Did I cause this rapid response?

  1. I'm a new grad in my 3rd week of training.
    I had an elderly patient who was admitted to rule out sepsis. He came in c/o weakness and experienced chest pain the day before coming in to ED. He had hx of DM, htn, stent placement, hyperlipidemia, and early alzheimer's. When I recieved him in the morning his BP was in the 150s and all his vitals were WNL. He was a/o x4 but the night shift nurse during report said for him he was a/o x1 which could have been due to language barrier.
    In the morning his sugar was 175 he was due for 20units of lantus, 5 units fixed humelog and 1 unit of sliding scale. I saw him eat his breakfast which was 1 pancake and some fruits. After i gave his 9am meds he seemed fine. Around 11 when i took his vitals it was 110 systolic and everything else seemed to be ok except he was sleeping and seemed a bit short of breath but he was saturating 96 in RA. I gave him 1L of 02 with humidifier to see if it would help and he reported he was breathing better. I rechecked on him 30 min later and again he seemed SOB and still he was saturating at 97 i increased his O2 to 2 units for comfort and he was sleepy at this time but when i woke him and asked him how he feels he said fine.
    Anyway at 12:30 he was due for 5 units of fixed humelog and 1 unit of sliding scale his fs was 190. I for some reason thought he had eaten his lunch and gave him his insulin. He had refused to eat his lunch. I should have held the insulin but didn't. When I continued to check on him after the insulin administration he seemed sleepy and was jittery and thought maybe he was having anxiety. When my preceptor took him down at 4pm for stress test she noticed he didnt look good so she brought him back up and then reported the charge nurse and unit manager which then they came in and he was lethargic and hard to awake. His fs showed 35 and his bp was in the 80s. 1/2 Dextrose was pushed IV which his blood sugar went up again but began to drop back down so the rest was given. Rapid response was called and he ended up getting transferred to the ICU. Last finger stick was 186.
    during the rapid response when my charge nurse called his dr the dr said last time the pt came in he ended up at the ICU and he was suspecting the pt was taking something that he was withdrawing from.
    Now idk what the deal is here and I can't stop blaming myself and want to quit. I wish i had made sure he had his food before giving the 2nd dose of insulin. Did this pt end up at ICU due to my actions?
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    About ns808

    Joined: Aug '13; Posts: 108; Likes: 57

    23 Comments

  3. by   hherrn
    Insulin lowers blood sugar.
    Food raises blood sugar.
    You gave insulin in anticipation that he would eat, which he did not.
    The insulin did its job, and dropped his sugar.
    Any reason you Did not check a sugar subsequently?

    Serious question. I don't work on the floor, and have no idea how things are done there.

    You gave him insulin based on the idea that he would eat.
    Insulin
  4. by   MunoRN
    The insulin certainly didn't help, but your description suggests hypercapnia may have been involved ('jittering' and initial anxiety is a common symptom of elevated CO2 levels). You said his oxygen saturation was 97%, yet you increased his FiO2?

    Contrary to popular myth, hypoxia does not cause dyspnea, hypercapnia does. While the relationship is often misunderstood, it's possible due to multiple physiologic mechanisms that by unnecessarily increasing FiO2 on a patient who doesn't need it you might be worsening hypercapnia.
  5. by   mrsboots87
    I'm more concerned about the respiratory status change not being reported. You should have verified the food was eaten, but honestly, stressed and sick diabetics typically run high sugars whether they have eaten or not. When realizing he didn't eat anything you should have checked his sugars more frequently and maybe gotten him to drink something if possible.

    But anyway, back to the c/o SOB, that right there was his first sign of deterioration. His second sign was the fact that his SBP dropped from the 150s to 110. Third, he was lethargic before you gave the insulin as he didn't wake for lunch. You didn't cause the rapid to be called. You just missed early signs of deterioration that should have been reported to the provider. You are only 3 weeks in. Where was your preceptor during these changes? You are not expected to recognize all this so early in your career, but you are expected to learn from it. Next time you will be more diligent in recognizing and reporting changes in status.

