Help! Admitted patient and he died 30 hours later...

Nurses General Nursing

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Specializes in Gerontology, Med-Surg, Telemetry.

This is a case that has happened and I wanted some feedback: (I'm gonna try my best to shorten it)

I work on a med-surg/telemetry floor. I get an admission with admitting diagnosis of AIDS/weakness. 53yo male who's been off HAART therapy for 2+ years; very cachexic appearance, very weak, but able to voice needs. Received him AAOx3; chest congestion heard w/o stethoscope (coorifice rhonchi--NP cough). Patient was on an admission diet (which means regular diet until further notice). He requested a sack lunch per diet orders. 15 minutes later portable CXR into see patient (ordered xray), I noticed he was very diaphoretic and tachypneic. We nasally suctioned him in atempt to try and relieve some of the congestion. Blood sugar of 170s. BP elevated c diastolic >110. Make a LONG story short we did everything on our unit to prevent this patient from coding (which he didn't)...he became unresponsive (c pulse) on our unit ICU team came in and intubated then we transferred him to ICU. That night he coded twice in ICU; family came in next morning and made him DNR. He died later that day.

My thing is I'm a new nurse (almost a year), but I made sure I did everything 'right'. I had my charge nurse in there c me. We had the crash cart in the room just in case he lost his pulse. The team docs were notified immediately when I first noticed he was diaphoretic/tachypneic. But I feel bad that he died. Knowing that I was the one that gave him that sandwich that he supposedly aspirated on. Of course, if I knew there was any chance of him aspirating I wouldn't have left him alone with that sandwich.

Also, my charge nurse stayed over with me to make sure that EVERYTHING we did was documented correctly.

Just looking for feedback on this. Thanks in advance!

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Specializes in CTICU.

You can't save em all. Live and learn.

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Specializes in ER OR LTC Code Blue Trauma Dog.

Sometimes it doesn't matter how "right" you might have thought you done things. They all just don't make it all of the time.

You did what you could, the best you could.

My Best.

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Specializes in Anesthesia.

I missed something. Why do you think he aspirated? Do think it was aspiration, because of the semi-sudden change in condition after he ate? It really sounds like the patient was probably septic and died from complications r/t AIDS/infection. From what you posted I don't see that you did anything wrong. Patient was awake, talking, and able to verbalize he wanted something eat. Those are good signs that he has some protection of his own airway.

These things happen....we can't cure everyone.

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Specializes in Gerontology, Med-Surg, Telemetry.

The docs came in and assumed since the change in status occured after the sack lunch, he aspirated. Also, SPO2 dropped from 99% on room air to low 70s with 4L on NC. We then placed him on NRB.

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Specializes in Anesthesia.
The docs came in and assumed since the change in status occured after the sack lunch, he aspirated.

It might have been aspiration, but that is just the easiest diagnosis. I have found that physicians often take the easiest diagnosis they can blame on someone else (common problem between anesthesia/surgeons/and OB). Don't spend too much time on it. It sounds like it was just this patient's time.

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Specializes in Certified Med/Surg tele, and other stuff.

Well, even if he did aspirate how would you know he would? We had a pt aspirate on contrast. Never had a swallowing problem but was a COPD and I think had a coughing fit and sucked it in. Sometimes you just don't know.

Did he come through the ER? I'm sure he had water or something while waiting for a room and tests, did he not? If he didn't aspirate on thin liquids and the ER dr (or whomever) ordered a regular diet, they must have thought he was able to swallow.

You did all you could do. Like the others said, don't beat yourself up.

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Specializes in Hospice, Adult Med/Surg.

It happens. You didn't order the diet, the physician did, so if the patient was dysphagic, how could you have known? It sounds like you did everything right. In fact, it sounds like you handled it better than a lot of nurses would have who have been in the field a lot longer than you have. Don't beat yourself up!

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Specializes in Gerontology, Med-Surg, Telemetry.

Thanks. Hearing these comments makes this easier.

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Specializes in Gerontology, Med-Surg, Telemetry.

We have clinics in our hospital; so he came in through the clinic. No radiologic procedures were performed prior to admission; at least none were told to me in report.

Thanks for the encouraging words : )

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Specializes in medical-surgical.

I would always be careful about any diet ordered for a patient who appears there could be any problem at all with swallowing, especially upon admission. Maybe put your hand lightly on his throat and ask him to swallow. If you feel you get a rise and fall in the throat, have him sip some water, if no problem...done, let him eat. If not page the doctor and relay your concerns.

I don't know when you called the code, I'm sure it was as soon as possible, but whenever you have any sense that your patient is not "right," immediately call a code or rapid response. Don't ever be shy about using your instincts, you know the patient and you spend the most time with him/her.

There was probably nothing you could have done, so don't beat yourself up...

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Specializes in M/S, MICU, CVICU, SICU, ER, Trauma, NICU.

Can't save the world.

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