i feel so guilty..should i have done more?

erin01 · Oct 23, 2009

yes i mean the pt was retaining co2..sorry. And i have to say that the comments about this being BASIC NURSING.. makes me feel horrible and i think very unhelpful! I did what i could, i saw a patient in distress and wanted to help and if thats not nursing than i dont know! I knew copd pts can retain, but its different when you have a patient and all you see is them struggling and all you want to do is help them!!!!!! The others who have commented and educated me and support me THANK YOU!!!!!!! This is why i come here. I am off to review on copd again! :specs:

CASTLEGATES · Oct 23, 2009

Don't sweat it!

Just relax, chill and realize you did the best you could at the time. Everyone can point fingers or accuse but if you were my employee, I'd stand by you regardless.

You've got unacceptable sats, you called resp who is more specialized, called the md and that's that. The rest is out of your hands so let it go however you can.

We care for people but we do not make the decisions that brought them into the hospital in the first place. Smoking kills, this person is going to die and so are we all.

In order to preserve your sanity, start believing in karma a little and things will happen as they are meant to be. Sure the copd co2 drive issue is there but with sats that low, it was appropriate and I'd stand by you. Furthermore, this is why hospitals are MULTIdisciplinary; so we've got rt, md and rn all working on this patient....and you've also got a supervisor and if you're lucky you'll be in a teaching hospital where there would be nice discussions on your actions and the best next subsequent actions to take.

It is what it is, ya know? You've got to stop beating yourself up, as others said and relax. It's when we panic or are stressed that we make the worst decisions. Remember...that's not you laying there so be objective and pretend it's all a knowledge game someone set up for you and they're grading you on the next right action.

Hospitals kill people and we all work for hospitals (look at the statistics); it's a fact. Just make it our business to reduce that number and be the best you can with the time you've got. SOunds like you're off to a great start! If you didn't care, I'd be concerned but I'm equally concerned you're taking it personally. My guess is they smoked for years and came in ill and you took care of an 84 sat. 84 is no good! Stick by it and be done with it. The rest of the course of actions were up to the team. You can push your will and if you don't have a gut decision to do so, someone else (clin spec, manager, supervisor, charge) is there to review and voice that gut decision.

Sure we can do what we can but after that, let it go. Caring and codependency is a fine line. You can care because it's a human but you should not allow yourself to internalize and fault yourself.

When I'm working, I make it my business to be the best of the best. Having said that, there's always some clin spec or co-worker who knows more. This makes up a good multidisciplinary team. We need newbies to take the place of the older nurses so we gotta start somewhere.

This patient was not under your care alone; they were under an entire system's care. Remember that.

kanzi monkey · Oct 23, 2009

the comments about this being BASIC NURSING.. makes me feel horrible and i think very unhelpful!

Don't take it personally when someone says this. Basic nursing, Shmasic nursing--no matter what you've learned in school, no matter how "basic" it is, when you see it the first time in real life you will feel like your head is going to explode. Now you've had this experience and it will support you through your next crisis. Eventually you will get to a point where you will encounter a patient like this and you will feel calm and collected, allowing your brain to consider "basic nursing" and which interventions need to be done first.

Also, you were relying on the doctor to understand the clinical picture that you were describing to him. That is not a bad way to deal with this, especially since you were feeling panicked, and you needed someone to take the reigns. This doc should have come to see the patient. Like others have said, if your patient is freaking you out or appears to be going downhill, tell the doctor to come up now, get the charge nurse in there. Look at the clock. If you wait more than a few minutes for anyone to help you, call a rapid response. Pull out a piece of paper, jot down the time, VS, all interventions, etc. And make your documentation clear and accurate on your flowsheet before you leave. Don't leave the patient, get your charge and other coworkers involved--get an EKG, get the patient on a monitor so that you can quickly cycle vital signs, get a blood sugar. If you can draw labs, do it. If you need phlebotomy, ask someone to call them. Make sure the patient has adequate IV access. Have all medication admin documentation, previous assessments, and vital signs close at hand. No one will question you for taking these measures for a patient you are concerned about even if you don't have an order. If they do, who cares?

