I think I made my first mistake..

[Courtforshort27]

I am a new grad nurse, I started on a primarily orthopedics however also a neuro/peds/med surg unit 6 months ago. It’s a lot mixed in one, but I feel I have gathered so much experience and knowledge. However yesterday, I think I may have caused more harm to my already sick patient. I plan on going straight to my nurse manager when I go back to work on Thursday, and if I am right and get the answer I am needing I will probably text her tomorrow. So here is the back story:

I apologize for how long this is going to be. I worked three in a row. I admitted this patient the first day. He was diagnosed with LLL PNU. Believe it or not, this is my first patient that I’ve had as an RN with pneumonia, we don’t normally get those types of patients on my floor because we have a specialty unit for that, which was full at the time. His RR was consistently 25-40 those whole 3 days. He was on 4LNC the first day, sounded very wheezy and crackly in all lobes, was getting nebulizers q8, and 2 different IV antibiotics. The 2nd day he seemed to be doing a bit better, wasn’t as SOB however I just still did not have a good feeling about him. I wasn’t comfortable taking care of him, with him constantly being that SOB I knew something was wrong, and with 5 other patients I did not have the means to monitor him the way he should have been. This is a constant problem in the hospital I work at. We are a pretty big hospital (the smallest of only 2 hospitals in a fairly big area) but we don’t have enough ICU/PCU beds, so these patients overflow in the med surg units. And I’m not just a nurse complaining about acuity, doctors notes specifically state that these patients would benefit from a PCU/ICU bed but there is just none available. This is where things go bad. The third day, after ambulating to the bathroom, his o2 sats would not come back up. He was in the 70s% on 4LNC humidified o2. The RT suggested a NRB. I have never had had to use a NRB on any patient, but I knew I had to crank it up to inflate the bag, so did that and I hooked it all up.. with the humidifier still attached.... I was texting the resident this whole time saying I was concerned his condition was worsening and that I felt like he needed to be seen, the resident then said a pulmonologist would be in to see him today, and to titrate the 02 to maintain sats above 90%. I’m standing at the patients bedside trying to monitor his 02, texting the resident, with my phone beeping notifying me of 3 of my other patients call lights going off, and a bed alarm. So I inform the resident he was on 9L NRB and was staying about 91% but that I still feel he needed to be seen soon, not just today. Finally, the hospitalist and resident come to see the pt, I rush into the room to see what they have to say. Which was nothing really, just wait for the pulmonologist. They went over to look at the humidifier and to see how many liters he was on, nothing was said. The pulmonologist arrives about 2-3 hours later and I’m caught up with another pt. The RT comes rushing to find to find me because the Dr wants to know who had him hooked up to the humidifier, me of course. The resident asked me the second day when he was on a NC to humidify it, and I didn’t even think about detaching it when putting on the NRB. I figured it’s a higher flow so yeah we need it, because he was already irritated by the 02 as it is. I told the RT I was not experienced with this, so could she please explain to me why we can’t do that. And she said that water bubbles could collect in the oxygen bag. I had no idea of know this. So anyway, the pulmonologist orders an echo and another cxray, and orders he be transferred to PCU. Do that, great. So as soon as I transfer him I get a post op so don’t really have time to process what happened. I am sitting in the back charting after everyone else from day shift left except one nurse. A night shifter asked what happened to him today, and the nurse stated she wasn’t sure but that she heard he had aspirated and then started whispering. They didn’t know I was back there so I was literally thinking what the hell he didn’t aspirate? But I got home last night and realized... could he have aspirated from the water accumulation in the bag from the humidifier?

[Here.I.Stand, BSN, RN]

I don’t think so... first there would have to be a sizable amount of condensation — enough to create sloshing water. I mean one can’t easily inhale tiny droplets of water clinging to a bag. Even if there was such a large amount of liquid water in the bag, gravity is going to make any heavy water droplets trickle to the bottom of the bag, lower than his mouth/nose.

It sounds like he was just sick enough to have needed a level of care you can’t possibly be expected to provide with a 1:6 ratio!

I think you did a respectable job... you listened to your gut, you advocated for him when the docs were dragging their heels, you consulted with RT.

I think this is a case where calling a rapid response would have been appropriate... but these judgment calls are a skill that come with experience.

Don’t be so hard on yourself!

[Just me.]

Was this an older person? Was he on swallow precautions? Take deep breath, no pun intended, I appreciate that you advocated for your patient. None of us are perfect and certainly don't know everything. You sought help when needed.

[akulahawkRN, ADN, RN, EMT-P]

Quite frankly I doubt the humidifed O2 through the NRB did anything significant to the patient. While there could (eventually) be a problem with water accumulation in the reservoir bag, it pretty much has to get to sloshing water for a problem to occur. Best to avoid that... longer term you could have bacterial or fungal growth in the bag.

When you use a NRB, you have to ensure that there is sufficient flow to avoid CO2 trapping. What you're looking for is somewhere north of 10 LPM, often 12-15 LPM. You end up with an inspired O2 in the neighborhood of 60-90% at those flow rates. I really like the Oxymask for those times I need to give more than 4-6LPM via N/C as it's very titratable and usually more comfortable than a NRB, but you can't do a breathing tx through it.

Another thing to consider is that if your patient needs a high concentration of O2 for longer than perhaps a couple hours, you might want to consider asking RT or MD to think about CPAP or BiPAP therapy. Also consider that while you might have a patient with good SpO2 numbers, unless you're also measuring EtCO2, you might not see hypercapnia until it's very late thanks to hypoventilation. I had such a patient on my last shift. Did well by SpO2 numbers, holding 90's on 5-6 LPM by NC, started getting loopy and drowsy/tired. That's a warning sign... Pt ended up on BiPAP for a while and mentation greatly improved thanks to better ventilation.

On the whole, sounds like you were handed a patient that was initially OK for a Med/Surg or Med/Tele floor but decompensated enough to need a higher level of care. Your job is to basically be a tripwire, be alert to a need for increased level of care, and sound the alarm if/when it happens.

By the way, I'm an ED RN and a Paramedic. You are, even with a year or two on your floor, far more expert in taking care of those patients than I am. If I respond to an issue on your floor, I take care of the immediate issue and get the patient to a floor/unit that has the experts to provide care beyond the immediate situation.

[Courtforshort27]

Thanks so much everyone for the support and education! I feel much better about the situation. And the tripwire analogy is a great one. Looking back at the situation, a rapid response would have been a good call. There have been situations where I have called a rapid and have been gauked at by the busy MDs who had to rush up there, but it was in the patients best interest and it was the right call. I think that’s one thing I’m learning, don’t be afraid to piss off the docs (for the right reasons of course)!

["nursy", RN]

Anybody who is satting in the 70's is not going to do well no matter what you do, until you resolve the underlying reason for their low numbers. You said he was satting in the 70's long before you put on the NRB. Chances are, the pneumonia he originally came in with was an aspiration pneumonia, that is what the nurse heard, and may have misinterpreted the situation.

[Diploma'82]

Could he have aspirated prior to admission if he did aspirate? You were in contact with Doctors the entire time. Yes, a rapid may have got them there sooner, but be nice to yourself you have learned from this and can use it to teach others. Hope the patient is OK.