where did i go wrong? please comment

Sounds like you did a good job! We all do the 'shoulda woulda coulda' game with ourselves after an event- even ICU nurses.

The petechiae were probably from the vomiting.

I have a couple suggestions for you: 1.) Get your ACLS certification. It'll be the best thing you ever do for yourself and your patients. You'll learn a lot about events such as the one you handled, and it'll help you prevent them at times, too. 2.) Know your lab values on your patients- especially electrolytes for those diabetics, and get an ABG on all resp. distress patients. 3.) Always get a blood sugar on your diabetic patients in distress- even if you got one half an hr before. 9 times out of 10, this is the problem.

You did just fine. Really, hang in there. We've all been there, and you are NOT a bad nurse. You picked up on a problem as soon as you saw your patient. Plus, you'll learn from this experience. Good job!

It sounds like you're developing good instincts.

I'd want to know, specifically, what you could have done sooner. You couldn't get the consult on your own, nor transfer the patient to the ICU without the doctor's order.

It sounds to me like you were doing everything you could, and the doctor and your charge nurse were aware that the patient wasn't doing so well. Maybe the doc should've done something sooner, but it's not like you weren't telling her what was going on with the patient.

Ease up on yourself, you did just fine.

No, no, no don't do this to yourself... as far as I am concerned--YOU are the person who saved this patient's life and you did this on top of an entire assignment of sick patients. What more could you have done, really? This is a severely ill woman with an EF of 10%, phew!! That is pretty brutal. I am surprised that you kept her from arresting for as long as you did!! Sometimes you are only as powerful as the support around you, including the Physicians on the case. You called in the troops when you needed to and she got the care she needed.

I'm not going to tell you that you could have done this or that better or different because we could ALL do that to our own nursing care all the time. As far as I can tell, you did great. You paid attention to the clinical signs and responded appropriately...you couldn't have possibly have known how sick she really was.

I want to tell you something as well. Sometimes patients like that patient will die. And it is NOT because anybody did anything wrong. We all do the best we can with the resources and the time we have to do our jobs. Sick people die in spite of our best efforts. I believe it happens because it is their time to go.

You need to see for yourself what an outstanding job you did. You responded appropriately and operated extremely well under that kind of pressure of getting someone to ICU. I am truly impressed. Let up on yourself, you are not omniscient...and you did save her life!!

Great job. ;)

No, no, no don't do this to yourself... as far as I am concerned--YOU are the person who saved this patient's life and you did this on top of an entire assignment of sick patients. What more could you have done, really? This is a severely ill woman with an EF of 10%, phew!! That is pretty brutal. I am surprised that you kept her from arresting for as long as you did!! Sometimes you are only as powerful as the support around you, including the Physicians on the case. You called in the troops when you needed to and she got the care she needed.

I'm not going to tell you that you could have done this or that better or different because we could ALL do that to our own nursing care all the time. As far as I can tell, you did great. You paid attention to the clinical signs and responded appropriately...you couldn't have possibly have known how sick she really was.

I want to tell you something as well. Sometimes patients like that patient will die. And it is NOT because anybody did anything wrong. We all do the best we can with the resources and the time we have to do our jobs. Sick people die in spite of our best efforts. I believe it happens because it is their time to go.

You need to see for yourself what an outstanding job you did. You responded appropriately and operated extremely well under that kind of pressure of getting someone to ICU. I am truly impressed. Let up on yourself, you are not omniscient...and you did save her life!!

Great job. ;)

I totally agree with every word deeDawntee has said.

However, there is just one thing that I would like to add:

TRUST YOUR GUT FEELINGS.

Don't start second guessing them based what others may feel-you had the relationship with the patient. Insist to the doc that something isn't right and that you have a bad feeling. Many good docs will trust the nurse that says this. That gut feeling that you had shows that you are a good nurse (it is what differentiates good nurses from those that have only technical skills). You are well on your way to becoming a great nurse. Keep up the good work.

I totally agree with every word deeDawntee has said.

However, there is just one thing that I would like to add:

TRUST YOUR GUT FEELINGS.

Don't start second guessing them based what others may feel-you had the relationship with the patient. Insist to the doc that something isn't right and that you have a bad feeling. Many good docs will trust the nurse that says this. That gut feeling that you had shows that you are a good nurse (it is what differentiates good nurses from those that have only technical skills). You are well on your way to becoming a great nurse. Keep up the good work.