If it turns out that you over react once in a while (especially as a new nurse), don't let it get to you. And if you see another nurse in a similar situation and your patients are stable, help your coworker, keep her brain from exploding too.

I have been through this. Most of us have. At the end of the day it's not about you--what you did or didn't do, or if you knew what should be done--it's about the patient and the outcome. It won't always be a good one, and hindsight can feel like your worst enemy. Allow it to be a teacher as well.

Oh, and you did great. You really did.

leslie :-D · Oct 23, 2009

It is my understanding that the drive to breathe in a non-COPD'er is increased CO2. Due to chronic CO2 retention, the drive to breathe in a person with COPD is low O2 levels, and that is why we must be careful when giving O2 to these patients. If we give to much O2, we can suppress their drive to breathe. That is basic nursing.

no, it's not basic nursing.

and may i add, there is nothing "basic" when it comes to copd.

when you see anyone struggling to breathe, you throw on some o2.

with acute copd, it is likely they will need hi-flow o2.

it's all a balancing act, but you administer o2 until pt is stabilized, OR until pt becomes symptomatic with the o2.

respectfully wisconsin, you know nothing about "basic nursing" until you become a nurse and have the ability to assess what constitutes basic nursing (less the condescension, please).

there is never anything basic about copd exacerbations.

once they get a loading dose of solumedrol and abx, you act on how the pt presents.

so when there is a pt satting in the 70's/80's AND is dyspneic, you give that o2 w/o reservation.

we all know to not give it long term, but then again, some pts will.

you really need the experience along with textbook knowledge, before one is truly considered wise.

good luck in your schooling, and it bears remembering, that sometimes our ears are better tools than our mouths.

leslie

travleur · Oct 23, 2009

and it bears remembering, that sometimes our ears are better tools than our mouths.
leslie

I love that quote!!

Bottom line: Hypoxia kills not hypercapnia!

aCRNAhopeful · Oct 27, 2009

Was just in critical care class today and it reminded me of this thread. The topic was COPD exacerbations and they gave us a scenario with a COPDer with a hx of CO2 retention and previous intubation presenting to ER with dyspnea and sats in the low 80's and all the signs and symptoms of dyspnea. They asked "Ok so what would you do first?" The answer was apply O2 AS MUCH AS IS NECESSARY and notify MD as well as closely monitor for signs and symptoms of CO2 retention. Not to beat a dead horse because I think many others have already made this point, but it just irritated me that the OP was being accused of not knowing basic nursing when in fact it sounds that she did the right thing.

drgnflydggr · Oct 27, 2009

Hey - My "Basic Nursing" comment wasn't directed at the OP. I'm all for seeking assistance. Some jerk early on jumped on the OP and said that the drive to breathe for people with COPD was their CO2 level, and that that was basic nursing. I was, in my own awkward way, attempting to stick up for the OP. I apologize. I'm with you all, there is no "basic nursing" - each situation has to be dealt with as it comes. So, again, especially to the OP, I'm sorry if I misspoke or made you feel badly.

GrumpyRN63, ADN, RN · Oct 27, 2009

I would have had that resident's a$$ at that bedside ( or go above him), and if he didn't show and she was going south fast I would have went ahead and called rapid response. He really let the pt down by not being there. Next time go with your gut, you sound like you did the best you could but clearly the pt needed to be intubated with this comorbidity. Sometimes you need to bevery clear and assertive with these guys to get their butts into action.

blondnursey · Oct 27, 2009

yes i mean the pt was retaining co2..sorry. And i have to say that the comments about this being BASIC NURSING.. makes me feel horrible and i think very unhelpful! I did what i could, i saw a patient in distress and wanted to help and if thats not nursing than i dont know! I knew copd pts can retain, but its different when you have a patient and all you see is them struggling and all you want to do is help them!!!!!! The others who have commented and educated me and support me THANK YOU!!!!!!! This is why i come here. I am off to review on copd again!

nursing is a practice, and thats what it takes. all nurses miss clues & make mistakes. GOOD NURSES learn from the mistakes. dont feel bad and beat yourself up too much. you learned from it, not all nurses do.

