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???
Anna Flaxis, BSN, RN
1 Article; 2,816 Posts
The OP didn't say an EKG wasn't done in the ED, or that the troponin hadn't been drawn.
STAT EKG and blood draw are standard of care for any chest pain patient, and I find it a stretch to believe that the ED didn't do them.
The most likely scenario is that the initial EKG was negative for STEMI, that the blood did get drawn, but lab had not run the troponin, and that the cardiologist accepted the patient without an initial troponin. My guess is that he was thinking it was being run and that he'd make decisions based on serial enzymes, but that it was okay to transfer the patient to the floor in the meantime. That was his bad, and why he reacted to the OP the way he did.