Vent...long, you have been warned.

[ND76]

I had a patient the other day that although I worked my butt off, but I was made to feel like I did a bad job with, and it's still nagging at me.

Pt was a sixty-something year old male, lifelong smoker, not been to a doctor in YEARS, who had been having SOB, productive cough, low-grade temp and chest tightness for two days. Seen in another ER day before, and dx with bronchitis, given a mega-dose of steroids/IV antibiotics, and discharged with amoxicillin.

Showed up at my ED with same complaints, RR of 26-30, sat of 90%, rhonchi and audible wheezing, yellow sputum, fever, so I did the complete pneumonia bundle on him, as well as a full cardiac workup. His labs came back crappy... 18000 WBC, K of 3.2, slightly bumped troponin (0.19), CPK of 1800, a pro-BNP of 1800, and a d-dimer of 1.3. But his x-ray didn't show an infiltrate, he responded very well to duoneb tx/solu-medrol, and his ct chest was negative for PE. Pt was actually wanting to go home...he didn't look as bad in person as he did on paper! He kept insisting, "I'm alright, I'm okay." I spent a lot of time with him, explaining lab results/medicine, talking about smoking cessation, the importance of getting a PCP and having regular checkups, etc. We had great rapport...he was getting a kick out of me fussing at and over him.

Every single issue that arose with him was addressed in the ED. He got two lines, BC x 2, sputum culture, Vanc, Levaquin, aspirin, NTG paste, Lovenox, K-Dur, and Lasix just in the ED. His admission orders were dx: bronchitis/chest pain, written for bedrest, serial cardiac enzymes, scheduled steroids/duoneb treatments, IV antibiotics, and an echo in the AM, and a stress test as soon as his respiratory problems improved. He literally had three pages of orders, and I checked off every single thing I could do in the ED, got all his meds, etc.

When I called report on him, his vitals were actually pretty good. HR of 96, RR of 24, 02 sat of 95-96% on 2 liters, BP of 130/80 and temp down to 99. I called report, and noticed that he was due for an albuterol/atrovent treatment. I called respiratory to meet me upstairs, and me and the pt went up. I put him on the monitor, hooked up his 02, bid him goodbye, went to the desk and gave additional report to the nurse, and told her respiratory was on the way for his treatment. When I left him at 2am, he was sitting in bed, laughing and talking, watching some infomercial on TV, and had only slightly increased work of breathing. Still some expiratory wheezing in his upper lung fields, but not audible without a stethoscope.

Then I get a call 20 minutes later from the nurse, yelling that this patient is too sick, he needs to be in ICU, why did I leave him up there, etc. I can hear him in the background saying, "I'm alright, I'm okay." Unbeknowst to me, the admitting nurse didn't go right into his room, and neither did the CNA. The patient took off his 02, went to the bathroom, then walked all the way down the hall because he wanted some juice. Respiratory never showed up to the room for the treatment, and by the time the pt was seen in the hallway and escorted back to his room, he was very SOB, audible wheezing, etc. Instead of calling respiratory, the nurse on the floor called the medical response team and the ICU doc to come see this patient that was probably going to need to be intubated(!) She pitched such a fit that the critical care hospitalist agreed to take him to the ICU. I went right up, and he was in ICU, FINALLY getting his breathing treatment, laughing at me, joking "Why didn't you tell me that I was going to get a tour of the whole place, I've done been in three rooms tonight already!" Sure enough, after the breathing treatment, he looked and sounded much better, and it was time for his steroids, so the ICU nurse gave them to him. I went back at 7am before I left, and they were going to downgrade him back to a tele bed after his echo was done. He spent less than four hours in the ICU.

Yet...I still got written up by the nurse on the floor. I feel like this patient was completely manageable. I took care of him along with my four other assigned beds in the ED most of the night, and we also had a full arrest and a STEMI come in that I worked on. I'm mostly just pissed that the patient really had confidence in me, and then it got undermined as soon as the admitting nurse called me yelling in FRONT of him.

[Mags4711, RN]

That admitting nurse should be spanked for her ridiculous behavior! I cannot imagine allowing a new admit to just sit there! SOMEONE, ANYONE should have immediately gone into the room and made sure he understood the importance of keeping that oxygen on and making sure he had his call light (but then again, you should have made sure it was within his reach, and explained to him NOT to get up until someone comes to see him). Though a patient like this will do what he wants, that is not your fault. I don't care how busy the place is, someone needs to get their tail into the room of a new patient right away. If for nothing else but than to say hello, someone will be with you shortly, don't get up.

This isn't going to be a popular statement but if I were you, I'd write her and the CNA and the RT up for not going in to see the patient/give his treatment (in the case of the RT) for over 20 mins.