RhiaRN75, RN · Oct 27, 2009

Hugs to you, Erin!

First off, you're questioning your actions in a complicated situation. You've already done the most important thing.... question. It's not always easy to question, especially if you feel you might have messed up. Even more difficult is to open up about it. Case review is essiential to becoming a great RN, and staying that way. However, guilt is basically useless in and of it's self. You could feel guilty till the day you die, but if you don't go past that stage you've accomplished nothing.

Should you have done more? Well, it seems like you did a lot. It doesn't appear that you ignored the situation. Should more have been done, yes. That's not entirely on your shoulders, though. I am an RN, say this was my pt, and I knew just by looking at her the exact measures that would lead to the ultimate best outcome. In this world of a perfect me, I still have limits. Scope of practice comes to mind, lol.

I am not perfect, and neither are you. I'll not criticise your actions, as it is not my style. I'll tell you how I would approach the situation instead and give my opinion as to who bears what responsibility.... even with time to ponder, I may be wrong.

Ok, my pt now. For simplicity and what ifs, let's say she's in moderate distress.

First off, I disagree that she doesn't qualify for tele. A negative cardiac hx is not a basis to assume no cardiac history. Every cardiac pt that exists, at one point, had no cardiac history. Cardiac risk, now we're talking! I see this pt, I see cardiac risk. You show me a COPD'er who died with no cardiovascular issues. It happens, but it's exceedingly rare. A COPD'er this sick has cardiac risk- even if a cardiologist gave them a clean bill of health prior to, things have changed. Now, we're in the ER- what to do? In my perfect world w/ fave doc- we put pt in bed, unless sat is horrific, take off O2 w/ continous pulse ox in place, call for ABG. (I will put the o2 back on, I'd rather have the ABG first if reasonable) Now, EMS should have an IV, so EKG,CBC, lytes, coag tube in case, BTNP, enzymes, CXR per protocol. Make room for Doc. I have all I need, Last VS from EMS, visual assessment of pt- quick chest auscultaion, RT on the way, my dinamap starting to take BP. Notice I'm not asking pt a ton of questions. I want my COPDer to breath, and everything the doc asks covers my stuff as well. I fill in the holes after I establish pt is as stable as possible. Now we monitor, and everything from here on out I will try to limit to things pertinent to eventual floor care, not ER flow.

-What other PMH, if any?

-Does pt still smoke? If so, I would like to know what the H&H is, and a desctiption of recent poops.

-CBC, esp. WBC, diff, and H&H

-Meds, duh-huh I know, but. There's PMH per pt, PMH per doc, and PMH per meds. Meds can tell a different story. Also home o2 and bipap.

-Lytes, and eventually a UA. Think renal function v/s dehydration.

-ABG, CXR

-EKG, why is it abnormal? (LOW chance it's normal- should be tachy at the least, and if tachy is not present, that is of concern as well.) Any changes? Pt now has a cardiac issue. Are they old changes? Pt has undiagnosed PMH. New? Pt has demand issues at best.

-BTNP. Yes, other things cause elevation beside CHF- and all are pertinent for this pt.

-Is it cold? What kind of heat, if any, does pt have?

-sick contacts

Now, I'm the floor nurse, and I want report. I want to know all of the above. When I was a floor nurse, what I wanted in report was::

-Admitting dx and doc.

-Quick pt status as of now. VS

-abnormal labs of high importance.

-EKG/tele findings.

-Tele order. I back you all the way on this one. I think tele is needed, and I'm prepared to fight for it.