    Don't beat yourself up. We all have to learn. The fallout is im your preceptor not recognizing these changes either to guide you into better actions.
  6. by   Been there,done that
    Nobody causes a rapid response, do not ever be afraid to call one.... that's what they are there for.
    YOU are blamless, it's all on your preceptor... where was s/he? Review your RR protocol. A systolic drop of 40 and change in mentation must surely qualify to call it.
    Good that you noted the change in respiratory effort. Now you know that the O2 sat means squat. What counts is the the effort it takes to maintain adequate saturation.

    One heeluva learning episode.

    No quitting now... best wishes.
  7. by   JKL33
    Quote from ns808
    I'm a new grad in my 3rd week of training.
    I had an elderly patient who was admitted to rule out sepsis. He came in c/o weakness and experienced chest pain the day before coming in to ED. He had hx of DM, htn, stent placement, hyperlipidemia, and early alzheimer's. When I recieved him in the morning his BP was in the 150s and all his vitals were WNL. He was a/o x4 but the night shift nurse during report said for him he was a/o x1 which could have been due to language barrier.
    In the morning his sugar was 175 he was due for 20units of lantus, 5 units fixed humelog and 1 unit of sliding scale. I saw him eat his breakfast which was 1 pancake and some fruits. After i gave his 9am meds he seemed fine. Around 11 when i took his vitals it was 110 systolic and everything else seemed to be ok except he was sleeping and seemed a bit short of breath but he was saturating 96 in RA. I gave him 1L of 02 with humidifier to see if it would help and he reported he was breathing better. I rechecked on him 30 min later and again he seemed SOB and still he was saturating at 97 i increased his O2 to 2 units for comfort and he was sleepy at this time but when i woke him and asked him how he feels he said fine.
    Anyway at 12:30 he was due for 5 units of fixed humelog and 1 unit of sliding scale his fs was 190. I for some reason thought he had eaten his lunch and gave him his insulin. He had refused to eat his lunch. I should have held the insulin but didn't. When I continued to check on him after the insulin administration he seemed sleepy and was jittery and thought maybe he was having anxiety. When my preceptor took him down at 4pm for stress test she noticed he didnt look good so she brought him back up and then reported the charge nurse and unit manager which then they came in and he was lethargic and hard to awake. His fs showed 35 and his bp was in the 80s. 1/2 Dextrose was pushed IV which his blood sugar went up again but began to drop back down so the rest was given. Rapid response was called and he ended up getting transferred to the ICU. Last finger stick was 186.
    during the rapid response when my charge nurse called his dr the dr said last time the pt came in he ended up at the ICU and he was suspecting the pt was taking something that he was withdrawing from.
    Now idk what the deal is here and I can't stop blaming myself and want to quit. I wish i had made sure he had his food before giving the 2nd dose of insulin. Did this pt end up at ICU due to my actions?

    Everything is okay. The patient is going to be okay (and if for some reason he isn't, it won't be because of this episode of hypoglycemia). You are learning.

    You don't mention how the preceptor relationship is going, so I will assume there are no major problems. Work closely with your preceptor. I favor very close oversight and frequent communication especially regarding assessments and interventions/medications/treatments. I think there are too many instances where new grads are given (burdened with) too much independence/too little oversight. You can have an effect on this by taking the initiative to stay in close communication.

    A couple of things about the scenario itself:

    1. Right off the bat:
    He was a/o x4 but the night shift nurse during report said for him he was a/o x1 which could have been due to language barrier.
    That's not how that works. A patient can't be less alert or oriented based on language barrier. And - the nurse noticing that the patient's mental status has changed and assuming that it actually hasn't changed but rather it just isn't able to be fully assessed d/t language barrier is not okay. Early alzheimer's patients often have periods of fluctuating orientation - - but whenever a patient has a change, it has to be accounted for/explained. That's our job ("why is this happening" or "why is this different now").

    Language barrier (without attempt to mitigate/use interpreter) makes it difficult to properly assess a patient. Interpreter must be used.

    2.
    who was admitted to rule out sepsis.
    What is the suspected source? It's easy to take a bunch of facts and write them down such as an admitting diagnosis or another nurse's assessment findings - - but how does everything fit together? As a new nurse, that's a big part of what you're working toward - being able to integrate a lot of information. You absolutely needed to know what suspected source of infection was being looked at, or why anyone thought this patient might be headed toward sepsis.

