Feeling worthless right now.....

[MarcusKspn]

OK, so right now I am feeling like a worthless piece of excrement. I just wanted to post here and let you guys know what happened to see what you think about happened. I also want to post this to serve as a warning to everybody else out there. So here I go......

On Oct 17th we admitted a patient to our floor (LTAC) with Dx of Closed Head Injury/Subdural Bleed d/t MVA. He has been awake this whole time but did not follow any commands, non-verbal, non-tracking, moves all 4 extremities. He's on Lovenox 30mg to prevent DVT's. He has made great progress, he's not pulling on his tubes anymore, has great muscle tone and will hold up his upper body when standing, actively sniffing when you hold a candle to his nose. A couple of days ago his wife started to notice a change in his behavior, yesterday his doc ordered a MRI, showed fluid around the same area of the brain that was originally injured. Surgeon came by and talked to family about doing surgery tommorow. They agreed and he left, no orders written about anything. This evening I called the doc up, asked him if he would like for us to hold the Lovenox, do any pre-op labs for him, anything of that nature. Got an order to draw PT/PTT in the morning, and any labs that have not been done in the last 7 days. Here is where it turns bad in my eyes:

I pulled up his records and since he has been admitted on 10/17, there has been a CBC, BMP on 10/19 and that is IT!!!!! No orders to draw any labs since then and today is 11/17/05. Now here is what makes me feel like I should just go and hand my Nursing License over.

Patient was admitted on 10/17/05 for rehab s/p subdural bleed, has been getting Lovenox 30mg daily x 31 days, has not had any PT/INR drawn in those 31 days, and now he is having a Bilateral Frontal Craniotomy tomorow for a sudden buildup of fluid pushing on his brain. Now granted - it could be a very slow buildup of fluid due to the old injury - but I am pretty sure its a hematoma thats causing all his problems.

I have had the patient 4-5 times in those 31 days. I have given the Lovenox without thinking "Gee, we are giving him a blood thinner, lets see just how thin his blood is, gee, we sure haven't done a PT/INR in a couple days, lets check that" and none of the other nurses or his doc or his surgeon thought about checking the PT/INR. I was thinking about going to our QA/PI nurse and talking to her about this, I think we should report this as a Sentinel Event if his PT/PTT is through the roof tomomorow. I think this would be a wakeup call to really shake us all through the core and teach us to pay attention to details. I talked to some of the other nurses about why his PT/INR slipped through the cracks, and there seems to be some concensus on the floor that goes "It's his doctors job to order meds and order labs, we just follow orders." So here is what I think.

1) Everybody is responsible for what happened to this patient, I had him as a patient, and I feel this is just as much my fault as anybody elses.

2) It is our responsibility to check that if we give any meds, we need to make sure that this med is save to give - Check lytes for diuretics and lyte administration, PT for blood thinners, Levels for Vanco, etc...

3) I think we should report it as a Sentinal Event, if for nothing else as to learn from this.

Any imput.......

[Bipley]

::::edit::::

Prefer to send OP a private message.

[MarcusKspn]

I think that I remember that PT/INR is not a very good test that checks for the effects of Lovenox, but shouldn't we have been running some sort of test to see how the Lovenox that we gave for 30 days is affecting thinks

[canoehead, BSN, RN]

Lovenox does not change the Pt or Ptt levels, if that is of some comfort to you.

[VivaLasViejas, ASN, RN]

Marcus, for goodness sakes, DON'T beat yourself up over this!! I'm assuming yours is a 24-hour facility, meaning there have been other nurses who could have caught this. Don't blame yourself for the whole mess........yes, the ball was dropped, but you are far from the only one who fumbled!

I recently dealt with a badly mishandled patient situation, and at first I was highly upset with myself for not doing all I should have. Guess what? I was merely the last in a long line of nurses, aides, doctors, radiology techs, and other personnel who missed clues and didn't pass on what they knew to the next person. The case was mismanaged from the beginning, and the reason it all landed on me was because I was the one who actually tried to DO something about it. (Like I'm going to fix three days' worth of mistakes in four hours.) I ended up taking it on the chin from the nurse manager and blaming myself for not being forceful enough in getting the pt moved to ICU; in retrospect, however, I've realized that I can't own the entire mess because I wasn't the only one who made mistakes.

It's the same way for you. You are the one who called attention to the issue and tried to get it corrected; yes, you gave the Lovenox too, but that's all you can personally take responsibility for. It sounds to me like everyone else was on autopilot, and that bit about "we just follow orders" is inexcusable......that is sheer laziness, not to mention an utter lack of concern for one's license!

Again, please don't be too hard on yourself........just consider this a valuable lesson learned.

Same with you. Learn

[mtnmom]

you are in no way responsible for this.

Did the surgeon not review the chart before planning the surgery and speaking with the family? if not, he certainly should have, and should have written pre-op orders also. In other words, he should have been a little more familiar with what labs this patient had (or did not have) on his chart!

Secondly, Lovenox does not affect the pt or ptt.

Lastly, unless I missed something in your post, it would have made sense to me that labs should have been ordered, along with a CT, when his condition first started to deteriorate.

In summary, it is not your fault that this patient did not get lab work. do not beat yourself up.

Maybe this can be a catalyst for change, though...maybe instituting some sort of protocol for at least biweekly labs, etc? I have never worked LTAC so I know nothing of your procedures, so I may be speaking way out of turn here. At least have something in place so that if a head injury pt starts to have dec. LOC, that there is protocol for IMMEDIATE notification of the MD, tests ordered, etc.

Again, dont beat yourself up.