When a patient states "something isnt right..."

[turnforthenurse]

And try just cannot put their finger on it, what do you do? I have encountered patients like this and was told to never ignore it, because usually when patients think they are going to die, they do. Thankfully nothing has happened with these encounters. I try to get an idea of "what is wrong" but the patient doesn't know. Usually VS are WNL, might be a little tachy from anxiety or something. Upon assessment, everything just seems benign.

So what do you do?

[CountyRat]

Jackfackmasta wrote, "My preceptor had told me it was probably from moving her but the fact she desated twice during the day shift and never before alerted me to something was wrong."

In the case that you describe, the key finding was that the desaturations were new phenomina. If it had been, "just because you moved her," I would expect it to have happened consistently. When it is a new finding, watch out (like you did)! the patient is decompensating.

[Chaya, ASN, RN]

Studies have been made to analyze the hours immediately preceding an arrest and see if there are any signs and symptoms that could be predictive of impending arrest within a timeframe in which reversal of the deterioration could be reversed. They are finding there are signs such as subtle cardiopulmonary and mental status changes that should serve as a red flag to caregivers. When failure to act on these warning signs leads to an arrrest and death, it is called "failure to rescue".

If your facility is blessed enough to have a Rapid Response Team this is exactly what they were created for. In my hospital this was a team of Critical Care staff, usually nurses who functioned in an on-site, on-call capacity to respond to exactly this sort of thing. One of the specific criteria they encouraged us to use for when to call RR to the floor was: nurse just feels something is not right. They were able to assess the need for early interventions re:labs, Respiratory Therapy and in general mobilize a higher level of care-before it escalated into a code.

As some have pointed out, sometimes it's just someone's time and all is futile. But early assessment by trained eyes used to seeing what happens in an inpending code maximized the chance of intervention and survival. Many lives saved!

[blondy2061h, MSN, RN]

We have lists posted of criteria to call a rapid response for. The last item on the list is bigger, bolder, and all caps: GUT FEELING THAT SOMETHING IS WRONG.

[treeye]

This past weekend, a pt was just admitted onto our unit. The son of the pt was nasty and screamed at us that his Dad doesn't look right. The charge nurse panicked, she called the rapid response team. They did EKG, blood gas and everything. There were nothing wrong with the pt.

I guess it is always safer to call the rapid response team or whatever, but that charge nurse really didn't do well in stress.

[Pistachio]

I have most frequently found this to be anxiety in my patients, I have yet to have one go bad or code after saying that. However doing vitals signs and a quick reassessment helps to rule out any problems that might be detectable and to reassure the patient. I've learned though just to ask then if they mean they want anxiety medicine first.

[turnforthenurse, MSN, NP]

There have been studies done that show that about 70% of patients who end up with cardiopulmonary arrest experience feelings of anxiety, 8 hours before their arrest. That's a big percentage!

[FMF Corpsman, MSN, RN]

I have most frequently found this to be anxiety in my patients, I have yet to have one go bad or code after saying that. However doing vitals signs and a quick reassessment helps to rule out any problems that might be detectable and to reassure the patient. I've learned though just to ask then if they mean they want anxiety medicine first.

Pistachio, While you may have found this to be true so far, I would urge you not to become complacent. As most of our fellow posters have also found to be true, in my 30+ years of nursing I have witnessed this phenomenon many, many times. If I have a patient tell me something, I believe it. Hands down. I once worked a second job at an LTC facility and had this young 14 y/o girl who had this really rare neurological condition, at the time their were only 6 or 7 patients in the state that had it and she and her younger sister were 2 of them, but anyway, it was extremely debilitating and the mother had finally placed Dottie in the LTC,(she's long since expired) but Dottie used to tell me she had a strange man in her room sometimes, this worried me at first, because of security, and Dottie was blind because of her illness. I told the staff they needed to take particular attention to her room and watch if she had any strange visitors. I also told Dottie if her strange man came back, to use her call light and let me know. The next day I was getting report and Dottie's call light went off and I ran to her room, and there was no one there, I asked her why she used her call light and she said he was there, standing in the corner, and there was no one there. Long story shorter, it turns out that Dottie's visitor was in her words, "a nice man named Gabriel, and he was there to protect her." Dottie died a few weeks later. No one else ever saw or heard of Gabriel again that I know of. While this story may not be clinical in nature, there are plenty that are. I just thought this one was interesting and somewhat on point.

ANYWAY, as soon as you fail to heed the words or your gut feelings one day, someone is going to die, and it will be needless because you will have had the tools you need to prevent it. It may well be anxiety, hell, it could just be gas, we all know what hospital food is like, but if your patient tells you something isn't right and I just can't put my finger on it, what harm does it do to take a few minutes to check it out, so you have to spend a few extra minutes you didn't count on, chances are you would have gotten tied up somewhere else doing something you hadn't counted on doing something else anyway, isn't that how it always works, we're Nurses, sure it is.

[R. Obias Jr., R.N.]

This is where the saying that "it won't hurt you if you take some time to check out their complaints rather than to be sorry later on for not doing so" comes in, taking simple things for granted is not the proper way of handling complaints as a nurse. Specially with parents , a large percentage of their gut feel or intuition is based on the bond that connects a parent to her child that not even a doctor may detect.

[Chaya, ASN, RN]

I kknow I'm kinda cynical but spending a little extra time periodically re-assessing your pt, maybe advocating for a lab or two and paging an MD if need be takes WAY less time than running a code..

[CountyRat]

Here is an interesting article relevant to this topic:

'Gut Feelings' Matter in Dx of Kids' Infections

[tushardeep05]

Check everything, Vitals, Lab, head to assessment, call MD. Stay with patient.

[All4NursingRN]

I recently had a patient who was demented at baseline, confused and at times agitated, all which was normal for her as per the family. She kept trying to get out of bed but later calmed down, then she fell asleep. Then about an hour later I went to check up on her innocently and she gives me this wide eyed look and starts saying ''I'm scared'' I reassure her but something in me thought ''what was that all about'' I thought she may have been saying she's scared because I moved her to a different area of the ED, her family had left and maybe she needed re-orienting. (she was stable btw) But I figured she was demented and etc.. and maybe was just having one of her moments of confusion. She was too confused to answer anything appriately and couldn't say if she was in pain or not. She went back to sleep, no longer agitated AT ALL and was quiet (hint/hint)

3 hours after I get ready to go on my break I give report to the nurse who's covering me. I make sure this woman has her fluids going (she had choleliathiasis). I re-take her VS just because she looked off to me somehow (just a feeling I got, but couldn't pinpoint anything), her vitals were WNL.

I come back from break an hour later. The woman is in full blown hypovolemic/septic shock. Tachycardic up to the 150's, bordering hypotensive. Lethargic, but arousable. Got intubated and everything.

I then realize what she has said to me almost 5 hours ago ''I'm scared'' and also remembered questioning myself as to why she was no longer her usual confused self (this was the hint/hint in hindsight) but had gotten so quiet. You see at the start of my shift this pt was very talkative, confused, trying to get out of bed, but progressively became quieter and less mobile in her stretcher. I mean this is what you would want for a confused pt right? for them to become calm. But now in hindsight, those were huge red flags!

It gets harder to pick out a crashing pt when they have certain co-morbidities like altered mental status. On an A&O pt they can much better tell you that atleast ''they don't feel well'' or they pain is getting worse, or you see a change in mental status. But when the pt's mental status is already altered how can you tell. Maybe her acting ''normal'' was an impending sign. Maybe although confused, her saying she was scared was her only way of indicating the events to come.