had an AWFUL night

[momof3al RN]

had an awful night and can't even lay down til i get this off my chest. two things happened tonight that really bothered me.

i work on a busy med/surg floor and i went in to work an extra shift because there were two call ins.

the night started out ok with 5 patients. all had issues but 4 were stable, except one that was worrisome. 46 y/o f was at the hospital with her husband who was a patient being treated for cellulitis. the wife went to the bathroom in her husband's hospital room and had a syncopal event struck her head, came to, tried to stand fell and hit her head again.

ct of head was neg, chest xray showed right upper lobe pneumonia. the weird thing is that she is hypotensive. her SBP stays in the 80's even going to the 70's. only med history is hypertension, depression, anxiety, and chronic back pain. all cardiac testing is neg so they can't figure out why her BP is in the toilet. she has been on NS @150 and it's not budging it. she has no fever, no cough and lungs all sound clear.

she has called out for pain meds, but the nurses have refused to give it due to the BP and the fact that the patient is always in a very heavy sleep, and when awake can barely keep her eyes open, and talks slowly and appears to be very sedated or drunk though she received no sedating meds. two different rx for oxycodone are on her home medication list.

i start out the shift by asking her if she has any meds in her room, "oh no." has she been taking any of her own pain meds? "oh no."

at 2000, her SBP is 83, i'm not happy about it, but i set the bar there, i tell her that if her BP goes lower i may have to call the MD and get an order for narcan, because i'm concerned that she has narcotics in her system making her BP low. she verbalizes that she understands. i tell the tech to tell me if her BP goes lower. tech charts a SBP of 80 slightly before 0000 and does not tell me. its almost 0100 when find out. i go check her myself SBP of 73. i call get an order for narcan, and get report on my 6th pt as im putting in the order.

new pt 78 y/o m admit with chest pain and sob, was told in report that pt took sub-ling nitro at home and by the time he got to the hospital the chest pain has resolved and the sob was resolved also, the pt was going to be NPO for stress test in the AM. daughter at the bedside is an RN who works at a different hospital.

get off phone go to med room gt my narcan, head to first pts room. after giving narcan, my phone rings. ER nurse wants to give me an up date. the pt is now having chest pain and SOB. one inch of nitro paste was applied and he's better and will be coming up shortly. this is all happens in about ten minutes from when she finished giving me report the first time. how can he recovered from chest pain so quickly? i tell her i'm worried that the patient is not stable, can they please keep him and observe him for a little bit longer to make sure he's okay, at least 15 minutes. she's not happy but says okay.

i'm also watching my other pt and checking her vitals every 5 minutes. her BP improves with every check till she is at 127 SBP. she has barely been above 90 for two days. she is more alert and looks sheepish and annoyed. she c/o "feeling funny all over". i want to say something snarky like, "that's what it feels like to be alive, instead of half dead." but instead just tell her its one of the effect of the medication.

i stay with her till told my new pt is one the floor. i ask a PCT stting in the hall charting on her WOW to watch the pateint and to let me know if she takes any medicaon. i go greet new patient, he is sighing and moaning, and hitches his breath in pain every few seconds. i ask him how he is doing, he says he feels lousy, he is having terrible chest pain. i'm surprised, i ask, didn't the nitro paste help? "they just put that on."

now, i'm po'd because the ER has sent me a pt they knew was having chest pain with a hx of quad bypass, pacemaker/defib, and aortic stenosis. his face is grey, he says he feels like a elephant is on his chest and he feels sick to his stomach. i reassure pt and daughter get them settled and run to check his labs, ER nurse didn't mention troponin results. can't find results of trop. call lab. do they have trop down there? no, they see the order but looks like it wasn't done. i go collect the blood and send to lab.

i get together all my info and call the cardiologist. i'm very worried that he/she will be angry when they hear how the ER ignored the pt's chest pain and sent them up to the floor anyway and be annoyed that i don't have troponon results. i did a EKG and it looks a lttle funny, but he's also being regularly paced at 80 so there are no obvious arrhythemia. in the ER, the EKG could be handed to a Dr, up on my floor i don't have that reource. all i can do is call a dr and hope they will give me orders to help the patient or call a rapid response. i'm worried about this pt, and feel like he needs to be watched closely but that's impossile for me when i have 5 other patients, including one who i think is in her room secretly eating pain medicine like it's candy.

