I don't feel like i did the right thing...

[Da_Milk_of_Amnesia, MSN]

To make a long story extremely short, we had a patient who was a MVC with multi rib fx some transverse process fx etc. Not bad all thing considered...The call bell light came on and i answered it. I go in and what do i hear but a very omnious noise and from my EMS experience I knew exactly what was going on, get me lasix and CPAP and maybe some nitropaste if your feeling lucky (that would be in the field of course). Any guesses? If you guess CHF then congrats, you're right. This PT was filling up and filling up FAST, i tried to get her to cough because I could hear it in her throat and thought well maybe it's just some phlegm chillen in the back and she can't clear it, I didn;t have to listen to her lungs cuz i could hear it but i did anyways and she's got rales all the way up. I got the RN whose PT it was and said call the doc, threw her on a venti and with sats at 90 i said lets try NRB. Well the 20 of lasix helped for like an hour, and then she went right back in to CHF. I talked to the Dr and he asked me if she needed to be intubated. I said listen I think if we give her about 80 of lasix, diuresis her and CPAP or Bipap her I think we might avoid having to tube her. I said I really hate to jump the gun on this, her lungs are crappy as it is and I hate to jump to something so invasive if it's not needed. . He said ok try and BiPAP her and if they need to intubate then do it, transfer her to ICU and consult the intensivist. So I helped the other RN with the patient and they tried BiPAP, it worked for a little while but apparently I guess her ABG was really crappy and they made the move to intubate. I feel like i did something wrong because it didn't work, I kinda feel like I'm a bad nurse and that I'm gonna get into all this trouble because my 'idea' didnt work. I guess I just need a little bit of encouragement and support and I'm hoping I'll get it here. I do work ICU/CCU so it's not like I don't know what I'm talking about when I speak to a Dr....Idk I'm hoping that she ends up ok

[jessiern, BSN, RN]

I'm currently on maternity leave, but in the last week I worked, I had to transfer two critical patients to the ICU with fluid overload. One I had the whole shift, about 3 hours, and the the other from ER about 30 minutes before. I felt like crap, and had a lot the same "bad nurse" concerns you mention. I agonized over what I did wrong. An older, abrasive nurse (that I LOVE) was supervisor both days, and I asked her what I did wrong. She told me sometimes patients go bad on good nurses. The difference in a good nurse and a bad nurse is that a good nurse sees the signs and intervenes when needed. Intubating a patient is not a pretty thing, and if I were the patient I would want the docs and nurses to be sure I darn well need on before doing it.

[bjaeram]

I think it's smart to try the less invasive measures first as long as the pt is tolerating it okay. I obviously can't see the patient but if she looked decent I think you did the right thing.

[southernbeegirl, BSN, RN]

one question.

if it wasnt your patient, then why were you doing the primary care?

[lifetimern]

It is a mistake to think that because you did everything right the patient will get better. Sometimes you do everthing you should, but the patient does not improve. Conservative management was completely appropriate in this case, and when the patient did not improve, more aggressive action was taken. You've reviewed your actions and learned from them. Now it is time to move on.

[Medic/Nurse, BSN, RN]

No regrets - I think you did fine. Spidey sense - check. Recognition of clinical change indicating impending need to rescue - check. Team player - check. Support less invasive treatment - check.

It is hard to know all the variables - this patient had a disruption of the integrity of chest wall and failed to respond to non invasive ventilation support. Multi fx's usually indicate profound soft tissue injury - depending on the co-morbities that the patient has - they were either behind (or way behind) before it became a race to save their life and prevent death from respiratory failure. Not unusual.

You put the patient first and that is always the right thing to do. Review and take the lessons with you. You will be a better nurse - one patient at a time.

Onward and forward.

Good Luck.

Practice SAFE!

[PostOpPrincess, BSN, RN]

Trying not to overdo seems the most logical path. You didn't say how old your patient was so it's hard for me to assess from the post alone. If she is older with a stiff heart, her WOB might've been too much for her and she kept going back into CHF--or her WOB = Increased Cardiac Workload = R/O MI. Could all of that CHF caused too much work and she ended up having cardiac issues aside from the MVC? I'm also assuming that an ECHO was called for after the MVC? I hope someone ordered it to r/o cardiac contusion......What was her ABGS on the NRM? Was she retaining CO2?

I couldn't tell you if you were too conservative--I have to see her for myself. As for diuresing and utilizing BIPAP, I'm assuming you ruled out all the other stuff first? If so, and you thought she could tolerate the BIPAP without narcotizing her, then it's the right call. Otherwise, I might have just had her intubated so she didn't have to work so hard. After all she is Multiple Rib FX and she must not be able to deep breathe...and have incredible pain....

Anyway....think about it for awhile...then move on....you learn from this....

But honestly...I couldn't tell you without seeing for myself.

[AlabamaBelle]

From your description, you did everything you could, and in the correct order. I work Peds ICU and it sounds as if you did exactly what we would have done - diuresing, least invasive and going up from there.

Sometimes you can do everything right, but nothing works. Ease up on yourself - I've been in your shoes - and got the very same advice I'm giving you. You can't save everyone, but remember those for which you have made a difference. There's nothing like a parent thanking you for "saving" their child (initiating that code) - that's what you remember.

My only question was, at first, where was this patient's nurse. I realized you were not in an ICU. He/she might have been tied up with another patient. Give yourself big pats on the back for awesome teamwork.

[Iris Santana]

You did great. You are a true patient advocate . It is fine to formulate a plan of care and have it fail. The important thing is that you tried your best to keep her from having to be intubated. We are there to monitor and assess the Rx plan implemented. We can not always expect that the patient will respond although we always want them to. Another nurse might have just wanted to go to the intubation and avoid the whole ordeal of monitoring and assessing that is the basic truth. Just continue to abide by your nursing oath and you will be alright. Do not care about criticism as there will always be that no matter what you do. People who will criticize you are just judging and they will be judged themselves when the end of times get here.

[bill4745, RN]

You did exactly what I would have done.

[leslie :-D]

After all she is Multiple Rib FX and she must not be able to deep breathe...and have incredible pain....

this was my first concern- that all those fx'd ribs would impede reg breathing.

combine that w/fluid buildup, it sounds like tubing her would have brought more immediate relief.

BUT, you were still prudent by going from least to most invasive.

why were you caring for this pt when it wasn't yours?

leslie

[heron, ASN, RN]

To those who asked why OP was caring for the pt ... it's because he answered the initial call light when the pt wanted help.

Major team player ... as they say on SDN ... strong work!