-Reporting nurses' impressions/concerns.

-That there is a patent IV access. I don't care where it is, what size it is, or who started it. What's helpful is that it exists, it works, what's attached to it at time of report, and maybe if it took multiple sticks. (Guard it!!)

-pt/family issues I need to know about. Not interesting facts-- but are they coming to my floor ticked off, have a vendetta, or needy. Not to judge, but to prepare.

-*If I am receiving report from a nurse who didn't care for this pt, I want whatever the nurse wants to tell me, and I skip questions, except to establish pt is stable enough for transport.

-Anything I need to do that didn't get done in the ER

-I'll ask questions at the end

-If it's not busy, and we feel chatty, we can go about the pleasantries now How are the kids?

This was what I wanted in report as a floor nurse, short and to the point. Everything else I can find out in the computer and pt's paperwork. It takes about five minutes to scan over labs, orders, and notes. If it's really busy, I can always copy what I need and take it in the pt's room with me.

Now comes my impressions and advice. I'll not skirt the issue, CO2 retention was almost assuredly the biggest reason for TSHTF, and you missed it. A newer nurse trying to take care of pts on a stepdown floor plus has a new admit whose not doing well who missed CO2 retention? I'm not shocked, folks. I'm not going to string her up for it. (Besides, it's a tricky thing at times, and can be a fine line to walk even if you're an expert on the subject. You can't base all o2 decisions solely on the co2 issue alone.) However, now you know. Research COPD care, complications, and redflags, and all is well. If it happens again, it's a different story.

So, the nurse missed it. Had she done nothing else from the point of pt distress on, I'd have a problem with it. Not the case. The nurse did a lot! Most importantly, she realized there was a problem- even if she didn't know why- and reported it. So what was done wrong otherwise, and by whom? (And other assorted ??)

-Tele. Yes, I'm still beating that dead horse. ABC. Airway? Check. Breathing? Well, pt is breathing, but said breathing obviously sucks. What more can I say?

-Support, or rather, a lack of it. Barring other critical pts, the charge nurse and/or supervisor dropped the ball. Unless overwhelmed, any other experienced nurses should have helped. It's not a matter of doing someone elses job, it's just basic teamwork and good work ethic. I would have helped this nurse, and I expect no less from her or others.

-COPD'er+this sick=tele

-COPDer+o2=retention

-RT+RT assessment+breathing expert=shoulda known.

-Doc+duh, a doctor!=shoulda figured it out.

-Doc+shoulda known=twit

-Doc+everything he did and didn't do=sabatoge

-Lasix order+"pt has PNA and doesn't need tele"= bullcrap

-refusal to agree to tele=twit

-Newer nurse+no help= bad karma/disaster/frustration/lawsuit/bad stuff

-Newer nurse+a little durn help here=many good things

-odds this pt ended up on tele for dayshift=99.9%

-this nurse+this situation=my support

I have further advice and opinions about all of this, but my post is already too long. Briefly......

-get a textbook for tele RN cert., even if you never plan on taking the test, and learn it

-time to learn CYA, defensive, and passive-agressive charting techniques. All double edged swords, but good to know.

-ACLS, etc

-EKG interp class/book

-Legal issues for nurses class/book

-documenting class/book

-medscape.com for tele rn which is free

-Never start a sentence with "I'm sorry for..." , esp. when waking up a doc.

-If you want to apologize for something you did wrong, "I apologize for..." It's not a grammer thing... think "I know your sorry, but you could apologize." Inconsiderate people love this play on words.

-class/book about assertiveness, how to do it, and why it can be a good thing

-review COPD, then try to take care of as many COPDers as possible until you're comfortable again

-sit down when you feel a little better about all of this, and self-analyze. Write down what you think are your bad traits, but you must list a good trait for each one. Even if it gets silly like, I have pretty eyes or I love puppies. Aknowledge the positive, work on the negative.

-make a list of pros/cons for your work enviroment. Ponder.