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???

[Simonesays, BSN, RN]

Yikes! What a crappy night! I feel tired just reading about your shift (and this is not a dig at your writing style!). It's true: we all have assignments like this at some time or another. Once in a while you get a perfect storm of unstable patients. But that really sucks that you didn't get the support that you deserved/needed. Reward yourself with something after all of your hard work- you deserve it!

One thing I would maybe bring up to your manager is the lack of support. Were you able to communicate with your charge nurse about your hypotensive patient and your emerg patient? Did she pitch in to help? What were your other colleagues doing? These questions might help your manager address problems such as workload (i.e. was everyone else very thinly stretched) and workplace culture (i.e. everyone for themselves).

As others have suggested, don't be afraid to use your rapid response team earlier next time (unless your hospital has strict initiation criteria- which hopefully it doesn't). They are my favourite resource and can help push for patients to be moved to a more appropriate setting, initiate orders, offer recommendations, and provide support.

The only other thing I would comment on would be possibly delegating more tasks to your colleagues. Is there someone else who could have obtained your cardiac pt's trop/BW? Is there someone who could have tended to your stable pts (i.e. hanging meds, answering call bells) while you dealt closely with your unstable pts?

Again, you really did an amazing job! And hope your days off are relaxing.

[jadelpn, LPN, EMT-B]

Know your resources and use them.

When said patient's wife bumped her head...did she go to the ER? They were not aware that her BP was in the 70/80 range? And when you give narcan, you can put someone into acute withdrawal. Rapid response before you do that in the future. And don't put a PCT in charge of monitoring an unstable patient's BP. That is something that no PCT should be put in the position of doing.

Chest pain, again, rapid response. That someone with that kind of medical history doesn't have troponins done nor an EKG is frightening. "An EKG that looks a little funny" is not an answer, even more of a rapid response situation. Yes, with this patient's cardiac history you could have higher troponins to begin with. But the second set spiking would be a indicator--all that can be done at a higher level of cardiac care. Not even getting into the delay in care, as the second set is important--and is now delayed due to a first set not being done. (which if they did a rainbow in the Er, can a set be drawn off of that so yours would be the 2nd set?)

Sounds to me as if your charge was not actively involved as to what was happening on her floor. Going forward, get charge involved from the first sign of instability in your patients. Do not hesitate to call a rapid response. Nurses call them for less than what you were dealing with.

And who cares if the MD thinks you are "freaking out". These calls should have been made by members of the rapid response team. And if your charge is NOT directing you to call a RR, then it is on her--and let her take the unstable patient and responsibility for same. The MD did you a favor, and it is now on the charge nurse to decide where to go from here--again, RR.

If you are "spoken to" about it, I would say the truth "I had 2 wildly unstable patients, both of which required immediate intervention, and little to no support with them" "In the future, I know that I need to call a rapid response, and will do so" Period. Then follow through.

[Been there,done that, ASN, RN]

You had two unstable patients. The charge nurse should have realized that, and intervened... or you could have called a rapid response.

As far as the cardiologist.... never let 'em see you sweat. Your anxiety came through loud and clear. Work on sounding/appearing cool, calm, and collected . Acting 101 should have been a nursing school requirement.

[TheCommuter, BSN, RN]

As far as the cardiologist.... never let 'em see you sweat. Your anxiety came through loud and clear. Work on sounding/appearing cool, calm, and collected .

You have a salient point. When our anxiety is visible and palpable, some people take advantage and want to treat us as if we're less capable. This is why you've gotta fake it until you make it. Let the confidence shine on through.

[Karou]

It sounds to me like you did an amazing job with a super crappy assignment. Your charge nurse should have supported you more. You were on the ball and got both of these patients the critical care that they needed! You need to pay yourself on the back for this shift.

[Oedgar]

My goodness how awful!!! You got the short end of the stick for sure, and handled it all like a pro. The tech failed to tell you the abnormal result after you had requested her to... so she performed less than adequately. I will say that when I have pts I am concerned about... I tend to follow up with support staff to check on them. But, really, she should have notified you, and the crap was hitting the fan for you in other ways.

My mother is a very similiar type of patient to your Narcan patient. She is bipolar, etc with a long history of manipulation, family estrangement, 7 marriages to mostly horrible people, etc. I was the last family member to hang in and try to interact with her. Her daily home meds included 1-2 Vicodin tid (and she would not hesitate to add an extra pill here and there), max dose of neurontin, antidepressant, Soma, klonopin and more. She had literally a large rubbermaid box... 9x13, that she took to the hospital with her. I told her it was inappropriate, that she would die if she took that stuff and IV narcs post op. She behaved like an angry lunatic when I took the box home and away from her. You did the right thing. Addicts can't be trusted. And if something had happened they would be quick to take you to court. I hope your next shift is much better!