[ND76]

Sadly, new admits often sit for a little while on the floors at my facility, this floor is particularly bad. They are so understaffed. They usually have at least 9 patients apiece, and two assistants, if they're lucky. That's why I always hook them up, and most of the time I stay in the room until someone comes. That night was so bad in my department, though, I had to scoot back down, we still had several patients and were expecting a transfer and I didn't want to leave the other nurse alone for too long.

From what I gathered, the patient "didn't want to bother anyone", so he just got up. He had done this a couple of times downstairs, and I had already fussed at him about it. The call light was in his hand, it's on the TV remote. I think the total time elapsed between me leaving and the nurse coming in was about 15 minutes. I actually called the respiratory supervisor MYSELF when I left the floor, because no one was up there to give the tx. He said that someone was on the way, so I relayed that info to the nurse.

[TazziRN, RN]

A) Write up your own QRR......RT never showed up the nurse you gave report to knew the pt was in the room with a respiratory problem. Not to mention the humiliation she put you through.

B) That said......I never leave a pt in the room until someone from the floor comes into the room. Doesn't have to be a nurse, it can be a CNA....just somebody. That patient is my responsibility until I actually hand him off to the admitting staff, and until a staff member comes to the bedside, I haven't handed him off.

[TazziRN, RN]

Never mind B, I just read your second post.

[Batman24]

Asked my nursing friend and she agrees that she would write them all up. Feels they wrote you up to cover their own errors and to shift the blame on you. She said not onyl would she write them up but she wouldn't sign a thing under the circumstances. Said you did everything right and then some.

[Mags4711, RN]

Thanks for adding that you had had discussions with him about not getting up and that you left him with the call light in hand. I agree it sounds like you certainly did everything right. It also sounds like (from your description of the way that floor runs) that floor needs to have a few "unsafe practice" reports written about them.

[ckh23, BSN, RN]

How can that nurse justify writing you up? Let's use the same scenerio, except it is four hours later and the pt decideds to go for a walk and the same thing happens. I would fight that write up and let your nurse manager know about it.

[UKRNinUSA, RN]

I agree with the other posters -the nurse is blaming you instead of blaming herself. Where I work they have just implemented a policy that the receiving RN or the charge nurse if he/she is not available should immediately assess the patient on their arrival to the floor. But then we have ratios in CA.

[UM Review RN, ASN, RN]

Stuff happens. I know that on our floor, a patient with a breathing problem can come up from the ER and seem fine in the ER, but just moving from the stretcher to the bed causes respiratory distress.

It doesn't take much for a patient like that to look pretty bad and frankly, I would've probably flipped out too if I knew I had 8 other patients just like him on my assignment.

All you can do at this point is to defend yourself with the charting that you did about this patient's hx of taking off his O2 and getting out of bed despite agreeing to keep it on earlier. That would prove that you also had the problem and were able to sufficiently stabilize the patient for transfer.

You might also note the time lapse, the floor nurse's absence and the patient's own admission that he removed the O2 and walked around despite your admonition to stay in bed with the O2 on.

[jellis]

Everybody always wants to write someone up!

I've only found it necessary to write up any incident once in 3 1/2 years.

Communication and forgiveness go a long way.

If you point the finger, you'll always have 3 pointing back.

Don't leave a patient in a new room without the nurse knowing.

I'm a cardiac nurse, the elevated Trop and BNP are evident of CHF exacerbation/onset in need of a diuretic and K is already low at 3.2

[ND76]

Looking back, yes, there are things that I could have done better. If the pt's respiratory status was that labile, I should have pushed for a bed near the nurse's station, or if he was really that 02 and bedrest dependant, maybe I should have called the pre-code team myself down in the ED. When I inherited him at 7p, I thought he might end up needing ICU, but he responded so well to the meds and treatments that the ER MD and the admitting MD agreed that tele was appropriate. I do feel for the nurses on the floor. 8 or 9 patients is a huge load...That floor is a medsurg/tele, and basically gets dumped on. Lots of total care pts...he might have been the straw that broke her back.

I spoke to my supervisor yesterday before I left for vacation, and she assured me that I have nothing to worry about, the 'write-up' was basically going nowhere. My charting from the ED reflected that pt had been non-compliant with the 02 and had ambulated without assistance twice. I had also assessed the pt and charted vitals 5 minutes before admission, and another nurse had charted on him 30 minutes before admission because she had interacted with him, and had charted that the pt was resting quietly, no c/o pain, RR 22, 02 sat 96%, etc.

So I'm going to take this as a lesson, and be more diligent in the future, and also know to watch myself with this particular nurse, because I was told that she basically writes everything up. I'm just grateful that the patient is okay and didn't suffer any permanent or serious injury.