Well said loricatus....intuition is where great nursing begins...

i don't know that there was anywhere that you "went wrong."

it sounds as though you spent a lot of time with the patient, and that you treated her appropriatly. you knew she wasn't doing well, and you kept both the doc and your charge nurse informed.

since i don't work with you, i don't know what is "normal" for patients on your unit. but, i think i know what the icu nurse meant by saying that you "waited too long."

having to put a patient on nrb to maintain a sat of 90% is a pretty ominous sign. i'm a little surprised the charge nurse didn't start pushing for and icu bed at that point (which is why i'm wondering if having pts on nrbs is pretty common on your unit). i don't like to see anyone on a nrb unless we are in the process of "fixing" them -- such as an er patient coming in with some sort of resp distress from pulmonary edema or acute asthma or something like that, waiting on iv lasix or whatever to take effect. otherwise, you might as well prepare to intubate them, 'cause they are heading south and won't be able to maintain much longer. (unless, of course, the patient is a "do not intubate.") i think i would have started pushing for the transfer to icu as soon as i had to put the nrb on the patient. (even when i have a patient in the icu or er, if i have one on a nrb for more than 30 minutes or so, and my sats are only 90%, i tend to start pushing for intubation, unless that is the patient's baseline.)

i don't mean to sound critical -- i really do think you did a good job. i'm just trying to give you some constructive feedback, to keep in mind for the future. it wasn't up to you to transfer the patient, it was up to the doctor. but sometimes docs need to be poked and prodded a bit. they come in for a few minutes and get a little snapshot of what is going on with the patient. you, however, are there all day, and know how the patient is doing, how she is responding to the medical/nursing interventions. sometimes that little snapshot that the docs get isn't a great representation of what is really going on, and you need to give them a more accurate description. even if it is to simply say "she is decompensating."

step-down units are really tough places to work. i started out my career as an rn on one, and it was the toughest job i've had in nursing -- harder than icu, er, or infusion. those patients tend to go bad on you very quickly. however, you will learn a ton there, and really sharpen your assessment skills and your assertiveness when it comes to communicating with docs and supervisors.

anyway, as others have said, you need to ease up on yourself a bit. you did right by your patient -- you stayed with her, and you got her to icu alive. as deedawntee said, with an ejection fractin of 10%, there isn't a whole lot you could have done for the patient. use it as a learning experience. hang in there!

I work in a progressive care unit.

Here is the patient's history. 49 yr old woman, obese, sleep apnea, smoker, brand-new onset DM, CHF, depression/anxiety.

Admitted for a-flutter and pleural effusion. Xray also showed severe cardiomegaly. Went into RVR (140's) around 2 am. IV metoprolol given, IV dig given, dilt bolus/gtt started.

I came on shift at 7. When I got there, her rate was 110. BP was 90's systolic. Spo2 was 88 on 4L nc. She looked pale, a bit cyanotic. I turned her up to 6. She was sleepy, but oriented, followed commands. At 8, she had a small emesis, I gave her zofran. The hospitalist had just assessed her at that time. By 9, her HR was 120's. I wasnt too excited about the increase in her HR because she had just vomited and was moving around, I held off till 930 to turn the dilt up to 15. at 920, her sats were in the mid-80's on 6L. I told the charge, and we put her on a NRB at 10L. That kept her around 90. Her affect started changing at 945, very anxious, kept saying "am I ok?". I gave her ativan at 945. Now, I had three other sick patients besides her, and I pretty much ignored all of them during this time. But I couldnt be right next to her every moment. I noticed at 1015 that her HR was in the 140s and her BP was 130's/60's. She was working hard to breathe, and only held her sats in the 80s on the NRB, and the waveform looked fine, so I felt it was an accurate sat reading. At 1020 I wanted to give her PO meds, because I thought it would help - metoprolol and dig. When I tried to give them to her, she was not able to follow commands, couldnt take the pills, she also had a strange ruddy appearance, petechial in spots. Thats when I *ran* for the hospitalist who was about to get in the elevator. She then finally called for the cardiologist consult, and instructed me to have the crash cart ready because she anticipated we'd cardiovert her. The cardiologist arrived a few minutes later, they ordered stat cxr, abg's, cbc, chem panel, xfer to ICU. She was somnolent at this time, sats around 90. HR 140's dilt at 20. She got down to the unit at 1100. The moment the stretcher hit the unit she went into respiratory arrest and vascular collapse, her BP was 50/30. They intubated her and did a TEE - her EF was 10%. It took them 2 hours to get an A-Line in her, and abg's drawn. She had 4+ edema and her H/H were extremely elevated, which I had never seen before.

THey thought initially that she threw a huge clot, but they had ruled that out in the ICU except for v/q scan which they couldnt do b/c she was intubated.

I spent most of my day hiding around corners crying, we were so busy I only got a 15 minute lunch for a 13 hour day. My poor other patients hadnt gotten any of their meds until after 11. I had 2 SNF discharges, and someone else getting prbc's.