i talk to the cardilogist and try to expalin the whole situaion, she asks to speak to the charge. i transfer call to the charge and call the other dr to report the positive result from the narcan and ask for order to search patient's room for narcotics. i get the order and call house sup and security to be present during search.

the charge gets off the phone and tells me that the DR wants her to take pt because i sound overwhelmed and like i'm freaking out. i'm annoyed because i don't lik having a pt taking away from me, and i think under the crappy circumsances i've being dealng quite well but i'm also releaved that i can pass off this responiblility to someone else. charge calmly goes to assess and returnes shortly after with a holy **** demeanor saying she needs an EKG on pt asap. i tell her i just did one show her the strips, she say she is going to collect a trop, i tell her i just got one, it's in the lab. she calls the card back now with her own concern for pt. me, house sup and security go to do search.

patient is zonked out again. her BP has dropped a bit. i'm worried she has taken alot of extended release oxy and may need more narcan. we find three large Rx bottles of meds. one is an antidepressant, one i'm not familiar with but house sup says is not sedating and a bottle marked lisinopril. the bottle filled with at leaste 100 tablets and capsules of so many different sizes and colors it looks like confetti.

i wake patient and tell her that these meds are being taken with a dr's order out of concern for her safety, they will be secured by security and returned to her on discharge. she nods. now she knows that know that she's been lying to me.

i feel kind of cappy that i've had to do this, but it's not the first ime i've seen this and probably won' be last time either. i hate how addiction to pain meds turns people into lying manipulatve jerks, and how they see me as a pez despenser whose job it to feed their addiction while they are in the hospital and then i also feel crappy and guilty for feeling this way.

though i was mosty busy with these two pts, i was also managing my other 3 pts. hjey were 2 totals whose doors open s i could walk i and check on witho waking, the other was a walkie-talkie, i hung antibiotis for and gave occasionl paian med to.

now that the shift is over, i feel like i've stepped out of a chaotic storm and am left to worr if i did the right thing? i thought i was managing okay, but the card's comment about "freaing out" bothers me. i've always thought that i've handled things proffessonally, but this hasmade me doubt myself. last night was not my usual night, and i don't know if i could continue in nursing if every shift was like that and that akes me feel like a wimpy nurse.

when i left, both were still live and rerlatively stable, why do i feel so crappy and like failure???

[RainMom]

Sounds to me like you did just fine. We've all had those shifts before! I wouldn't take to heart (pun intended) what the cardio said about you being overwhelmed. When you have multiple pts nose-diving at the same time, take the help when you can.

I would consider writing up the incident with ER sending you the unstable CP with no work-up. Also, in the future, I would suggest calling the rapid response so you get immediate help. Our ICU covers the RR & pretty much takes over, initiating the protocol orders & then following up with the MD.

I've been there where I tried to manage a pt report of CP on the floor by myself...never again (not if I think it may be truly cardiac related). It was also the same night I started the shift with a RR, a death about an hr before the cp complaint (comfort measures, so expected), & a stable asymptomatic CP with a critical troponin near the end of shift.

The best thing to do now is to get it all out (like you did in your post), think about what went right, what went wrong, what you will change or improve on next time...and then let it go!

[LibraSunCNM, BSN, MSN, CNM]

when i left, both were still live and rerlatively stable, why do i feel so crappy and like failure???

Ah, probably because you were handed a cluster**** of an assignment? A rule out MI patient with severe chest pain who had no troponins drawn??? That is incredibly substandard care. He should not have been transferred in the first place, much less to a regular floor. It sounds like you handled the woman taking her own meds appropriately, given the circumstances.

For both patients, I personally probably would have called a rapid response due to the situations you've described, but at the hospital where I worked med/surg, we had a pretty low threshold for calling (this was encouraged). Possibly where you work it's more frowned upon? I would at least have involved my charge nurse earlier for help.

At any rate, I'm sorry you had such a bad night, and I hope your next shift is better. It sounds like you did a good job with the hand you were dealt. That'll teach you to pick up OT!

[RainMom]

Sooooo... I had a long reply but now it's not showing? Try again.

Sounds to me like you did just fine. We've all had those shifts! Don't worry too much about the cardio thinking you were overwhelmed. When you have multiple pts nose-diving at the same time, take help where you can get it.

