Head case...

hrtprncss · May 14, 2006

Just a question, with a gcs of 3 and on 2lnc even with spo2 98, what was the abg...if there was a decreased level of conc i'd be concerned why he wasn't intubated with such a low gcs on a brain injured patient, just curious....just wondering, i'm sure a neuro nurse would come and explain it to us. :)

telehead · May 14, 2006

Just a question, with a gcs of 3 and on 2lnc even with spo2 98, what was the abg...if there was a decreased level of conc i'd be concerned why he wasn't intubated with such a low gcs on a brain injured patient, just curious....just wondering, i'm sure a neuro nurse would come and explain it to us. :)

An abg done earlier that morning was wnl. He was in no respiratory distress, unlabored, regular rate, good depth. When I did my first assessment, I asked another nurse (who had 10+ yrs experience with brain injury patients before coming to our floor) to also perform an assessment after mine so I would feel more confident with my baseline assessment.

I share your concern regarding no intubation tho. As I said, I thought he should be an ICU patient anyways (tough to have him along with my 7 other patients last night!). The neurologist consulted came to see him at approximately 2230 and evaluated him. He also agreed with my gcs=3 score. I'm sorry to say that I was unable to provide more effective advocation for him. I was swimming in uncharted waters. I spoke with the other nurse (neuro experienced) about him often throughout the night.

Thank you for your thoughts!

hrtprncss · May 14, 2006

I believe you did a great job, let's wait and see what the neuro nurses think, maybe they can enlighten you much better. I'd be interested on his follow up when you go to work next and see what they've found out. Bless you for having seven patients, my goodness I can't even imagine. Maybe move this post to the neuro forum? Cuz i guess cross posting's aren't allowed.

HappyNurse2005, RN · May 15, 2006

I thought a gcs of 8=intubate b/c pt is in a coma! He was hopping btw a gcs of 3 and a gcs of 8?

and you had a guy on hourly vs and hourly neuro checks and 7 other patients. thats not cool. that sucks, actually

telehead · May 15, 2006

I thought a gcs of 8=intubate b/c pt is in a coma! He was hopping btw a gcs of 3 and a gcs of 8?
and you had a guy on hourly vs and hourly neuro checks and 7 other patients. thats not cool. that sucks, actually

There have been a couple references to my gcs of 3. If I did it incorrectly, please, someone correct me! I'm used to heart problems, not head problems.

Under "eye opening", the options were spontaneous (4), speech (3), pain (2), no response (1).

I scored "1" because for the first few assessments, he would not open his eyes to anything. As a matter of fact, varying degrees of nail-bed pressure or sternal rub brought forth no reaction whatsoever. In the early morning, I entered a score of "3" when he would show even the slightest attempt to open his eyes on command.

I likewise scored "1" to motor response because he did not follow any commands to move any part of his body nor did he move anything spontaneously. Again, during the early morning, he would attempt to open his eyes and he was moving his feet (even if in milimeters) so I entered a score of 6, attempting to note his highest level of function. As such, for a couple hours in the early morning, his score was actually 10. He had no verbal response at any time so that was always "1"

3+6+1=10 for a couple hrs (I believe I said, incorrectly, 8 in my initial post).

Early in the shift and then again after about 4am, I had him back at 3.

One thing I did notice but didn't know how to score/interpret- when the neurologist was evaluating the pt, he did have reflexes present. But he had no spontaneous movement.

If I did any of this incorrectly, please inform me. Not that I expect to have many patients like this, but I want to handle it properly if I do.

I also concur that he was comatose, per the GCS which considers anything below 8 as comatose. His respirations, however, were equal and normal in number and depth. He even snored a few times.

Also, I agree that it sucks to have this patient + 7 others but I'm sure that's something many other nurses on here can relate to!

babynurselsa, RN · May 15, 2006

I wonder that anyone with a GCS of 3 should be out on a floor. This guy should have been on the unit.

Indy, LPN, LVN · May 17, 2006

I think I'd have been flat out insane with that patient load. I did read where you said even the doc came to sit with the patient and help monitor due to lack of unit beds.