    3.
    seemed a bit short of breath
    again he seemed SOB
    Here you have noticed an alteration in respiratory status. You are calling it "shortness of breath" and I'm going to get a little nit-picky because sometimes it matters. Shortness of breath is subjective - - it's what the patient reports ("can't breathe," "hard to breathe," "can't take a deep breath," etc.). Patient might report shortness of breath for lots of reasons that don't indicate any airway compromise or overall change in respiratory condition. And sometimes they say "I feel fine" or "I'm okay" when things are not fine or okay and something is changing. Here you say that he seemed short of breath while sleeping - which means you're seeing something. What did you see. Maybe increased work of breathing. Labored breathing. Increased respiratory effort. Use of accessory muscles, nasal flaring, retraction. Something like that. Maybe it was "old person in deep sleep" or maybe something more - but that's what you have to piece together before you decide what you're going to do about it. You applied oxygen which does sound unnecessary at this juncture, but I wasn't there. A key point is to make your diagnosis before deciding that a certain intervention is appropriate.

    4.
    When I continued to check on him after the insulin administration he seemed sleepy and was jittery and thought maybe he was having anxiety.
    Lesson learned! For the future: Anxiety is kind of a "diagnosis of exclusion" in situations like these - always. Meaning there are handfuls of other things to be considered before deciding that something is simple anxiety.

    I think this will end up having been a good learning experience. Key points: Assess thoroughly, don't assume things, consider possible diagnoses, figure out which are most pressing/likely and why, decide how to best intervene and keep close tabs on what happens next. Basically....nursing process. Easy peasy! (Okay....just kidding on that "easy" part.) You'll get it. This is how every other one of us learned things...situations just like this.

    Hang in there!
  8. by   cleback
    Aren't pts npo for stress tests in your facility? So it wasn't as much as he refused his lunch. Either way, I think you had a med error and shouldve reported what happened to the provider. They would've given you guidance on how often to check his blood sugar (which in my facility is every 4 hrs for npo anyway).

    Also a sbp of 80 is to be reported (when that is not thrir baseline). Sepsis causes a drop in bp.

    I'm honestly a little surprised at what happened. There were a lot of opportunities missed to rescue this patient, and the two I noted were fairly basic. I feel like you need much more 1:1 training with a different preceptor.
  9. by   not.done.yet
    You did not cause the RRT. The low blood sugar definitely contributed to it. Now you know - always check a blood sugar reading when your patient isn't acting right, whether diabetic or not. Its a good first line assessment. You are a three week new grad. I blame your preceptor, not you. Also never give the insulin until the tray is in front of the patient and they are ready to take their first bite.

    The physician said he thought the patient might be coming off something. Info that would have been great to know prior to crisis.

    Patients become unstable. Please do not quit. This is going to stick with you and its going to hurt. It is also valuable experience that will become foundational in making you a better nurse. Hang in there. When people talk about "seasoned nurses", this is the kind of stuff that made them seasoned.
  10. by   JKL33
    Quote from cleback
    ...I think you [had a med error and] shouldve reported what happened to the provider. They would've given you guidance on how often to check his blood sugar...
    An excellent point and something not even on the radar way too often these days (not just with brand new nurses). As soon as you recognize that you've administered insulin to a patient who won't be eating for one reason or another, this should be communicated to the provider.
  11. by   CharleeFoxtrot
    Lots and lots of good advice on this post. Take this experience and learn from it
  12. by   CCU BSN RN
    It's a bit unclear from your post how much you were in touch with your preceptor from 11a-4p, and/or how much/little time she's spending with you/in your patient rooms. If you're a new nurse with 3 weeks of orientation under your belt, I'm impressed you can locate a nasal cannula and check a blood sugar (I'm exaggerating, of course, but the point is that you require and DESERVE more careful supervision t this point in your training.

