I'm a new graduate that just got off orientation, so now I'm on my own, and I've been having a run of really bad patients. They start out fine at the beginning of my shift, but towards the end, they wind up intubated, comatose, and/or requiring surgery of some sort. The first patient was a patient that received tpa. I admitted him, his wife at his side, and I started doing my assessment. Everything was looking fine, and I told the wife, when she asked me when he was going to be able to go home, that I thought he would be able to go home pretty soon, by the end of the week at most. Vital signs were stable, the patient was awake and alert x3, and the only abnormal sign that I saw upon assessment was a big hemotoma where they had tried to place a peripheral iv. Otherwise, everything was normal, and I thought things would be pretty easy. A couple hours into my shift, the patient starts c/o of n/v and a headache. I thought maybe it was the nitroglycerine and so I told him that that was a frequent symptom of ntg. Then, he told me that he was having a really bad headache, and then threw up all over the bed. His eyes floated to the back of his head, and I went and got help from one of the more experienced nurses and I called the doctor. One of the interns, as soon as he came into the room, said the patient was stroking out, and we wound up coding the patient, intubating the patient, and placing him on pressors to maintain bp.
A week later, I had a patient that was admitted for cerebellar stroke. It was obvious that she was having muscular deficits, but she was able to talk and was aao x2, had to reorient to time. Pupils were equal and briskly reactive, right side was slightly weaker than the left. Otherwise neuroassessment was normal. Vital signs were normal. Patient was on a NRBM for O2 support. Then throughout my shift (I work night shift, btw), the patient began to get lethargic. I thought maybe she was just tired and sleeping, but still I told the on-call MICU doctor whenever he came by that the patient was getting more lethargic. He said to keep watching her. Towards the end of my shift, the patient got really combative, trying to get out of bed. I paged the MICU intern, and he said restrain her, which I did. All throughout, I was performing neuroassessments q15 minutes. Finally, I saw that her right pupil was slightly more dilated than the left. I pgd the MICU intern again, and he said he was coming to take a look, but it took him a while, and all the time the patient was confused and kept trying pull her lines off and pull her NRBM off and being very difficult to manage, despite restraints. Finally the MICU intern and resident came by, they looked her and called for the neuro on-call, and he suggested we take her straight to CT stat, but by this time the patient was so agitated and confused that there would be no way that she would lay still for the CT. The MICU resident said I could use propofol, 30 mg IV, so I gave it to her, which made her quiet, but on the way, her O2 sat fell to 40, and we almosted coded her down in CT. Fortunately, the ED shockrooms were right next door, and we wound up intubating her there. I got a lot of heat from the ER nurses for giving 30 mgs of propofol to an unintubated pt. Even the RT down in ED wound up writing on the big board "30 MGS PROPOFOL + UNINTUBATED PT = INTUBATED PT". Finally, we get the pt to CT. Neurosurgery comes by, looks at the pics, and they zoom her off to surgery, and I'm standing there by myself in this big hallway in front of O.R.
Then just last night, a week after all that, I get another patient. He's got a massive cancer/infection of the face. ENT comes by and does a biopsy of it. The man starts oozing a small amt of blood from his soft palate. They told me that this would be normal and just just watch it. If it starts to bleed a lot, pg them or the MICU intern. Well, all throughout my shift, everything is okay. I suction the pt frequently to get rid of the blood in his mouth. (FYI: the patient is a 60 y/o BM, retarded, who's' been taken care of by his family all his life. the pt is mostly stuporous, but does respond to pain, with severe contractions of the bilat LE's and UE's--think your basic nursing home pt.). Anyway, I'm working a 16-hour shift this night, and halfway through, I decide to give this guy up because he's giving me a bad vibe--his breathing is raspy, his O2 sat is erratic (because he doesn't sit still????), and his mouth is still oozing blood (8 hrs after the biopsy). I've told the on-call MICU intern, and he says just watch it because this is to be expected because he's been oozing blood from that area for a while now anyway because of his coagulopathy due to his infection/cancer (????). Anyway, as soon as I give report to the on-coming nurse, the patient starts to desat, his breathing is labored, and we pg the on-call MICU intern and resident. They come by soon, and then the call the on-call anesthesia because by now the pt's o2 sat is 80 and his breathing is really bad. Turns out that it takes us almost an hour to intubate the patient because his anatomy is so twisted. Surgery had to be called to intubate the patient because anesthesia couldn't make any sense of it. When surgery came by, he put his hand in the patient's mouth and pulled a clot about as big as his palm out, and finally they intubated the patient.
I'm so tired. On top of all this, the nursing assistants have been giving me a lot of heat. They act like they're my boss, and they say that it's time for pt hygiene now or never. the charge nurse/supervisor doesn't do anything about this, and lets these nursing assistants get away with anything because all during the shift, the nursing assistants are helping the charge nurse do whatever needs to be done.
Sorry for the long thread. I don't know what I'm doing wrong. I feel like i'm slowly sinking in quick sand, but I don't know how to get out. The other nurses are teasing me and calling me the angel of death. it makes me sick each time i hear that. i feel like crawling into a big black hole.
May 24, '03
So sorry, Ghetto. Patients today are much, much sicker than they used to be. There are patients who are routinely admitted to med-surg units who just five years ago would have been in the unit!!! Don't be too hard on yourself--emotionally, such experiences are very hard. You did your professional best. Ignore the teasing. Stick it out for at least 6 months. Things tend to run in cycles for some unknown reason. You WILL have your nights when everything is haywire--everybody in the hospital is coding, your L & D is overflowing, the ER is full of very sick patients. Then other nights are just as smooth as glass. I remember when I was doing OB in a community hospital. Was new to OB and "helping out" the more experienced OB nurse--had two HORRIBLE deliveries back-to-back in ONE night. Never saw anything like it again the whole remaining 3 years I was at this hospital. As for the "bossy" NA's--this is something that can make you totally miserable if not properly dealt with. Discuss this situation ASAP with your supervisor.
Last edit by VickyRN on May 24, '03
May 25, '03
You stated you are on nights and it is near the end of your shift when these things happen. It is to be expected. It seems related in some way to the cercadian rythm. Statistically most codes and deaths occure between 4 am and 9 am. It is a time when our metabolism is in a dangerous flux. (Remember how the DM will have a drop in their glucose level at 4 am?)
It is in appropriate and cruel to refer to you as the angle of death. Rest assured though they would not be teasing you if they thought there was any truth to this. Still it is cruel. I am not sure how to ask them not to do this. They are not thinking or they would not do it if they realized how this was effecting you.
You have some extreemly sick patients it is the nature of things that these will be ones who go bad on us.
As for the CNA you need to have a talk with her. It is your place to do so. Contrary to what many believe the correct answer to the interview question "what do you do when you have a conflict with a co worker?" is not "take it to the supervisor." The answer the interviewer wants to hear is, "I prefer to handle conflicts myself. So I discuss it with the co-worker and work it out."
Your boss is not there to settle petty squables. She would much rather you solve your own problem with the CNA. In fact managers are generrally advised to stay out of these things and to alow you to settle it yourself even when you do bring it to her.
Demonstrate your maturity and LEADERSHIP take the bull by the horns and deal with this person.
Last edit by Agnus on May 25, '03