Please help me figure out what happened to my pt

  1. 0 I had a 90 something patient admitted for SBO. She did not speak a word of english so I could only base my asessment on objective data. She was NPO, had NG tube that drained ~400 cc over my shift, IV fluid @75 cc/hr. She was drowsy throughtout the shift (had sleeping pill & antipsychotic meds), chest clear, VSSA, abdomen slightly distended w/ faint BSX4. Voided twice in bedpan. I checked on her regularly and she seemed fine.

    So I went on my break and told my covering nurse to do a set of vitals in an hour. When I came back the nurse told me that when she went to do her vitals her sats were 70% on 2L O2 via NP. She had coarse crackles thoughtout her lung fields and bladder scanned for 400 cc. Raised O2 to 5L and sats remained in low 80%. Throughtout this time her VS continued to be WNL, RR was 20/min. Breathing fine, not using accessory muscles. Rousable to speech. RT was called and she was placed on high flow O2 mask @ 80%. Sats slowly rose to >95%. Resident paged & ordered chest x-ray, abx, lasix, and something else that escapes my memory.

    I was shocked that such a fast change would occur within an hour. I was also wondering what happened - I know that it could not have been fluid overload - she wasn't getting much. She was also peeing fine and her NG output was Ok. Someone said that she could have aspirated - but how with an NG tube? She was in semi-fowler's throughtout my shift and I can't really figure out what happened. I left before the results of the x-ray came.

    What do you guys think? I can't stop thinking about her and wondering if I missed something...
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  3. Visit  Florence NightinFAIL} profile page

    About Florence NightinFAIL

    Florence NightinFAIL has '2' year(s) of experience and specializes in 'Medical - Surgical'. From 'Earth'; Joined Feb '07; Posts: 267; Likes: 549.

    44 Comments so far...

  4. Visit  brandy1017} profile page
    1
    Most likely it was fluid overload, she was a 90 year old person her heart was probably not as strong as you or I, could of had a history of CHF. Also if she was septic from the SBO or if there was a perforation unknown to you she could have went septic with ARDS. Although CHF would be my first thought!

    Well the resident covered the bases, CXR, lasix, antibiotics as far as the hypoxemia goes. What did the CXR show? Were they going to repeat a KUB anytime soon to check the SBO?
    SilentfadesRPA likes this.
  5. Visit  Florence NightinFAIL} profile page
    0
    ^I was discussing this with my supervisor & we went over her chart. No history of CHF or any other heart issues. Pretty good for 90+ year old.

    This happened my on my last shift so I don't know what the results were or what happened to her afterward.
  6. Visit  RoyalPrince} profile page
    0
    For future note I would have called a Rapid Response and get all those thins ordered stat right there and than after putting patient on a NRB
  7. Visit  thelema13} profile page
    0
    Any resp hx? Older pts decompensate quicker, it sounds like fluid overload by what the doc ordered. The nurse covering for you should've responded quicker, rapid response should have been called, but these things happen. Why was she NPO and on NG suction? Dont forget sedatives lower RR, possibly allowing fluid to build up, adding to the already compromised lung status.
  8. Visit  nrsang97} profile page
    0
    Fluid overload.
  9. Visit  canesdukegirl} profile page
    2
    I like Brandy's response. It isn't uncommon for a SBO to perforate, however I would expect the classic signs of sepsis such as tachycardia, hypotension, oliguria and SOB to be apparent during your initial assessment.

    It's gotta be fluid overload. Do you remember what her sats were before you went on break? What did her lung bases sound like? Were they diminished? Did she take deep breaths when you were listening to her lungs? How long had her NG tube been in?

    Sometimes pts don't like to take deep breaths with an NG because it 'feels weird'. The NG tube coupled with the sedative in a 90 year old would make me think that she wasn't taking deep breaths, resulting in atelectasis.
    netglow and VICEDRN like this.
  10. Visit  Cat_LPN} profile page
    0
    I had a pt who did something like that.. stable on minute, circling the drain the next. ARDS was cause of death due to pneumosepsis. And NO, she didn't have any respiratory symptoms at all, nor was she febrile. Very bizarre.
  11. Visit  mama_d} profile page
    1
    I'm voting for fluid overload here too.

    Although I have had a couple of pts go into flash pulmonary edema on me, CHF acting up (even if previously undiagnosed) is way way more common.
    ladyboyd likes this.
  12. Visit  Biffbradford} profile page
    21
    "So I went on my break and told my covering nurse to do a set of vitals in an hour."

    OKay, I gotta ask. How long are your breaks?
    ChristaRN, Krista09, rnmi2004, and 18 others like this.
  13. Visit  nerdtonurse?} profile page
    0
    Okay, here's my thought. Small bowel obstruction -- you get GI contents backing up, you get pressure on the diaphram as the belly distends. You didn't mention any pedal pulses, but I've had a patient have a SBO due to mesenteric artery narrowing; resulted in sudden, full onset right sided heart failure.
  14. Visit  Jenni811} profile page
    2
    i work in cardiac/pulmonary unit so we get patients like this ALL the time. To mee, it sounds like she may have some CHF and had fluid overload with pulmonary edema.

    I'd be curious to know what her EF is. But pulmonary edema/fluid overload can happen very quickly especially to a 90 year old who i'm guessing has some CHF. You didn't do anything wrong.
    ladyboyd and leslie :-D like this.
  15. Visit  canesdukegirl} profile page
    1
    Nerd2-

    But she had an NG tube...and it was draining. Are you thinking that it could have become clogged?
    LookingAhead likes this.


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