Did I make an error?

FolksBtrippin, BSN, RN · Apr 30

You had a stage 4 cancer patient with Mets to brain and bone. Thats a very poor prognosis. Blaming you is ridiculous. I'm not sure that it's workplace violence because that nurse could just be ignorant. But this patient should be on comfort care. Sorry you went through that.

JzK CCRN · May 1

Whenever any of us write anything, it's subjective therefore it's hard to say what should have been done without looking at things objectively ...

What maybe could/should have been done: check vitals more frequently and not await for anyone else to do that for you.

Decrease in mental state could be bc of poor prognosis or acute issue. Granted, RNs don't diagnose but we need to do thorough assessment.

Ask for help and give help. Healthcare is a team gig. We need to ask for help from our seniors and/or more experienced colleagues and also recognize those who need help. Based on you're description, doesn't seem like you asked for help from you're coworkers and didn't get any help either.

It's a *** situation to be in but any day that you can 1) breath on your own, 2) wipe your own *** 3) see the daylight, 4) not a patient in the hospital, that is a good day and the rest, those are hidden miracles.

Moving fwd, ask MORE questions ... Ask fellow RNs, ask Docs, and my favorite Qs (not a week goes by that I don't harass my coworkers) what can I do to get better and what do I need to know for (whatever) case?

DM if you want to talk more.

MJJFan1, BSN, RN · May 1

First, don't beat yourself up though it's hard not to. You being told a rapid should have been called at midnight comes from armchair quarterbacking hindsight. I'm certain if you went back and reviewed the chart, you'd probably come to the same conclusion. The reality you lived in the moment was much different though. In the future, I'd say when approached with such snarky behavior ask, "are you able to help me understand why I should have XYZ because I'm still an advanced beginner in all of this and I'd love any help or tips that you can give.” If they are a bully, they won't expect that back from you and will fumble. If they genuinely care, they will provide the guidance. But go back and look at the chart yourself and put a story together from the beginning of your shift to when it occurred. I'd also offer that when you have low BP's and have to intervene-stopping the ketamine, calling the doc-be sure to increase the frequency of BP monitoring. You don't need a provider order for that.

emtpbill, ASN, RN, EMT-P · May 2

It's sad to say but more than likely day shift came in and had to "work". Like said earlier this patient has a very poor prognosis and being unresponsive t this point means the patient cannot feel pain, which is probably good for the patient.

Don't knock yourself around too much for this. You did what you thought was in the best interest of the patient given the information you were presented with. Now if you hadn't called the provider and didn't do anything to address the low BP that's one thing but you did your job, appropriately and in a timely manner.

JKL33 · May 4

Quote

Dayshift called another rapid on the patient before I left, the charge RN was making snarky comments on what had happened on my shift and how "We don't leave patients with a blood pressure of 75".

It sounds like you were working on the situation.

Regarding the quote above:

This person does not mean to be helpful or instructive with their comments--the type which are often not directed as a personal instruction but are spewed out harshly as a means of public criticism. People who act that way need to continually put others down as a means of helping themselves feel better (about themselves). This is miserable behavior and IMO they are miserable people. It's sad, really.

As for one critique of the situation which I feel is fair (while acknowledging that we were not there and you likely did not write every single detail so may have left out other assessments you did) -- following your initial assessment of hypotension and your interventions for that, this patient is really no longer appropriate for "routine" vital signs/nursing assessments q4 hours. They have proven that they need to be assessed far more frequently than that. You don't need a doctors order to check your patient more often. So in the future you would want to adjust your nursing care to accommodate the patient's situation, needs and risks.

Other than that, don't get too down. We have ALL had learning opportunities like this. It's okay. Don't pay attention to people who try to lift themselves up by putting others down.

Wolfmoon_ · May 4

Hi yall, thank you for the comments with uplift and words of advice!
during the time of lack of vitals, to make this clarification, he was agitated which became his baseline while in the hospital. I didn't check the vitals as frequently because the perception of his vitals being skewed because of this agitation was a major factor in my mistake. I did, hourly with the help of my charge nurse all night, assess his neuro status for any further acute changes.
the patient ended up being maxed on pressers and passed the following night.
as for my lack of vital assessment my manager is putting me on a performance improvement plan. She told me that when rapids happen in the morning it's usually a sign that something wrong happened on night shift. I asked her if there have been found any other issues with me care and she said she doesn't think so and is planning on having a meeting with me.
while I do think that this patient was going to pass anyways from his condition I should have taken his vitals more frequently as sort of my full, more frequent neuro assessment to rule out any further ailment and ensure faster arrival to ICU/intervention.

