Growing pains

[chill1121]

So let me start off that I'm overly critical of myself. I do it to help me figure out what I could of done differently. So my story goes like this.

Im a new grad working in critical care for about six months. I always wanted to do critical care and or trauma so it's exciting and I learn something new a least once a week. I also know because it's s tough unit, the learning curve is steep.

I had a patient who was transferred from a cardiac floor for a rapid response. She was dx with a NonSTEMI and her BNP sky rocketed. Doctors related her increase with her MI and previous CHF issues. Patent was alert and oriented but forgetful all day. She was in a first degree HB, sounded slightly coorifice, BP was in the low 100s. Her MAP was borderline and so was her urine output. Cardiology saw her and increased her lasix, put her on looted and aspirin. Typical MI protocol. Her temp gradually climbed so I got an order for Tylenol. Her white count was 15 and was on daily rocephin. I iced her up and took the blanket off her. Temp didn't move. She was on 60 percent heated high flow all day. She sat around mid 90s until she would take the cannula off. Respiratory talked to her about it and so did I a number of times. She did that all day. She only desat when she removed the cannula.

Her son comes in around the end of my shift and he talk. Her urine is now cloudy and output is pour. I page the doctor after I get report about her urinr and her desat issues and her temp. They talk about rethinking her code status because they don't think she should be a full code. She's 85 years old and her recovery wouldn't be that great. The son was receptive but wanted to talk to his sister before they made any decisions.

So so I go to leave and all the sudden she is very restless. At this point it's almost 2 hours after my shift and I've clocked out. I stop in because I felt she was off compared to her mental status all day. I call respiratory and tell them she's not sating well and is anxious. They tell me they were just there and weren't concerned but I convince them to come anyway. I stay with her until they come and I head out once they charge nurse told me to leave.

I had a bad feeling but I knew she was in good hands. Well about two hours later I get a text from my friend saying she died. I was dumbfounded. She went into PEA was intubated got a rhythm but Brady down and the son said to stop efforts. I feel horrible.

So now I'm thinking about my day and how I could of prevented this. I'm kind of brainstorming here so next time I can be more in tune with this.

So maybe her desat was hypoxia?

Maybe her cloudy urine with poor output with her temp and being tachycardic was sepsis instead? Maybe pay more attn to her MAP?

Maybe this just happens with a NonSTEMI and heart failure in an 85 year old with co morbidities?

Im new so I really don't know. I know what's done is done but I want to know for next time what to look for.

Of of course I'm convinced I'm losing my job. Probably doesnt help I'm 6 months pregnant either.

I know if she had that change of mental status on my actual shift I would of rapid response her. I know change in mentation is a first sign of crap hitting the fan.

I'm looking for some input to help me be a better nurse. I know I can't prevent everything. This could of been inevitable. I just want to think of things I could of done differently.

Sorry it is so long but thank you for advance for your input. I'll be impatiently waiting.

[Lev, MSN, RN, NP]

You did fine! Stuff happens.

[Been there,done that, ASN, RN]

"Maybe this just happens with a NonSTEMI and heart failure in an 85 year old with co morbidities?"

Yes, death happens. You did a good job, it was her time to go.

Please stop beating yourself up, you will see this a thousand times in your career.

Now for the suggestions you are looking for... did you get ABG's? Did you administer an anti-anxiety agent?

[calivianya, BSN, RN]

I don't think you could have really improved her outcome. Sounds like she was ready to go.

That being said, here are some thoughts:

You mentioned paying attention to the MAP, so definitely pay attention to the MAP! It's way more important than the systolic. If her MAP was under 65 with that systolic of 100, the low UOP could be related to her kidneys taking a hit from the low BP. Heck, I've had patients with bad hypertension drop their urine output well above a MAP above 65 because their bodies are so used to extremely high levels of perfusion that the kidneys don't know what to do with a normal BP because they haven't seen one of those in years.

It does sound like she was septic. Do you have a copy of the SIRS criteria? They are:

- Temp >38C (100.4F) or

- Heart rate >90

- Respiratory rate >20 or PaCO2

- WBC >12,000, 10%

We have those criteria as badge buddies at my job. Every RN in the system has a copy right under the badge. You have to have at least 2 of them to be considered in SIRS (you definitely have the temp and white count here, not sure about the rest), and when coupled with a possible infection source (cloudy urine) you can call it sepsis. If she was on daily rocephin already prior to this happening, I would suspect whatever she was brewing was resistant to rocephin and would have suggested redrawing blood/urine/sputum cultures and changing up the ABX regimen just to be sure.

The restlessness would have made me nervous, too. She could have been hypoxic even satting in the low 90s. Have you seen this chart? A SpO2 of 90% correlates to a PaO2 of as low as 60. It was a little counterintuitive for me at first, but I also like calculating the p/f ratio to think about how poorly a patient is really doing. Even now I sometimes think a patient sitting up and talking to me is doing okay, but when you crunch the numbers, you can realize how sick your patient is and it can really change your perspective. If your lady had a PaO2 of 60 on 60% FiO2 via the heated high flow, which she could very well have had... holy crud, that's a p/f of 100. She could very well have been in ARDS already.

So I hope I gave you some food for thought, but showing signs of kidneys and lungs failing on top of heart failure... plus being 85... plus probably being septic... I'd say there was almost zero chance your patient was going to be okay. You are not going to get fired. Patients die. Everyone dies eventually, after all - especially someone this sick.