I would consider writing an incident report for ER sending up an unstable pt with no work-up. Also, in the future, an immediate rapid response would probably be your best action when presented with a symptomatic CP pt. Even the hypotensive & sedated pt would qualify for RR (although I'd probably do as you did, & see what I could do myself). By calling the RR, you get more eyes on the pt & protocol orders to implement without going back & forth with the MD.

I've tried to manage a pt report of CP during a shift by myself...never again (unless I don't feel it to be truly cardiac related)! It was ona similar night as yours where I started the shift with calling RR on a different pt at 2300, had an expected DNR death at 0015, pt reported cp at about 0130, & morning labs revealed another observation pt for CP had a critical troponin (although aymptomatic).

What you do now is get it all out (like you did in your post), think about what you did right, what you would change or improve...& then let it go.

[calivianya, BSN, RN]

It always feels awful when people don't recognize your awesomeness.

You were doing everything right with the patient who looked like he was having a MI - getting EKGs, getting labs, calling the physician. You were on your game. It blows that the cardiologist found some imaginary fault with you - and in reality, that fault was probably that he was a hot shot cardiologist and one of the ones where you have to earn his trust before he wants you touching his patients and wasn't anything to do with you at all. I would have been a little miserable after that shift, too.

[NursingInChaos]

I am sorry you had to deal with that. I work on a telemetry floor in florida and deal with this a lot on our floor- just trying to get my one year of experience and move to another city with more options- out hospital is still all paper charting AND a plethora of useless staff- hope your shifts get better- sounds like you handled it beautifully!

[kalycat, BSN, RN]

All I can say is at my hospital, that chest pain would have gone straight to our unit - CCU/CVICU step down that takes everything from heart caths to VADs and transplants. Seriously, no troponins drawn by ED? He would have come up with 2 sets run, an echo to assess EF, a nitro drip at the least and been npo for a potentially emergent trip to the cath lab. Actually, he may have never left the ED depending on his 12 lead and enzymes. Might have gone straight to the lab. If for some reason they tried to send him to a med bed, the charge for whatever floor they tried to turf him to would have delivered him to our unit herself/himself, no ifs ands or buts.

I'm sorry you've had to deal with all that. Sounds like a feces fest. The narcan patient? You did the right thing absolutely. You kept the patient safe. You're not an addictions counselor. You can advise and educate, but you're not a rehab unit. You kept your patient safe and involved the right resources.

Speaking of, Don't forget to use your resources. Use that rapid response, your charge, your buddy, or your helper nurse. Let them know as soon as things start to go south; give them an update on the fact that you're seriously tied up and are going to need assistance.

Not saying you did anything wrong at all, just to keep in mind when/if something else presents itself. Hang in there and get some rest! I had a mega RRT last night too along with an additional very unstable patient. I'm ready for a bit of rest and I'm sure you are too!!

[lavenderskies, BSN]

To me.....sounds like you were amazing. PS I would be "freaking out"

[Libby1987]

Perspective.

You needed and should have gotten support from your charge. The cardiologist needed and should have made should there was enough support and coverage for her patient.

You feel wimpy because you left nothing on the field and you're exhausted but you rocked it last night.

Instead of feeling like a failure, feel like an essential part of getting sick folks thru a rough night that could have gone a whole lot more sideways if not for you. Allow yourself to feel fantastic about that. Then eat some chocolate and go to bed.

[BiotoBSNtoFNP]

Sometimes doctors make these comments because they dont want to believe the patient needs a higher level of care and deal with the transfer. The charge nurse told him everything you did, so onviously you were not mistaken with you "freakingout"-ness but in fact correct!

[martymoose, BSN, RN]

good lord, sounds like a typical day for me. Im so sorry you had to deal with that.

Id be very angry at the first patient- we dont have time for games like that

Sounds like you dealt with it all ok. Sorry about the doc misunderstanding your concerns.

ughhh.

and we do this job ,again, why?????

[mrsjonesRN]

It sounds like you did an amazing job and you are a great nurse. When I worked med surg, and spent all my time with 2 out of my 5 patients, I felt like a sub par nurse too. It's just a natural feeling when you are a good caring nurse. Sometimes we don't give ourselves enough credit.