Feeling bad

[lorias]

I've been feeling bad the past few days since a resident at a LTC where I'm a nurse died unexpectantly on my shift. When I say unexpectantly I mean she was not in the dieing processl, not that she wasnt very sick. She had COPD and chf and wasnt always compliant with her breathing treatments in that she would refuse the maak nebulizers in favor of the pipe, but did these poorly. She almost died a few weeks ago when she started having trouble breathing due to a lot of fluid in her lungs and throat. At this time she got suctioning and because wasnt fully conscience, got a mask neb treatment. She recovered and was doing OK for a while until last week she decided that she was going to not do the mask nebs but only pipe. This meant she would not be getting the full benefit of the treatment, but we could not force her to do the mask nebs. A few nights ago on my shift, she started to have audible gurgles and labored breathing. She had just had her scheduled breathing treatment, using the pipe about 15 minutes before. Her o2 sats were in the 50s. I put oxygen nasal canula 3L on her and then gave her another neb treatment, this time with the mask. Her sats got to 69 but woulnt improve past this. About five minutes into the neb treatment she took off the mask saying she couldnt breathe. I tried to get her to leave the mask on but she wouldnt. She had refused suctioning when this all started but now asked for it. This is the part I feel bad about. I went to get the suction machine and it was not hooked up properly and ready to go. Being a fairly new nurse I did not know how to get it hooked up correctly so I called the nurse from the other unit who came to help me. We got it hooked up and I began suctioning my resident. This was maybe 5 to 10 minutes between when I went to get the machine and when I started suctioning. Once we started suctioning my resident did not improve but went downhill. Her sats started to drop into the 50s, then 40s and was 38 at one point. The other nurse suggested high flow oxygen which we did at 5L. We continued with the mask neb treatment which was still hooked up. Nothing worked and my resident died. She was a DNR. The other nurse said we did everything we could but that her heart had probably just gave out. She did say that if the suctioning machine had been ready it may have made a difference but she also said at the same time that this resident was very full of fluid that it may not have made a difference.

I just feel so bad because I should have known how to hook up the suction machine but had to call the other nurse. Also I think I was the one who hadnt hooked it back up correctly after it was used on this same resident the time she almost died. At that time I called for an emergency because this resident was turning blue and our acute floor charge nurse came and suctioned my resident at that time. It was my job to get the machine ready to use should it be needed. Im not positive it was me who didn't hook it up right but it probably was.

The other nurse who was helping me this last time just said to remind staff to hook the machine up so its ready to use right away.

Should I feel bad or is this a case of I did everything I could with what I had at the time?

[Chickenlady]

What could you have done differently? Seems you identified learning the suction set up. Learn that down pat and move on. Sounds like this lady was non-compliant from the get-go. I assume she was a Do Not Hospitalize and or Do Not Intubate or you would have called 911.

[lorias]

Yes she was a Do Not Resuscitate.

[Lynker, LPN]

From the sounds of it, you did everything you could. You are not perfect, nor are you a superhuman. Don't beat yourself down over this. You called another nurse, suctioned the patient, did all the treatments that the patient allowed. I see nothing wrong here.

It is sad, but you did well. If anything you should be proud of yourself for all you did. Not everything will end happily. And that's okay! You learn from what happened and move on, god forbid you have a similar patient down the road.

Proud of you. ?

[NurseBlaq]

Don't feel bad, you did the best you could and sought help from another nurse. However, I would have contacted 911 to get her to a hospital unless the facility's policy stated otherwise. DNR means do not resuscitate, not do not treat to the best of your ability until they pass away and all else failed. Sending a patient to the hospital should not be avoided because of a DNR. Also, high flow oxygen is not good for a COPD patient and their pulse ox usually reads lower but not 30s-50s, that's abnormal for anyone.

You've done all you could for a patient who was consistently noncompliant. Did she have CHF or pneumonia? Asking due to you saying she had fluid in her lungs and throat but the only treatment was nebs and suctioning. Was the provider aware? Did they not do more? So many questions but those actions would have been out of your scope of practice. You did what you could for the situation you were in.

It was a learning experience. You'll have many more through your years of nursing. Also, ask the nurse educator for an inservice on respiratory equipment. If there's ever anything you feel you need further education on, that's the person to contact and ask for an inservice, even if it's a quick one to one refresher. Never hurts to ask or refresh your memory.

[JKL33]

One thing to consider is that the active orders you have on hand will not always be sufficient to care for your resident's situation. And in those cases you should contact the provider right away while continuing to handle the situation as best you can with what you have available.

Also agree with @NurseBlaq that you would want to pursue a higher level of care unless your resident had indicated that she did not want that--it is a different matter than indicating that she doesn't want to be resuscitated if she arrests.

Seek to understand the overall pathology of what is/was going on with your resident.

Although it doesn't sound like the suction situation is what caused her to die, it is inappropriate to have a 15 minute delay when you believe that a patient needs to be urgently suctioned. Maybe you can use this experience to help your workplace come up with a better system for the next patient.

As NurseBlaq said, it is a learning experience and you will have many more. Try to move your thinking from "was it my fault" to a more neutral evaluation of the overall situation, including what you did well and what you can improve upon.

Take care ~

[amoLucia]

4 hours ago, NurseBlaq said:

It was a learning experience. You'll have many more through your years of nursing. Also, ask the nurse educator for an inservice on respiratory equipment. If there's ever anything you feel you need further education on, that's the person to contact and ask for an inservice, even if it's a quick one to one refresher. Never hurts to ask or refresh your memory.

