Feeling guilty about elderly patient.

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Hello, everyone! I'm due to graduate from an LPN program in a couple of weeks. We just had our preceptorship this week; I chose to shadow a home health nurse.

On Tuesday we visited an elderly man, who coincidentally was a family member of mine. I gave him a very thorough assessment (or so I thought), and everything sounded fine. He had been to the doctor the day before, and he said he felt good except for occassional abd pain. My preceptor had said several times to different clients that I was giving very good assessments, and I do agree that I have good assessment skills.

When I assessed him, his lungs sounded perfect - I didn't hear a single wheeze or crackle. However, the very next day the man started coughing up blood and was admitted to the hospital with pneumonia. My question is this: is it possible for someone to have or be developing pneumonia and still have clear lung sounds? I'm very worried that his family (a.k.a. MY family) might think that I did not give him a good check-up, and I'm wondering if my nursing skills are up-to-par. :o I keep thinking that had I caught it, he might have been better off, even if only slightly. I would appreciate any feedback or opinions.

Thank you!

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Specializes in Telemetry, ICU, Resource Pool, Dialysis.

By the time you're coughing up blood with pneumonia, you've been sick for a while. Sounds more like he had a case of flash pulmonary edema. Does he have a cardiac history? CHF? Those episodes can come on super fast.

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

Pricklypear gave you a great response! I am sorry you feel so bad......I am sorry this happened.

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no, i've never auscultated clear lungs w/the pt ending up w/pneumonia.

what i have experienced is a hospital giving me an admitting dx that was completely irrelevant to what i sent them out for.

w/sporadic abd pain and coughing up blood, my first thought was an active bleeding ulcer.

often w/pneumonia, it is pink frothy sputum.

nor should you be held accountable for anything.

and yes, flash pulm edema comes on suddenly but don't understand the correlation of him coughing up blood.....

wishing him well....

leslie

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Specializes in Telemetry, ICU, Resource Pool, Dialysis.

and yes, flash pulm edema comes on suddenly but don't understand the correlation of him coughing up blood.....

leslie

Pink, frothy sputum is also a sign of pulm. edema! She did say "bloody", but that could mean a whole spectrum of things. You're right, the admitting dx doesn't make sense either way. The only reason I suspected pulm. edema was the pneumonia dx. I suspected there was some reason for it, like SOB - which would also make me suspect pulm. edema.

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By the time you're coughing up blood with pneumonia, you've been sick for a while. Sounds more like he had a case of flash pulmonary edema. Does he have a cardiac history? CHF? Those episodes can come on super fast.

He does have CHF, as well as HTN and NIDDM. I'm not sure if what he coughed up was frothy and pink-tinged or bright red blood. We were at a different client's house, who just happened to also be related to the sick man (small town!), when she received a phone call from another family member stating that he was "coughing up blood" and that EMS was on the way.

Leslie, I also wondered about that admitting dx. When we did our clinicals at this hospital, I had patients who were there with a dx that seemed to come from out-of-the-blue, with absolutely NO s/sx or lab data to back it up. Let's just say this hospital isn't the best around... as a matter of fact, I refuse to go there and that's a common sentiment around here. So, it could very well be an active bleeding ulcer. I'll try to find out more at my baby shower tomorrow.

SBE, thank you for your sincere reply.

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Specializes in Med-Surg.

In the future, it might be best not to take care of family members.

Don't feel bad. You did hear clear lungs. Pulmonary symptoms can sometimes happen quite rapidly. I've had patients with clear lungs in the morning and crackles and coorifice lungs in the evening.

Yes, it is possible to have clear lungs one day and be in the hospital the next day with pneumonia, CHF or other COPD. The bloody sputum is worrisome that could be a tumor or TB in addition to the above mentioned scenerios.

So relax and give yourself a break. You did indeed hear clear lungs. The underlying condition was probably brewing all along but he wasn't symptomatic until the following day. Unless you have X-ray eyes, assessment isn't always exact until there are symptoms.

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This sounds very familiar to me. I'm not a nurse yet, but I just never thought that you could be as sick as I now know my father was and not really know it.

He never complained of chest pain or any other s/sx. He thought that - despite having had a flu shot - he'd managed to catch the flu. He said his chest didn't hurt at all. He started coughing up blood - apparently, though we didn't know it, quite a bit (I saw it - it was blood - not frothy, not pink, but red) - so he went to the hospital (I tried to get him to the doctor but he was so weak he couldn't even get down the steps so I called the ambulance). His doctor met him there, conducted a physical exam, and sent him for a chest xray. He told us he heard no abnormal sounds or any indications of pneumonia, but my father's lungs were FULL of gunk according to the ED chest xray. His CAT scan was unreadable because his lungs were such a mess. They transferred him to a larger hospital, and we were all afraid that all the years of smoking had finally caught up with him.

He didn't have cancer - a bronchioscopy confirmed that, so he was spared that much - what he had was a necrotizing pneumonia of unknown etiology and we were told he'd had it for weeks. The pulmonologist said it just spread like wildfire- probably due to age and advanced COPD, among other things. I saw the bronchioscopy and his lungs were downright frightening, to say the least. They cultured that horrible mess he was coughing up every way possible - tested him for everything from Legionnaire's Disease to MRSA to SARS - and just kept coming up with bugs that listened to no antibiotics whatsoever.

My dad had peripheral neuropathy and COPD - he'd also had a triple bypass and an aortic valve replacement in 1996, as well as carotid grafts in 1998 and 1999 - so he could have thought the shortness of breath that he HAD to be experiencing was just due to the advancing COPD, and he may not have noticed any more pain than usual due to the 125 mcg fentanyl patches and the the 5/500 Tylox he took several times daily, as well as the fact that he generally felt like crap anyway.

My dad's doctor was INCREDIBLE, as were his pulmonologists. (Even the pulmonologist said that, given the lack of distinct chest sounds, he would have sent him for a regular workup expecting cancer and not what he saw.) I consider the medical team he had to have been excellent; I would have no problems trusting the doctors to care for me in the same situation. I believe that medicine is quite often an inexact science - whether it's a physician, a nurse, or WHOEVER providing the care and making the decisions. We do the best we can and provide care according to the best of our knowledge and with the best of intentions. I, too, am sure you did everything correctly and provided wonderful care.

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