong, horribly, terribly wrong."
    My eyes shoot up to scan for MI, or Arterial or PA pressure problems....nothing. "What else are you feeling?" I ask.

    Suddenly all panicking stops. "Love," he says. "Love?" I ask. "Yes. Wonderful, peaceful love. It's all around us. Can you feel it?" He askes as he gently places a hand on my arm and slowly looks at me with a distant, almost stoned, looking expression.

    All I can think at this point is HOLY CR*P! Oh no buddy. Not on my shift! There will be NO LOVE on my shift!!!! (This was the "funny" part)

    It turned out this guy was a severe retainer. Blood gases revealed his CO2 was off the charts. It would have been off three charts stacked end to end. He was intubated after becoming non-responsive shortly thereafter and was taken off life support a week later.

    Sooooo....I have learned that the sudden immense sense of peace and love we've heard people talk about with near death stuff is a sure sign that someone is CTD (circling the drain). I've also seen that diaphoresis, pallor and panic often precede a code by seconds.
  8. 0
    I always like it when a pt rings the call-bell and tells his nurse he's going to go into shock----then vomits blood off the ceiling and goes into shock! Or the pt who says her thank-yous and good-byes before going to sleep---peacefully dies during the night.
    However, most pts aren't thoughtful enough to provide you with a warning!
    As previous person said, it's a combination of things that give you a heads-up: color, change in behavior (I loved the one about "love"), etc, etc. Give it time, sometimes there's no warning at all, other times you'll look back and see there were slight changes and you'll learn from that.
    Amongst all the stress of things going wrong with a pt, remember that the main fear most people have is dying alone. So even if things don't work out for life, you can bring relief to family when they remember that their loved one had someone caring with them. All the best.
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    The worst one is when your cardiac patient says: "I have to do "poopoo"! Oh! Mama Mia! This is the worst! :redlight:
    You don't know how many times they vaso-vagal on the John and... departure?
    No matter how many time you tell them how important it is.
    My co-worker says that for her, it's when the patient says that their feet are burning! (Like they are going to hell?!!!) :angryfire
    Remember, they come in threes!
    Keep posting!
    connyrn :flowersfo
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    not two hours ago, my preceptor and i were tasking care of a 6-hour old baby with hypoplastic left heart syndrome. now, i have to say, i really hate the cardiac babies. it freaks me out that they turn purple when you take their pulses, or look at them cross-eyed. this is precisely the reason i'm going to be a non-cardiac nurse on my unit after orientation!

    but i digress.

    so, we had to pick up this patient at 4 pm. she was just hanging out, on room air, sats weren't too bad. she clamped down whenever she got mad, but i've gotten used to that. i was filling out the flowsheet on the computer when her sat montior alarmed. my preceptor was standing by the crib, talking to mom (who looked fantastic for someone who'd just given birth!), and she looked down and grabbed the bag-valve mask. eek- bad sign. i popped up out of my chair and saw that the baby was dark purple. sats in the 40s. I said, 'do you want rt?' and she said, 'no- call a code. now.'

    so, i looked around the room and saw the code button on our side of the pod was BEHIND THE BED. in my panic, I didn't think to go to the other side of the pod- i ran into the hall and pulled the button. then, thundering leagues of code team members come running down the hall, asking where the *** the code was. it turned out fine- i'd hit the button *right* outside our door- but god, i felt like a moron. then, as i ran in the room, the code team said, 'oh, nevermind. kid's breathing again.' my preceptor looked like she was going to pass out. now, this person wasn't originally my primary preceptor, but we'd had a patient code and die on one of our first shifts together. i started wondering if we were combining to become the angel of death or something.

    anyway...kids are weird when they crap out. they're fine, then they're purple. just like that. i worked in an adult icu when i was in nursing school, and you could watch someone circle the drain all day long.
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    I had a code experience on my 9th week of training, with a pt who had been having severe dyspnea on exertion, and PE had been ruled out. I had this pt for two days before she coded and she was able to tend to her own needs well, was A&O, and sat in bed knitting. As each test came back negative she would become more bewildered about her state of ill health. She told me several times that she just wished someone could tell her what was wrong.

    She had a port-a-cath that was suspected of being the cause of her misery, as it turned out that part of it had an occlusion (we were unable to access the device).
    When I came in on the third day, the night nurse told me and my preceptor that the pt had been confused and having trouble talking,saying the wrong words or things that didn't make sense.

    When we first saw her that morning she was sleeping and snoring heavily; she had hx of sleep apnea. When we tried to wake her up to check her status, she did not respond to verbal or pain. She had a resp rate of about 28. As my preceptor and I were trying to figure out what to do next, the resource nurse came in the room and started screaming to call a code. I was surprised at the time because I am a trained EMT, and I had never seen a code from this end before (the circling the drain part, usually the pts have already gone down the drain by the time we got there).

    So there I am in the room, which is beginning to rapidly fill up with people. I took a BP which was 120/72 with pulse in the 60's. People were asking ME all about the pt, since I was the most familliar with her. So here I am, new grad, with my pathetic scrap of pt notes and my poor overwhelmed brain, trying to remember what her test results were. Someone behind me was commenting on the fact the the pt had an actual BP, and the resource nurse was arguing with the Dr. running the ambu bag about why wasn't the pt going to be tubed in the room. (Doc wouldn't tube pt because we had to go to CCU in the elevator)

    Now my question is: Is it customary to call a code on someone who's still breathing and still has a BP?

    Rebecca
    Last edit by Fairemaid on Sep 27, '05 : Reason: spelling error


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