I think you'd be well within your right to request your charge nurse to find a way to get another nurse up to the floor to take over a part of your patient load, let's say at least half, for the rest of your shift. Reason is, it's unsafe, both for your neuro patient and the rest of your patients. If one of your others had crashed, do you really think the hospital would step up and say, "sorry we gave her a bad assignment"? And I realize it's advice AFTER the fact, but hey, if you have a patient so bad off that his doc is sticking around to help you, maybe he could lean on management a bit if they don't seem eager to get you some extra help. Sometimes there isn't extra, but with the right spin on things, you'd be surprised what can pop out of the woodwork.

I've seen nights in our facility where there weren't unit beds available, and I always pay attention if I hear that from supervisors. Your charge nurse has a responsibility to you and to all the patients on the unit to get you some help if you are basically one on one with an ICU patient who can't leave the telemetry floor due to lack of beds. A unit patient is still a unit patient, regardless of where the patient may actually be.

And don't misinterpret me as being harsh; I think you did a good job and were very, very lucky nothing else went wrong. I'm just sticking an idea in there in hopes it will help you next time something like this comes up.

telehead · May 17, 2006

I think I'd have been flat out insane with that patient load. I did read where you said even the doc came to sit with the patient and help monitor due to lack of unit beds.

It was actually the intern on call and she was going to sit with the patient while we increased the dopamine above the limit we're restricted to on our floor. Fortunately, a unit bed was made available shortly after we bumped the drip.

I think you'd be well within your right to request your charge nurse to find a way to get another nurse up to the floor to take over a part of your patient load, let's say at least half, for the rest of your shift. Reason is, it's unsafe, both for your neuro patient and the rest of your patients. If one of your others had crashed, do you really think the hospital would step up and say, "sorry we gave her a bad assignment"? And I realize it's advice AFTER the fact, but hey, if you have a patient so bad off that his doc is sticking around to help you, maybe he could lean on management a bit if they don't seem eager to get you some extra help. Sometimes there isn't extra, but with the right spin on things, you'd be surprised what can pop out of the woodwork.

Well, allegedly all other beds in the hospital were full and there were no nurses available. There are many factors at work here and I won't go too deeply into them because frankly, in the midst of a nursing shortage, I'm sure many others are dealing with it to. Long story short, our previous nurse manager insisted to the nursing supervisor that our floor was always open, regardless of staffing levels. So while other floors were capped by their managers due to staffing levels, admissions were directed to our floor, staffing level be damned. As such, float pool nurses (we're part of a health care system with 1 other inpatient hospital and 2 outpatient centers) started refusing assignment to our floor. Who wants to start a shift with 8 tele patients and then get an admission? The good news? We have a new nurse manager who is looking to deal with some of these problems.

Anyway, on this night, the charge nurse already had 8 patients and the 2 other nurses had 9 each (and one of those nurses, I'm sorry to say, is incompetent).

I've seen nights in our facility where there weren't unit beds available, and I always pay attention if I hear that from supervisors. Your charge nurse has a responsibility to you and to all the patients on the unit to get you some help if you are basically one on one with an ICU patient who can't leave the telemetry floor due to lack of beds. A unit patient is still a unit patient, regardless of where the patient may actually be.
And don't misinterpret me as being harsh; I think you did a good job and were very, very lucky nothing else went wrong. I'm just sticking an idea in there in hopes it will help you next time something like this comes up.

I'm not interpreting this as harsh whatsoever! I truly appreciate any and all thoughts on this situation, including criticism. Discussion from many points of view usually brings the optimal solution bubbling to the surface. So certainly, don't ever hesitate to bring agreement or a contrary point of view any time I post. I'm not easily offended.

Indy, LPN, LVN · May 18, 2006

The reason your post hits home with me is that I could see this happening. My tele unit doesn't normally have an 8:1 ratio but there have been nights when ICU was full, when PACU was staffed fulla ICU nurses opening extra beds and those were full, ER was full, etc.

And on one of those nights... my unit's in 3 large sections... on one section there was a patient who needed transfer and didn't get it. Doctors and supervisors were scrambling and changing their minds every four minutes or so as to whose patient would get any unit bed that opened up. So it's started me thinking, what would I do for my unit, my nurses, myself and my patients if this happened. I would hope that there would be some help I could call in. It makes me quake in my boots to think that I could be stuck with no help in such a situation.