I think we missed the signs and my pt died because of it

[picurn10]

So in clinicals last week I had a 52y old pt who was there d/t a colostomy that wasn't healing properly. I went in at 7am to take vitals and on my bp I got 210/100. I thought, "ok, I must have done something wrong because that's CVA-level" So I went and got my nurse and asked her to check it. She didn't pump up past the 210 level, so even if it were that high, she wouldn't have known. She said she wasn't able to get a good reading, said she thought it was 160/100 but to have my clinical instructor check when she came down (about 30min later). She said she got 178/98 but she also didn't go up past 200. Either way, it was too high especially since she was on bp meds. She was feeling nauseated so we gave her something for that. My instructor was upset that she didn't have a prn order for bp meds and said something to the nurse.

The pt also told me she had a HA and rated it at 8. I went and told the nurse and the nurse gave her tylenol. She did have morhpine prn, but I figured the nurse wanted to see if the tylenol would work first. I checked back with the pt an hour later, she said the tylenol and not helped at all and her pain was still an 8. I went and told the nurse. She didn't give her anything more during the time I was there.

The next day, I got another high bp reading in my vitals (in the 170's but I don't specifically remember). Again the pt was rating her pain an 8 d/t her HA. I asked her if she ever got any relief from it and she told me it had been unabated for 24hrs. She had a different nurse that day, so I explained about her HA the day before and the high blood pressure. She thankfully gave her morphine and the pt said it felt better but she was still rating it a 7. My instructor was there when her Dr. came in and she mentioned to the nurse (intentionally in front of the Dr.) that she should probably have something prn for the high bp. The Dr. wrote it up, ordered a UA and left. I believe she saw the pt, but I'm not for sure.

When I was done I went to check on her and say goodbye. She was in there with her son (he was just 18). I asked again about her HA and she said she was still in a lot of pain, back to an 8. So I said goodbye and again let the nurse know.

A few hours later she started to have a seizure which they couldn't get under control and they wound up transfering her to a bigger hospital where they determined she'd had a massive CVA. She died a couple days later.

This pt had other health problems that could have caused this DM, lupus, HTN, and she was overweight, but it just seems like there were warning signs the nurses/Dr should have picked up on, right? Does this kind of thing happen a lot? I guess it's just freaked me out because when I'd seen her the week before, when she wasn't my pt. she didn't seem sick at all, she was young (my mom's age) and the plan was just to get her on the path to healing and send her home. I just can't help thinking that the high bp that was basically untreated for days was a big clue that people should have been picking up on. I guess I feel like I should have been more assertive with the nurses, I don't know.

When I was there yesterday, the nurse who had her on the second day remember her high bp that day and said "well, she did have high bp that day" and I said "well, it was high the day before too" and she looked really surprised. She was talking with her friends about it, because it apparently was upsetting to her as well that she seemed ok and then had a massive stroke.

I don't know, what do you all think? I've seen several med errors, and stopped one that almost happened so I don't feel really confident in the nursing staff at this hospital. Is this normal though?

[jmgrn65, RN]

I think the high blood pressure should have been addressed! period. Geez it is part of the ABC's c=circulation. The HA was due to the BP, which is a classic sign of CVA.

[CoffeeRTC, BSN, RN]

Okay...if I'm the nurse and getting a high bp like that, I'm going to be checking a few things out. What meds is she on? What are her dx, what are her BP trends, what else is going on with this pt. Next, I'm going to present this all to the md and get some orders. Pain not relieved by morphine, headache and bp??? Ding Ding Ding.

As a student, you should be reporting all of this to the nurse and instructor, they should be making the calls.

[picurn10]

I was reporting it all to my nurse and instructor, but I just didn't know how hard to push, you know? I mean, they are the nurse and I assumed they have a base of knowledge that is much more than mine. I figured they knew better than I did. I was frustrated with the first nurse who didn't seem the least concerned that the bp was high with a bad HA, and then the nurse the second day was more proactive, but still she didn't do any investigating of it.

[FireStarterRN, BSN, RN]

You are correct, the nurse really dropped the ball on this one, from your account. You, however, are a student. You did the right thing by reporting your findings to both your instructor and the nurse.

I hope they investigate this one, it does sound bad to me.