[Lola Lou, BSN]

I'm going to attempt to pass on some words of wisdom that I recently received and I hope that I don't butcher the message!

The poor condition and/or negative outcome of a patient does not reflect on your ability/competency as a nurse.

Now that obviously isn't the case if a nurse has neglected to perform essential tasks to ensure the patient's well being. But, sometimes people are just plain sick. I would have a super sick patient and if they were still that sick when my shift ended I would take it personally that I wasn't able to improve their condition. I placed that weight on my shoulders and would run through scenarios the rest of the evening wondering if there was something that I could have done better or differently. It sounds like you did the best you could under the circumstances. There are some shifts that are so crazy that I deem "good" if everyone stays alive and you accomplished that. Hopefully by writing your post you were able to get it all out there and rest peacefully! Best wishes!!!

[imintrouble, BSN, RN]

You wouldn't be questioning yourself if the cardiologist hadn't dissed you. He dissed you not because of what you did or didn't do, but because of the tone of your voice. Keep that in mind.

The mess you found yourself in was because somebody else didn't do their job. I count the hypotensive for two days lady as something that should have been handled much earlier. Keep that in mind too.

[MaxAttack, BSN, RN]

I would've written an incident report. That's beyond substandard care. That's the type of **** that puts you in a room with lawyers and has you looking through open positions at Taco Bell.

[canigraduate]

I think you could look at the cardiologist's comment from a different point of view. Maybe he was worried that you were being handed a cluster and was looking out for you.

I would have called a rapid response on the lady with the low BP. Most places I've worked have you call for BPs in the 80's/50's.

Also, I think you did the right thing with getting the chest pain guy stabilized, but I also would have asked for help there, especially if you were dealing with the hypotensive lady at the same time.

You did a great job, both of them lived when they were trying really hard not to!

[Anna Flaxis, BSN, RN]

First, it sounds like you did a fine job. It's completely reasonable to second guess yourself in hindsight, and when that helps you figure out what you can do better next time, that's useful- but when you're just beating yourself up for your perceived shortcomings, that's not so useful. So stop that. Use the experience as an opportunity to improve your practice.

I think you could look at the cardiologist's comment from a different point of view. Maybe he was worried that you were being handed a cluster and was looking out for you.

More likely, he was looking out for himself.

When the ER doctor makes the decision to admit, the ER doc gives the admitting doc a physician to physician report. At this time, the admitting physician can accept the patient and say send them to the floor, or they can request further diagnostics or treatments be done while still in the ER prior to making their final decision as to whether to accept the patient, which unit they meet admission criteria for, or whether to transfer to a higher level of care. Once the admitting doc has accepted the patient and they have a bed assigned, the ER is pressured to get the patient to the floor pronto (for reasons ranging from throughput, patient satisfaction scores, bed control, to medical liability).

I'm guessing that the cardiologist accepted this patient without knowing what his initial trops were (maybe he was on auto-pilot, eating dinner, or playing Candy Crush), told the ER doc to go ahead and send the patient, and when you called, he had an "oh poop" moment, and threw you under the bus in order to cover his own behind.

Patients can be really unreliable when it comes to things like what time they got their med, and it can be like pulling teeth to get them to give you a straight answer about pain relief. It is quite possible that the ER nurse put the nitro paste on, the patient reported relief of his symptoms while still in the ER, but then had a return of those symptoms either on his way to you, or while still in the ER but he neglected to say anything. If ever in doubt, check the documentation. The ER nurse should have documented what time the nitro paste was applied and the patient's response (pain assessment and full set of VS), as well as a brief note describing the patient's condition at the time of transfer to the floor (if none of these things were documented, it would be reasonable to assume that the ER sent you a symptomatic patient since there is nothing in the EMR to state otherwise, and so an incident report would be appropriate). This is information that you should have ready for the cardiologist when you call. It should be part of your SBAR.

It sounds like you handled everything well, but I'll give you a few more pointers to keep in mind for next time. As others have stated, never let them see you sweat. When you call the cardiologist, have all your ducks in a row and pay extra attention to maintaining a calm, professional demeanor (not saying you didn't- I wasn't there). I think that considering the balls you had in the air, it was appropriate for your charge to jump in and take over on either the chest pain patient, or watch the rest of your patients while you got the chest pain patient all sorted out. Next time, don't be afraid to ask.

Again, well done.

[RescueNinjaKy]

Ed should have gotten an ekg done and troponin drawn prior to transferring the patient. They're quick things that can be done without much effort and it's a standard for any chest pain. The real issue here that I found was that they sent him up without doing an ekg and that they gave nitro prior to doing an ekg. They needed that ekg to see if it was a stemi and they should've done an ekg first just because nitro can affect the results of an ekg. Definitely submit a safety report on this. Even if nothing came out of it, it is good to let management be aware that chest pain/stemi protocols aren't being followed. Also if it was a patient having stemi then their care just got delayed by a lot.