Did I miss something?

Published

Hello all...

I''m a nurse in a long term/psych facility. As we all know, this is the time when flu/cold symptoms are abounding. I work third shift, and I should mention that I have only been a nurse for 3 months. One of my residents who is an elderly woman with a hx of CHF was of the many who were suffering from cold symptoms. This resident was noted to have wheezing in all lobes and some ronchi. She was sating at 91 when I came on. However, later in the shift when I assessed her, she had audible wheezing and was sating in the 85-86 range. I administered her PRN albuterol nebulizer and her sats went up to 95. Her respirations were normal, heart rate normal, BP only slightly elevated. I checked her out an hour later and the wheezing was greatly decreased but her sats were back down to 85. I called her doc and got an order for a chest xray the next day..

The next day, the oncoming nurse seemed annoyed that I had not sent her out, stating that this woman tended to deteriorate quickly. However, when I had consulted my supervisor about her, and when the sup checked her out, he agreed that we would not send her out. Needless to say, the oncoming nurse sent her out.

Did I miss something?! Was i wrong not to send her out? I know her sats were low but not necessarily critically low for a CHF patient??I'm feeling really incompetent right now!

Up Vote Up Vote ×

My question: was the doc aware that after the PRN breathing treatments her sats were in the 80's? Also, you don't mention if you placed her on oxygen... It sounds like she was stable even with her sats being low but for her to desat within a hour of treatment..I don't know... You ran this by your supervisor & hopefully documented your call to the doc etc. CHF does obviously effect breathing capabilities however you commented about cold/flu so her issue could be pneumonia related and not CHF and a CXR would be the way to rule this out.

Where you work would've have been possible to get a chest xray on your shift? Maybe a portable? I know some facilities do not have this ability on night shift.

Doesn't sound like you did anything wrong but I don't know - I can see the both sides of this one.

Up Vote Up Vote ×

No, you didn't do anything wrong. You notified the doctor and the doctor ordered a chest x-ray and not an order to go to the ER.

Up Vote Up Vote ×
Specializes in cardiac CVRU/ICU/cardiac rehab/case management.

Next time you could ask about getting a lasix order? (and request pottassium to prevent PVC's post diuresis. That might have solved the problem to lessen the heart failure symptoms. The problem seems cardiac in origin,respiratory issues are a consequence of heart failure progressing. The supervisor made the final call,so you are covered, The treatments were just a temporary solution but didn't really address the fluid issue. Are you sure it wasn't rales rather than rhonchi? Was there edema?

Up Vote Up Vote ×

No nothing wrong, the oncoming nurse had a history with this patient, and did the patient have CHF in the end?

Up Vote Up Vote ×
Specializes in LTC, Rehab.

I've been a nurse for 8 months and I've come to the conclusion that other nurses are always judging each other, I'd like to see more support & helping and less judging. I've decided that I will do my best for my patient, follow all policies & procedures, document everything, consult with my supervisor/MD's as needed, and after that I don't worry about stepping on toes or other nurses who like to find fault in decisions they weren't involved in. Don't spend your precious time off worrying about what others think !! If you did all you wre suppose to, then let it go, if you could've done better then I say learn by it to make yourself a better nurse. OP: if the doctor thought she should've been sent out, that was up to him/her not you, so don't fret !!

Up Vote Up Vote ×

Hi MimiLPN,

This is my take on the situation: You told us the patient has a history of CHF. With cold symptoms present, wheezes in all lobes, and a sat of 91 I would have reported these symptoms to the doctor asap, as I would be concerned about a respiratory infection i.e. pneumonia, which can cause a lot of problems for the elderly and for someone with a condition such as CHF. The audible wheezes and decreased sats (moderate to severe hypoxia) would have further concerned me in this regard. It sounds as though the doctor was concerned about the potential for respiratory infection also, hence the chest X-ray.

The oncoming nurse was justified in my opinion to be upset that the patient was not sent out sooner.

Up Vote Up Vote ×

There are so many other factors here that are missing. Was she on oxygen? Did you increase it? What did you do to get her sats above 90? If you just left her sating in the 80s and did nothing for her, then I agree with the other nurse. 80s is too low, and if she had pneumonia or CHF then she could have declined very quickly. If you were able to stabilize her saturations then you did everything you were supposed to. Low sats doesnt automatically mean they have to go out to the hospital, but something needs to be done, quickly, to stabilize them.

Up Vote Up Vote ×
Specializes in Rehab, LTC, Peds, Hospice.

Did the hospital admit her? Just curious. And despite what the nurse felt, you did call the doctor and if he wanted her sent out, he would've sent her out. Though I will say I have sent patients out and informed the doctor after the fact. In situations like chest pain, etc. Don't second guess yourself. Experience will be a good teacher - decisions get easier and keep in mind that even experienced nurses decisions can be off. She should take a teaching role with you, not a judgmental one anyway. Not helpful.

Up Vote Up Vote ×
+ Join the Discussion