Dangerous nurse?

[RoyalNurse]

hi, i've been reading the "dangerous nurse" posts, and all i can do is wonder about myself sometimes.

long post:

assigned to an elderly woman, who looked terrible when i first went in to assess her. multiple serious issues, her nephrologist and attending came in, both saw how she was, both agreed she wasn't doing well, attending called her son and told him the poor prognosis. intensivist came in to see her, saw her mottled feet, poor mental status, i told him about the plan, he alluded that he would be back later to assess her.

later that morning, this patient was slowly deteriorating in mental status, and becoming more hypotensive. i called the intensivist, told him about the blood pressure, he ordered a different vasopressor. i asked for an a-line, he said he would be over, and that "if she needs an a-line, that's what we'll do."

i didn't tell him about the mental status, i hadn't even thought about it at this point. mostly because it wasn't that great to begin with, and i was more concerned about her bp.

waited, and waited for this intensivist, meanwhile checking the bp every 10 minutes by cuff, it was staying up with the new pressor, but the patient was looking worse. her respiratory rate started increasing, about 24-32, becoming more labored.

finally the bp was dropping, and not picking back up, i maxxed out the new drip, and called the intensivist again. he came over, took one look at her, said: "she looks a lot worse than this morning, doesn't she?" (with a condescending sneer, of course) attempted an a-line, not successful, talked to the family, who agreed to let her go with comfort care measures. she passed on my shift.

now that i look back, i know i should have told the intensivist: "you need to get here now, she's not looking good." i only told him about the occasionally dropping bp, that's all i was thinking about.

i talked it over with my manager, who said i did fine, of course. i really think the standards are too low for nurses on my floor, management seems to have a tolerant attitude towards incompetence.

the thing is, i don't think i'd be smart enough to do the right thing the next time this happened. i don't have a system in place for this, i use sbar for communicating with doctors, but it doesn't seem to be good enough with icu patients. sometimes everything's so subtle, you need to be clairvoyant just to get through your shift.

here's the thought that keeps nagging me: "a good icu nurse would have seen clearly what was going on, and got that intensivist over immediately." this patient wouldn't have made it anyway, but what if this happened with someone who could survive?

anyone else have a similar situation?

[Bella RN, BSN, MSN]

Hey there...you did your very best. A matter of fact I dont see anything that you did wrong. I also work in the unit and you did everything within your power to assist that patient. Its true--every minute is subtle and vital but her neuro status was not the MAIN concern--Remember circulation--her BP and you remembered that...so don't beat yourself up!!

[BrnEyedGirl, BSN, MSN, RN, APRN]

You say a good ICU nurse would have seen what was going on. What was going on that you didn't see? What did you want the doc to do? What do you think he needed to do sooner? I'm not sure I'm seeing what you think you are misssing! Don't beat yourself up over this!

[mcleanl]

This comes with time and experience and from your post I can see that you have learned something from this situation. I remember when I first started in ICU (in the olden days!), I had some similiar experiences and I think I turned out to be a fine nurse! The sheer fact that you are concerned over what you didn't do tells me that you are a very good nurse......continue to learn and grow and don't be too hard on yourself.

[Christie RN2006]

The only thing from your post that I can see was clearly going on was that woman was slowly dying. It sounds like you did everything you could to help her. The deteriorating mental status, mottling, dropping BP, increasing resp difficulty all goes right along with her dying. A lot of times with patients like that, they don't end up making it no matter what you do for them. When you add a vasopressor it will usually help at first, but then it stops just like what happened with your lady.

[UM Review RN, ASN, RN]

OK, so if you stepped back and looked at the Big Picture, how long do you think this patient could've survived if all measures were taken?

What you've described, IMO, is a patient in renal failure whose organs were shutting down and who was actively in the dying process by the time you got to her -- and the Intensivist knew it.

[RoyalNurse]

You say a good ICU nurse would have seen what was going on. What was going on that you didn't see? What did you want the doc to do? What do you think he needed to do sooner? I'm not sure I'm seeing what you think you are misssing! Don't beat yourself up over this!

I guess what I was saying was a good ICU nurse would take one look at that patient, say "Gee, she looks worse than this morning", called the intensivist back, and told him to get his butt over there immediately, because she's going down the tubes or something like that. She had all the signs of septic shock. There's probably nothing he could have done, she had a lot going on. The main thing is I would feel better about myself, which is all that really matters. (ha ha)

I can armchair quarterback with the best of them, but I'm still having a hard time thinking on my feet. It's one thing to choose abcd on a test with the right answer, it's another to choose the right thing to do when you involve hospital politics, and multiple subtle problems all presenting themselves at the same time, not to mention another patient with his own needs on top of it all.

Thanks for the replies and encouragement! :)

[RoyalNurse]

OK, so if you stepped back and looked at the Big Picture, how long do you think this patient could've survived if all measures were taken?

What you've described, IMO, is a patient in renal failure whose organs were shutting down and who was actively in the dying process by the time you got to her -- and the Intensivist knew it.

You're right, we were thinking of starting CRRT later that day. The thing is, she was still a full code at this point, and we were still actively treating her. (She originally came in for an orthopedic procedure.) I've had patients that "turned into" hospice cases throughout my shift, but the whole process was a lot cleaner than this. All the loose ends ended up in my lap.

It was the intensivist's comment: "She looks a lot worse than this morning, doesn't she?" that got me going.

Anyway, thanks again for your help, you're right, there's nothing I could have done, but I can't help but beat myself up anyway. :)

[nrsang97, BSN, RN]

I think you are being too hard on yourself. I think you did just fine.

[Blee O'Myacin, BSN, RN]

I agree with the others, you are being way too hard on yourself. You called the intensivist right away, and s/he had the option of coming and writing the order in person at first as opposed to showing up later in the day. She had already been seen by two physicians early in the shift. I'm willing to go out on a limb and say that the intensivist knew just what the end result was going to be and gave you some phone orders to keep the patient going until s/he had the time to sit down and talk to the family.

I'm also willing to go out on a limb and say that you were probably in that room every 15 minutes for at least a 1/2 hour at a time, repositioning, reassessing, doing mouth care, giving meds, answering 200 questions from family members, explaining procedures...etc. That's inbetween making calls and assisting during invasive procedures.

Focus on all you did for that patient on the last day of her life. She was lucky to have an advocate like you.

Blee

[BelleKat, BSN, RN]

I think you did fine too,learn from it,any intervention would have just prolonged the inevitable,seeing the overall picture and stating that to the physician comes from experience and confidence. It wouldn't have changed the outcome but might have eased your mind that you and the physician are on the same page.

If I have a deteriorating pt and the doctor doesn't seem to be responding the symptoms the way they are usually treated I say something like "you know she's deteriorated overall from this morning,etc,etc. They usually say something like "I know....she's dying and there's not much we can do,try these few things and see how she responds but we'll probably end up putting her on palliative care when her family comes in"

That way you know the "game plan" and aren't overly hard on yourself like you're being now. You did fine,it's hard I know. Thanks for caring,that is a sign of a good and caring nurse.:redpinkhe

[LaneyB]

A dangerous nurse usually does not realize they are dangerous, and does not learn and grow. I think you obviously don't fit that definition. Don't be too hard on yourself or you will burn out quickly.