Yes to the above! In the many LTC/NHs I worked, suction was always avail, set-up and ready to go. All its needed equip was right-at-hand and/or connected. It was usually located on a unit 'crash cart' or 'emergency cart'. All the nsg staff was SUPPOSED to know how to set a unit up quickly. Freq there would be a check-off board that had to signed each shift by a floor nurse or supervisor. (Some facilities also had a suction cart ready-to-go- in the dining rooms in case of mealtime chocking/aspirations.)

To those NOT familiar with LTC/SNF/NHs, our 'crash carts' were nothing super-sophisticated. Just basic equip that would be needed in an emergency. Like lots of bandages, oxygen masks & doo-dads, sterile saline/water, etc.

The intention was that 911 was being called and our equip was only meant for short-term temporary use. NOTE: it was always supposed to be restocked after each use or if some item was found 'missing in action' (also known as being cannabalized.)

As nsg supervisor, I always made it a point to Inservice my staff on equip use and I was a stickler for suction equip. And I did it FREQUENTLY. I also showed them the major troubleshooting problem to be an improper suction canister lid SEAL.

So for any LTC/NH staff out there, if you recognize a need for yourself for training on suction equip/crash cart contents, PLEASE, make it a priority to approach your UM, supervisor or Staff Devel Coord for training.

[amoLucia]

Just thought of something - as I used to inservice my staff re suction equip, I also made sure they could connect an O2 green tank. Not every facility has piped in wall oxygen, nor do they always have unlimited O2 concentrators (which can fail during power failures). So that leaves connecting the big green O2 tanks.

Just know that I use home oxygen (electric) concentrator with my bipap. And as many years I worked in LTC and set up the tanks, I looked at my emergency replacement tanks like they were foreign rocks just standing there!

Had to check out the setups just to refresh myself. (Have been having some wicked lightening/thunderstorms in my home area lately!)

So for staff who could use the information, check out O2 tank setups along with the suctioning equip. Soooooo less stressful during a crisis situation. And less guilt-evoking like for OP. Also for any nurse supervisors, UMs, SDC, etc, consider the suggestion.

[Missa310]

I don't know what state you're in, but this is EXACTLY why I always put my mom on FULL CODE when she was in a LTC facility. Staff does NOT understand that calling EMS even when a patient is DNR does not violate the DNR, especially a comfort-care DNR. I would bet that bipap would have helped this patient, which is non-invasive and does not go against a DNR. So instead of helping this person by calling people who know what they're doing, they just let her die because she's "non-compliant" and DNR. NOPE, NOPE, NOPE. I hope this patient has family and sues the pants off this facility.

[zoidberg, BSN, RN]

On 7/27/2020 at 8:21 AM, Missa310 said:

I don't know what state you're in, but this is EXACTLY why I always put my mom on FULL CODE when she was in a LTC facility. Staff does NOT understand that calling EMS even when a patient is DNR does not violate the DNR, especially a comfort-care DNR. I would bet that bipap would have helped this patient, which is non-invasive and does not go against a DNR. So instead of helping this person by calling people who know what they're doing, they just let her die because she's "non-compliant" and DNR. NOPE, NOPE, NOPE. I hope this patient has family and sues the pants off this facility.

Right. You should always know if your patient is DNR while continuing medical treatment (do everything you normally would, other than resuscitation, intubation, defib, etc), or strict comfort care with no escalation of care, which would mean morphine for air hunger or ativan for agitation, and so on. I mean... the patient could have just needed some diuresis, so a call to provider and potential inpatient stay may have been appropriate.

There is so much gray area in goals of care so remember to ask specifics on what patients and families wishes are, and find out if no one seems to know.

Not being critical. Every shift is something to learn from.

[Tweety, BSN, RN]

On 7/22/2020 at 1:41 AM, lorias said:

a case of I did everything I could with what I had at the time?

^^^This

However, you've learned something to move forward with.

[amoLucia]

Missa - I have concerns re your response. In all the NHs I've worked, bipap machines were NOT ROUTINE resp equip provided by the facility. The resident would have had to be followed by pulmonology and then have her own individual machine provided. Not poss in an emergent situation that was unfolding like for OP. EMS would NOT just happen to have a spare machine just lying around!

Are you in any healthcare provider capacity??? When dispatched to a NH, the usual role of EMS is to try & stabilize the pts and transport them to another facility for a higher level of care. They are not facility-extenders (there are exceptions).

Now if a DNH (Do Not Hospitalize) was in place, that would REALLY affect the purpose of EMS being dispatched. EMS can provide SOME more aggressive treatments, but it DOES seem like EVERYTHINGthat could be done for that pt WAS being done. (I didn't see where morphine may have been a consideration.) I'd venture that the staff DID truly try to get the pt to use the mask. I mean, like they can't strap here down or hold her arms/head restricted. There may be a whole lot MORE to this scenario than has been discussed here.

So for you to consider the threat of lawsuit is rather disingenuous at this point.

At this time, I might bring up the point, that perhaps, maybe just PERHAPS, the pt was flat-out asked if she wanted to be hospitalized & she refused. In some select situations, I have confirmed the pt's /DNR/DNH/DNI decision with the pt when things were just too difficult to treat in-house AT THE TIME. That decision can be changed at the last minute.