[FireStarterRN, BSN, RN]

Sorry about the double post, the site is having glitches today. The quick reply box won't seem to be working with an hour glass showing, but then it turns out it has worked.

[Natingale, EdD, RN]

What ashame it happened .. I kinda know what you mean, theres so much you can do because you are "guests" in the hospital. You could only step on so many toes. Were you allowed to document the high BPs with your professor? Its unfortunate it happened, and I think you tried to do the right thing ..the only thing I can think of is tell the nurse over and over and over again until she finally does something. Just terrible, its sad.

[flightnurse2b, LPN]

as a student, sometimes it's hard to be a bystander for stuff like this, because you really can't push the envelope too much. to me, it sounds like this nurse really could have done things differently.... pt with BP that high on antihypertensives and pain 7/10 unrelieved by morphine, i would have been on the phone with the doctor right away asking for a stat CT at the least. just out of curiousity, the pt i am assuming was a full code? some hospitals have a "stroke team" when a CVA is suspected, instead of calling "code blue" or "rapid response".

there are so many things that should have been done in this situation that weren't and unfortunately this is going to be a learning experience for you as to what NOT to do when you get your license.

i'm sorry for this patient. please don't beat yourself up over it, april&em. you did nothing wrong and did the best you could under the circumstances. i'm glad you had the knowdlege and intuition as a student to know that there was something very wrong with this situation... you will be a great nurse.

[talaxandra]

Those other conditions you mentioned (SLE, HT etc) all contributed to why she was at risk of stroke. The clinical picture you paint certainly indicates that she was at increased risk of that happening relatively soon, particularly if the kind of stroke she had was haemmorhagic.

While it's understandable that you may feel partially responsible, I don't think you - as a student - could have done anything more. You reported both your findings and your concerns to the nurse and to your clinical educator. As the more experienced nurses they ought to have contacted the resident to intervene.

What you can take from this experience is more confidence in your sense that when there's something wrong you should (as you did) bring the situation to someone more experienced than yourself, and monitor the patient more closely than usual.

[chevyv, BSN, RN]

This stinks for you! Please don't let what happened make you feel responsible. You are the student. You did exactly what you are supposed to do when your a student. You assessed and passed on your assessments appropriately. You rechecked pain levels and passed that on.

This is an awful situation that you ended up in, but this situation will make you a very good nurse. If you ever have a pt with these signs, you will know what to do. Its so difficult as a student to know how far to push. It really sounds like you did what you were supposed to do. I wonder why the nurse didn't get the auto bp machine and check her bp a few times each shift. I wonder why this and I wonder why that, but you did very well. I hope you were able to chart your assessments, especially the bp and pain. I'm so sorry your going through this.

I wish I had words that would make you feel better, but I think the only you can do is gain knowledge and know that as a student, you did exactly what you should have done.

[Jolie, BSN]

I'm sorry for your experience. It certainly seems like your instructor, the staff nurses and the physician may have failed this patient.

Please take from this an important lesson that, as a staff nurse, you will have the professional obligation to see a patient's needs thru to the highest level necessary to get a satisfactory response. You couldn't do this as a student. But as a staff nurse, this should be your course of action:

Patient with high B/P, numerous risk factors for stroke, c/o severe head pain without relief from Tylenol or morphine. First course of action would be to obtain current vs and assessment and call physician. Present the patient's condition, state your concerns and, if necessary, your desired orders. If physician blows you off, politely inform him/her that you will contact your CN for further guidance. If the CN can't get a satisfactory response, go to the nursing supervisor. If the nursing supervisor can't get a satisfactory response, s/he will call the chief of medical service, who will contact the attending and work something out. Some hospitals have hospitalists and/or rapid response teams that can also be utilized for emergency management of a patient's changing condition. Document every conversation and response.

These steps are necessary to protect the patient and to demonstrate that you gave the necessary and proper attention to her changing condition.

I'm sorry you had to experience this.

[aerorunner80, ADN, BSN, MSN, APRN]

It sounds like you didn't miss the signs at all. It was the primary nurse who failed to go to bad for her patient that had OBVIOUS signs that shouldn't have been ignored.

As a student you did everything that you could possibly do.

Big hugs to you. I know that feeling of wishing you could have done more.