When my shift was over, I went down to ICU to see how she was doing. I asked the nurse caring for her if it was my fault, and she said I waited too long, but it's ok, she didnt code. (huh?) She said that there wasnt enough support for me upstairs because all the nurses up there were inexperienced and the charge was busy downstairs. I went home and cried and drank myself to sleep. I really dont think I'm any good at this, and I'm really thinking there's gotta be better out there for me than nursing. I'm not really helping anyone, despite my good intentions. My 6 year old thinks the world of me for being a nurse and wants to be one too, but every day i keep thinking "I'd never wish this upon anyone, no less my child!!"

Was this really my fault? I kept second guessing the gut feelings I was having that something was very wrong with this situation. I felt it right away, but the Dr looked at her and wasnt too excited. The charge nurse looked at her with me an hour before she fell apart and wasnt so excited. But in hindsight, that doesnt seem to matter, it seems like I'm the one who should have managed this better.

Any words will help.

I think you managed the problem fine. Your gut told you something was wrong and you had two -- no, three -- people assess her before it was finally decided to transfer her to the unit.

Please stop beating yourself up. The nurse who said you might've transferred her sooner did not have all of the facts, obviously.

I've had similar situations many, many times. Because I trust my gut now, I just keep watching those patients and I actually get the doc aside and tell them that I'm not sure what's wrong, but my gut says something's wrong, and if the doc knows me, he'll actually transfer the patient based on that.

I guessed a PE too, but my first hint was seeing that her sats kept dropping and having to turn up the O2 would've made me start bugging people to do something, even if I didn't know exactly what. I might've called Respiratory to verify the labored breathing and recommend ABGs, but it's hard to say when I would've done that. Those folks tend to go downhill pretty quickly if they're going. Others can just stay like that and they're fine -- how I do not know -- but not always. It's hard to play Monday-morning quarterback.

It might be more helpful for you to just try to figure out what you could've done better. In this case, I'd say that one thing you will take away from this is to trust your gut. If you cannot get anyone to listen right away, that's OK, just stay with it. You have good instincts and often that does a lot more for a patient than experience.

I agree with everyone's comments here and applaud you for trying to save the patient despite a clueless hospitalist and charge RN.

We have a system of early ICU notification at our hospital. We call it the Rapid Assessment Team or RAT. If the floor RN suspects that a patient is not doing well, he/she can call up to the ICU to request a RAT assessment without a physician order. That gets the ICU charge and ICU resident down for an assessment. If it was something simple, then no problem. The team is happy to provide assistance because we all know how difficult stepdown and telemetry units can be. Oftentimes, the team is able to provide interventions to head off an ICU admission or arrest before it happens. We have decreased the rate of arrests on the floors so much that we are having to do mock arrests to retain resuscitation skills!!

I agree with everyone else. Sometimes when pt's go bad they go bad FAST. you trusted your gut instincts, the pt made it to the ICU (EF of 10% yikes), you did your job good. Take this as a learning experience and pat yourself on the back for a job well done.

With a change in mentation, and a need for a NRB at 945, the doc needed to assess the patient, as she was trending towards worse, instead of better. I've also found any patient that questions whether they are OK, or whether they will make it or not needs a serious reassessment, but that knowledge came with experience. I think there was no question that something additional was going on, because she was trending toward worse instead of better.

At 1015 she definitely needed critical care interventions to maintain cardiac and respiratory function, and was going to code without them. PO meds would be minimally helpful at that point, and if your charge was still not concerned at that point I would question her competency. YOU got a doc though, shortly afterwards, and did well. Next time you antennae will go up that much sooner, and you'll be that much more experienced.

ACLS would be a huge help, you'll understand so much more about what to expect. My only suggestion would be that you insist the patient go to ICU, if she's going, ASAP, and get the orders started DOWN THERE. So often you get a page of orders on a sick patient and someone wants to wait for the blood draw, or the Xray, or whatever, before moving them, and they end up spending another 30-90 minutes on the floor. If you've anticipated the transfer and gotten all the moniters, O2, chart, in the room and ready to go, get them OUT. You can always help out or finish notes when you get there.

I agree with the others that you did very well in assessing your patients. Your charge and the doc needed to be kicked harder, (with spurs apparently) but experience will give you the strength you need to do that. Think about how your concerns will be listened to after this great catch- Nice job.

what an experience,

First off, if you still like being a nurse, and you want to, then dont let one experience where you DID advocate for the pt get you too down, but I too would have felt bad about that situation. All of the instict advice you got is right on. For me the point in which I would have been strongly advocating to get that pt what she needs is when she threw up and had to have 6L to be in the 80s, all though it is so different looking at things in hind site. with the s/s of CHF showing, and maybe some other acute event. sometimes it is the destiny of a nurse to be in a situation where they might be the only one to think that a pt needs something more or different ( including docs).

Thank you everyone for your replies. The weekend was plenty of time to process everything that happened. I do think now that the critical point was when I put her on the NRB. I had the charge with me though, and he wasn't as nervous as I was - that was the time I should have gone with my guts there. I work tomorrow, and I bet it will be a much better day :)