A nurse's intuition

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    Hi PICU nurses! I'm coming up an a year in the PICU, and just beginning to trust my intuition in regards to when I think there is a problem with a patient. Have you ever gotten that feeling in your gut that something is up? Even if there is no assessment changes or vital sign changes to indicate it yet? I used to feel that way a lot when I was new, but I think it was more nerves that anything. Now that I'm more comfortable, I'm starting to get some internal feelings that are more accurate.

    Recently I had a patient with sickle cell admitted in acute chest syndrome. Something was telling me that she just didn't look right, even though clinically she was okay on the nasal cannula. I kept pushing for another blood gas, increased O2, and another chest x-ray, even though there wasn't any real clinical signs to indicate that they were necessary. It was only when the patient started having some retractions and nasal flaring that we got the gas (bad) and the x-ray (almost a total white out) and put the patient on BiPAP. She ended up intubated and needed an exchange transfusion by the end of the night.

    So I'm curious- what stories do you have about your own nursing intuition? What situations did you feel that something was off and were you able to avert a crisis because of it? Please share!
    Joe V likes this.
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    I've thought long and hard about Benner's novice-to-expert model. She describes the expert nurse (which I don't think most are after one year of practice) as functioning intuitively - which you mention in your post. I do not believe that (most) nurses function on an intuitive level. HOWEVER, I do believe that we are able to discern subtle, sub-clinical changes that precede a crump/crash. The biggest problem I have is convincing the doctor that a "normal" value is not "normal for this patient."

    My story (and I do LOVE hearing/reading nurses' stories) is a 3 month old, former 32-weeker, who was "learning to eat" and close to discharge. Suddenly one morning, she was different. She kept falling asleep, having a pause in breathing (not long enough to "count" as apnea), and then crying. Repeat. Repeat. Repeat. I told the doctor. I told the charge nurse. I told my co-workers. I told the blinkin' housekeeper! I was concerned that she might end up apneic enough to require intubation and I did not want to be feeding her and then having her vomit into her trachea during intubation. So I "bugged" the doctor some more. And by noon, I had convinced him to order NPO & an IV. . . . for small breathing pauses & crying. I still remember THREE other nurses standing in her room, questioning me, while I maintained that this baby was WRONG. She was not herself.

    So I placed a PIV and kept her NPO. I had another nurse snuggle with her cuz she was fussy and called her mama to come in. Finally around 4pm (8 hours into my 12-hour shift), she spiked a fever. Another image that is burned into my brain: the doc's posture and facial expression when I reported the fever. He was SHOCKED. We did an LP and there were HUGEMONGOUS indicators of sepsis, meningitis and encephalitis. Later the CSF culture grew out nasties.

    That's my story. Next?
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    Many, many years ago while working medsurg/tele, I actually and literally told the MD "to HUMOR me, just HUMOR this nurse, chalk this up to my INTUITION, my ESP, but something is WRONG. She needs ICU - something is WRONG". I couldn't be specific with anything special, but I KNEW she wasn't right. He questioned me, he hesitated, but he acquiesced. I had her transferred out by the end of my 11-7. Heard that just after 8 am or so, she coded in ICU. Don't remember how it turned out for her. Ever since over the years, I listen to that little voice. I've got this psychic 6th sense at times esp for diabetics who'll bottom out at 2am. I'll just feel this pressing urge to check somebody out of the blue. And 99 44/100# I'm right!
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    Unfortunately my situation didn't end how I wanted it too.

    I was working NICU, I had signed on as a primary nurse for a 2 month old who had come in from home in sepsis/resp failure. Sick as snot for weeks, on the HFOV, pressors, iNO, she finally turned a corner and started getting better after a few weeks. She weaned down to a nasal cannula, was working on PO feeding again (she had a gtube d/t a cleft palate but was po feeding some). She had previously been home on oxygen so we were working on getting her back to her baseline.

    Then one shift I came in and she was extremely tachycardic, to the 180's while sleeping and over 200's when awake (not crying, just awake). I hounded the Dr's about it and they challked it up to withdrawal (though there were no other symptoms) and they increased her meds. Over the next few shifts I had with her she began a slow slide downhill. She was tachy, then she started sweating for no reason, she became irritable and fussy when she had previously been quite a happy/pleasant baby. Each day I told the doctors there was something not right with her, something was up but they didn't see it. Finally she started desatting so the docs figured we weaned her oxygen too fast and started increasing her back to high flow/vapotherm.

    Then I came in on my third or fourth shift of this and she was completely hypoxic, all morning, she wasn't in any apparent resp distress (no increased WOB, no nasal flaring, grunting, anything). We increased her to 10: then 15L. The doctors didn't want to intubate her because her blood gasses were ok, I begged all day for them to do an echo, i thought something had to be up cardiac-wise. Initially they didn't want to because she'd had one on admission that was normal (with a "small" asd) but finally I told the doctor I wasn't going to leave her alone until she ordered an echo.

    Well 30 minutes later I had my echo, which revealed severe pulmonary hypertension. We started her back on nitric, loaded her with milrinone and started a drip but it was too late. Over the next 7 days she wound up intubated, sedated and paralyzed yet still having severe hypertensive crisis, bradycardic events and "mini" codes. She died one week after that echo.

    To this day it kills me that I couldn't make the doctors see what I was seeing and that I couldn't save her. The day she died she had coded throughout the night and into the morning, her parents were there the entire time and finally just asked us to stop. It broke my heart.

    I haven't been in this very long (2years NICU, 1 year peds CICU) but I listen to my hunches, I get other nurses to valididate them with me and I have no problem pestering a doctor until they come and actually LOOK at my patient. I do not want another patient of mine to die because the doctors ignored my concerns.
    Elvish, Aerielle, and amybeets05 like this.


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