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.
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 :)
Don't be to hard on yourself, this was a good learning experience for you. I work in the ICU and have many tools on hand that you don't by working on the floor. The ICU nurse was right, that you did wait to long the first reason is...if the pt is on a NRB and their O2 sat is only 90, this pretty much means they need to be tubed. The hospitalist should have been in again to see the pt also. I'm not being mean so don't think I am, but the best advice to give is to TRUST YOUR GUT INSTINCT, always push the dr. to be more proactive don't just "trust" their opinion because their drs. and take this learning experience and grow from it. You did the best you could and thats all that matters, you are not an ICU nurse and the ICU nurse who said you waited to long should understand that. Good luck! You'll be fine!!
She said that there wasnt enough support for me upstairs because all the nurses up there were inexperienced and the charge was busy downstairs.
Well, the ICU nurse nailed it. No, it was not your fault. As new as you are how should you have known what to do and when to do it? You're psychic, maybe?
I'm impressed that inspite of you letting other "team members" know of these changes, YOU LISTENED to the patient and went with your gut! Good Job and I'm sure ACLS will be a confidence builder for you. Good job!:balloons:
I hope you didn't give up nursing or if you moved that you moved to a different facet of nursing like in a rest home where the acuity isn't so stressful. thanks - I learned from your post.
If your charge nurse was informed she/he should have stepped in, that is part of their job. I never back off calling a doctor and put it squarely on them. Call until you get someone in the chain and if you have to, get the nurse supervisor. It is tough at times with the pt loads and until you get the flow of things. Yes, ACLS is very important and get to all the codes you can as they help you see in a crisis the ebb and flow.
BandEmom
87 Posts
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 :)