    Others have brought up good points, but I'll reiterate them for fun:

    1. Sepsis. If your guy was septic, there's only a roughly 50% chance of him living through it anyway, in case that helps you to not feel so bad when things go south for them.
    2. Anyone acting weird gets their sugar checked. Always.
    3. Any change in mental status gets your preceptor in the room. Always. Until you're off orientation, then replace 'preceptor' with 'charge RN' or 'trusted experienced RN'. Altered mental is a great thing for them to teach you about: How to tell a CVA from seizure activity from detox from hypoglycemia from acid/base disorder'.
    4. My guess is that the overnight nurse assumed his disorientation/AMS was from dementia/sundowning/infection. Let's venture a guess and say he has sleep apnea and is either undiagnosed or noncompliant with his CPAP. Anyway, gets moderately hypercarbic overnight, then severely so for you.
    5. Your guy's hypoglycemia was not entirely because he got insulin and didn't eat. That contributed, don't get me wrong. Look into what sepsis and its associated processes do to blood sugar. Not always, but has been known to cause severe hypoglycemia.
    6. Your preceptor needs to know when your systolic drops by 40 points. But your guy has HTN and chest pain. You probably gave an AM dose of a beta blocker and/or other antihypertensives. They could easily be the culprits. So could sepsis. You have a preceptor, their job is literally to be asked a million mildly annoying questions and deliver advice and guidance. Take advantage.

    Lastly, You did way better than I'd expect anyone less than 6 weeks into their first job to do. Sounds like you need to work on communicating with your preceptor and getting a little more supervision. I've seen way more preventable RRTs from way more seasoned nurses. I wouldn't have been anything but proud that you prevented a death if I were the RRT nurse that night .
  13. by   neonn965
    Although you made some mistakes, I think overall as a new grad (and brand new/in orientation) you actually have a solid understanding of the situation and managed it pretty well. You seem to understand where you went wrong so take each component and use it as a learning experience. You will not make these classic new grad mistakes again.

    You can't give insulin w/o food. You clearly know that and clearly realize your mistake there. Always ensure that your patient eats. If they don't, report it and check sugars. Follow up here is the major lesson. If something doesn't go the way you expected, or even if it did and you had any concern, you continue to follow up with more BPs, blood sugars, assessments, or whatever it is until you are 100% certain that whatever concern you had is completely stable.

    A normal blood pressure is not normal if it is significantly below the patient's baseline. Again, you seem to realize this. For the most part, any change from the patient's baseline is abnormal, even if it falls within normal limits. Report changes from baseline.

    I don't work the floors, so I don't know if it works the same as in ICU, but the change in respiratory status is probably the biggest issue for me in how this was handled. A cannula is merely a band-aid if the change in the patient's respiratory effort is new. I would never start a cannula without reporting the change first. Usually if there is no obvious reason behind the change, we'll give the patient a cannula for comfort while the patient gets a CXR, septic workup, and potentially prophylactic abx. Again, I am in ICU (NICU, so things especially might be different), but I can't imagine increased WOB being something I wouldn't report, on any unit. This is where I am concerned about your preceptor. Why would this have been overlooked and a cannula simply started w/ no further investigation? Your new grad mistake is just that, a new grad mistake. You will learn from this and manage the next situation that is similar in a much better fashion. Absolutely no reason to beat yourself up and quit your job.

    Every new grad experiences situations like this. The patient likely would have ended up in ICU anyways, so you likely didn't cause anything, but you can definitely learn from it and manage it better the next time. I am a better nurse for the mistakes I have made because that is when I did the most learning. Any situation I mismanaged in the beginning shaped the nurse I am today.
  14. by   neonn965
    Ultimately, when a patient wants to go south, I find that they are going to do it no matter what nurse they have. In the beginning as a new grad, it's hard because you might not treat the situation with the same sense of urgency a seasoned RN would. And then you beat yourself up and wonder if you caused it. The reality is usually the patient simply wanted to tank. Even with more experience, I will wonder if I overlooked something or could have done something differently.

    Never trust a patient no matter how stable, constantly reassess and follow up, report to the doc if you are concerned even if you know your concerns will be blown off, and document all of it. The more experience you get the better you will be at this and you seem to already have a good foundation.

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