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?

[talaxandra]

Also, I think it's great that you see this as "we missed something" - that indicates t me that you'll do well as a team member once you're registered :)

[Jolie, BSN]

I don't mean to frighten you unnecessarily. Nothing may come of this. But if the patient's family has questions and begins to look into this woman's care, they may realize that her complaints went unaddressed.

Please consider a de-briefing session with your instructor. If you have Liability Insurance (many students do), then it might be prudent to contact them about this incident. Whether or not you have insurance, I think it may be a good idea to write out your objective recollection of your care of this patient, including your conversations with other health care providers.

If the family files an action, you may be called upon to give a deposition. That may happen a few years from now, making it almost impossible for you to recall the details of the situation without something to prompt your memory.

[vashtee, RN]

As a 2nd semester student, I also had a patient who had a stroke right before my eyes. Her blood pressure was elevated (although not as high as your patient's), and she had a severe headache too. I never dismiss severe headaches now.

[Vito Andolini]

Your Instructor and those 2 nurses should all be reported to the State Board and written up and sued. YOU are not to do the reporting, at least not outright using your name. That would be a great way to ensure trouble for yourself, I imagine.

Write this down for your own records. Who you reported to, when, what, staff's names, your teacher's name, all the details. Keep it for your records, do NOT tell ANYONE. Just keep it in case you ever need to refer to it. Watch this chart in the future if you can. You might see the charting change. If you can, make a copy of the progress notes. No, this advice is probably not legal and you should do the right thing. I'm just telling you to not be surprised to see a little cover-up take place.

I guess you could have said to your Instructor and/or the nurses that you would like practice calling a physician and reporting severe, unrelieved pain and very high, out of control blood pressures. A licensed nurse would have to have been with you, though, to take any new orders. Do don't feel badly that you didn't think of this. You're just a student and you did what you were supposed to do.

I don't know what kind of relationship you have with any of The Three Stooges or with the Dean of your school or with the Nurse Manager or with the patient's doctor. I'd love to be a fly on the wall to hear what they are all saying about this horrible event, this unnecessary death. Do you think you can talk to any of them about it? You'd have to be the one to decide if that would be wise, if it would help avoid such incompetence in the future.

This type of stuff just infuriates me and it is terribly scary. I keep picturing her 18 year old son, now motherless. What could these monster nurses have been thinking? Depraved indifference, negligence, incompetence. I know you will never treat your patients like these nurses did. God bless you.

[Vito Andolini]

Also, I think it's great that you see this as "we missed something" - that indicates t me that you'll do well as a team member once you're registered :)

But do not admit to wrongdoing that other team members did. Team mentality goes only so far.

[loricatus]

As a student you went above and beyond to advocate for your patient.

http://www.merck.com/mmhe/sec06/ch086/ch086d.html

You recognized that the BP and HA meant there was something seriously wrong. I fault your instructor for not recognizing the classic signs of a 'brain bleed,' especially since the history suggested its possibility. Did your instructor tell you to do a neuro check on the patient after the high BP was confirmed by repeat testing? I also noticed you were astute enough to notice that the instructor and another nurse did not attempt to go past the systolic reading you got. That patient needed a nurse to call the doc to give a history, the current BP reading, the results of a complete neuro check and a suggestion for a CT Scan- "Do you want me to order a CT Scan for you immediately to r/o a bleed? If the doc says no need, you then repeat back the suggestion and the response, letting the doc know that you are documenting it-that usually works very well to wake up a doc to reality.

It is a pity that what you have seen is not all that uncommon. I have many times seen some ER docs refuse to address anything but the chief complaint, even though there may be a more pressing issue with the patient. I cannot tell you how many times I have heard the phrase, 'let's not open up a can of worms.' I do not do the floor anymore, so I can't even begin to imagine how bad it must be there. All I can tell you is that once the doc realizes that you are going to be documenting your finding and the docs response, you may see the patient get the proper attention. Although, you will also see some nurses give in to the doc. I suspect that is what you encountered.

You did a good job. However, the instructor, the other nurses and the doctor did not. Learn from this and you will be one great nurse and probably save a few lives along the way. Maybe this is why you were put into a situation like this. I firmly believe that many times we are put into situations for a reason, that only in hindsight do we see why.

[SnarfGirl]

I think you did a great job as a student you couldn't do much more. Unfortunately in my experience in nursing school - I've have learned more of what NOT to do, then what you should do. It's actually very very scarey. I don't ever want to be hospitalized at some of the hospitals around here.

[nurse901]

I have so much sympathy for you. As a student we have only so much power and when something like that happens than it you feel so hopeless. That is definetely an extremely high blood pressure and is probably one of the reasons why she had a CVA and passed away. Your instructor should have felt the pulse while pumping up the blood pressure cuff in order to obtain a baseline to ensure that she was pumping up the cuff high enough. I am sorry this happened to you because it seems like it could have been prevented. You will be a better nurse because of this situation. However, it is unfortunate that you learned with these circumstances.

[talaxandra]

I also forgot to say that I'm usually loathe to take a stance on how nurses ought to have acted when students have stories like these, but in this case there seems to be a really clear case of cause and predictable effect, as well as opportunities for them to catch the issue before it became a problem.

Not so articulate today - post night duty and well past time to sleep

[Little Panda RN, ASN, RN]

You were in a very tough situation, but you did what you needed to do. I agree with the other posters is was this patients nurse and your instructor who let this pateint down. How very, very sad! I sure hope this incident is looked into.

When I was an LPN student I was taking care of a patient and I noticed that he had tiny red spots on his feet. It looked very much like petechiae. I asked the patient if he ever noticed this before, he said oh yes, it is a rash I have had it for awhile. I am thinking to myself, doesnt look like a rash to me. So I bring this to the primary nurses attention and she says "yeah it has been there". So I go home that night pull out my books, because I know I read something about this condition. My book says that the petechiae is a sign of DIC and can be related to endocarditis. This gets me to thinking, the pt is gets sick after an MVA and they discover he has MRSA in a cut on one of his fingers. The patient is on continous 02. So I go back to clinicals the next day and asses the patient again and it looks to me the petechiae is getting worse. So I tell the nurse and she does not seem worried at all.

Well I happened to be the one in the room when the doctor made his rounds and I said to him "have you seen the spots on his feet"! The doctor looks at me and said "no, what spots". So I take the patients socks off and the doctor proceeds to really check his feet over. He walks out of the room and tells the nurse to order and Echo and some blood tests. He then looks at me and says "thankyou, thankyou very much"!!!

I was floored, all I did was bring something that the nurses were not concerned with to his attention. That night the patient was transferred to the ICU with DIC related to endocarditis. He was a very sick man. He did get better.

I was in the right place at the right time and was not afraid to speak up. I will never forget this because it taught me a very valuble lesson.

[suanna]

No matter where you work in health care you are going to see this every now and then. The best you can hope for is to work for a place that put a high premium on quality patient care and attracts only skilled practitioners. As much as you are a fine patient advocate you cannot prescribe or diagnose. Short of telling your patient " your doctor is screwing up, why are you continuing with him as you provider" (which risks your job and maybe your licence), I don't know what else you could have done. If a patient is satisfied with bad medical management there isn't much the nursing staff can do about it. I watched my brother die from medical missmanagement and was helpless to affect the course of treatment. In my career (21years) I have said to exactly 2 patients that I felt thier medical management could be doing more and if I were them I would insist on seeing another doctor or transferring to another hospital. I wish all the students(and nurses) I see would have the followthrough you showed in this case.

[Reno1978, BSN, RN]

Don't forget this experience and continue to advocate for your patients!