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.
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.
seemed a bit short of breath
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
When I continued to check on him after the insulin administration he seemed sleepy and was jittery and thought maybe he was having anxiety.
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!