Tweety, BSN, RN · May 5

When I have a low blood pressure like that and I'm treating it and not calling a rapid, I will still make the rapid nurse aware. "I have a patient with this low of a blood pressure, and the doctor ordered a bolus." just so the rapid nurse can follow and maybe offer some advice or be aware of the patient should they crash later.

I do agree that perhaps you might have monitored the blood pressure more frequently since you had a problem earlier.

Day shift playing the blame game is lame. You can't predict the timing when a patient goes south.

Been there,done that, ASN, RN · May 5

Putting you on a PIP is ridiculous. Too bad management couldn't put the attending on a PIP. The patient needed to be on comfort measures only. Fiddling with BP and pain RX is ridiculous, The man was dying.

JKL33 · May 6

Been there,done that said:

Too bad management couldn't put the attending on a PIP.

Manager is the one who should be on a PIP. I bet that unit is full-on toxic.

FolksBtrippin, BSN, RN · May 6

Wolfmoon_ said:

Hi yall, thank you for the comments with uplift and words of advice!
during the time of lack of vitals, to make this clarification, he was agitated which became his baseline while in the hospital. I didn't check the vitals as frequently because the perception of his vitals being skewed because of this agitation was a major factor in my mistake. I did, hourly with the help of my charge nurse all night, assess his neuro status for any further acute changes.
the patient ended up being maxed on pressers and passed the following night.
as for my lack of vital assessment my manager is putting me on a performance improvement plan. She told me that when rapids happen in the morning it's usually a sign that something wrong happened on night shift. I asked her if there have been found any other issues with me care and she said she doesn't think so and is planning on having a meeting with me.
while I do think that this patient was going to pass anyways from his condition I should have taken his vitals more frequently as sort of my full, more frequent neuro assessment to rule out any further ailment and ensure faster arrival to ICU/intervention.

I feel like that's the wrong way to look at this. This patient was dying, experiencing terminal agitation, and was narcanned for his last days on this earth, causing more suffering than was necessary.

That's what went wrong here. He didn't need ICU/ further intervention he needed to die in peace.

I feel like the questions for your meeting should be "what is my role with a dying patient?” If a patient isn't on comfort care, and should be on comfort care, what should I do?” And also, "what is the process for getting to comfort care in this hospital?”

Your missed vital signs were not the big problem here, they were a small problem. If the big problem isn't being addressed, you're dealing with either incompetence or toxicity. And I'm leaning toward incompetence. I think it's important to call it out. But you need to understand what went wrong here. You can't just accept responsibility for a bad outcome if it isn't really your fault. You add to the problem when you do that.

One thing to keep in mind though, is that there isn't such a thing as agitation "skewing" the vital signs. Agitation increases heart rate, blood pressure, respiratory rate as does pain. It's something to consider as a possible cause for the increase. It's never something messing up your data. It's not the same as getting a false reading.

good luck. I hope this gets properly handled

UrbanHealthRN, BSN, RN · May 7

FolksBtrippin said:

I feel like that's the wrong way to look at this. This patient was dying, experiencing terminal agitation, and was narcanned for his last days on this earth, causing more suffering than was necessary.

That's what went wrong here. He didn't need ICU/ further intervention he needed to die in peace.

I feel like the questions for your meeting should be "what is my role with a dying patient?” If a patient isn't on comfort care, and should be on comfort care, what should I do?” And also, "what is the process for getting to comfort care in this hospital?”

Your missed vital signs were not the big problem here, they were a small problem. If the big problem isn't being addressed, you're dealing with either incompetence or toxicity. And I'm leaning toward incompetence. I think it's important to call it out. But you need to understand what went wrong here. You can't just accept responsibility for a bad outcome if it isn't really your fault. You add to the problem when you do that.

One thing to keep in mind though, is that there isn't such a thing as agitation "skewing" the vital signs. Agitation increases heart rate, blood pressure, respiratory rate as does pain. It's something to consider as a possible cause for the increase. It's never something messing up your data. It's not the same as getting a false reading.

good luck. I hope this gets properly handled

Yes to all this! If this was a patient who had a more hopeful prognosis and an actual chance at survival, then yes let's work on frequency of vital signs. But this patient wasn't that scenario. If this was my patient, I would have been wondering all shift how much of my patient's physical changes were due to active stage of dying vs. something else in need of intervention. BPs drop when someone is dying. Mental status changes when someone is dying.

If your manager is going to put you on a PIP, which is nuts, I 100% agree with FolksB to ask about management of an actively dying patient. Sounds like your whole unit needs to be PIP'd on comfort measures only.