Just need to get this out of me

[haldolnism]

I apologize in advance for gaps in my knowledge. I am newly hired in a cardiac unit and Im also a 3rd year nursing student with med/surg, maternity, and telemetry interpretation experience.

I only had 1 patient with CHF for three days 12 hr shifts and she was stable for the most part, until about 1 hour before shift change today. She started crashing. Her bp was very very low, she was symptomatic, and she had all the symptoms of decompensated CHF, plus possible cardiogenic shock (due to many of her symptoms, but most importantly low urine output). The low urine output has been occuring for all the three days I took care of her. The hospitalist today ordered to make her lasix iv direct twice a day instead of once a day, so after talking with my nurse, we gave the second dose of her lasix 8 hours after the first one was given. This was okay, however, she still did not pee at all. for my entire shift today, she only peed about 200mls. And she had a fluid intake of about 700mls.

When her blood pressure medications were due, I rechecked her vital signs and she was hypotensive 70s/40s when her normal is above 120 systolic. She had all the symptoms, as I have said. Many things started happening, RN ordered stat ecg and bloodwork and showed st elevations throughout. RN called the hospitalist and the doctor was not responding so RN gave me the phone to wait for the doctor. RN said to give the doctor report if doc answers because rn will be busy putting leads on the pt for bedside monitoring and doing a bunch of other things while we waited. the doctor picked up so i gave report and i thought it went alright but the doctor started giving orders and as a student i cannot write verbal orders so i looked for the nearest nearby rn (my rn wasnt there anymore) and a different rn took the orders. The pt got a bolus of Normal saline and more blood work ordered. shift change started and i charted as much as i could think of. the hospitalist finally came and this is someone who has never met the patient before. the doctor walked in the room, looked at the patient, told us to call her if she has chest pain, and did not even look at the charts or anything..

now that i am at home, I am overthining and now unsure if what i did was ok. I probably shouldnt have answered that phone because it was such an emergent situation? are CHF patients ok to have saline bolus if theyre hypotensive? what if they have congestion? am I at fault for any of these if anything goes bad? What if i forgot to say some of the information during that call? isnt the hospitalist supposed to at least look at a chart while the patient was still somewhat managing?

im just really worried that I might have stepped outside what im allowed to do as a student, especially not having an instructor. I was feeling a bit ok during the situation and still managing it fine even though i felt weird that the RN would leave that phone call to me. It all happened so quickly. and now after it all happened im really feeling uneasy and nervous. i dont want to mess up. please calm me down.

[AnnieNP, MSN, NP]

The hospitalist may have already reviewed everything from a different location.

[Cowboyardee]

- The RN shouldn't have left the phone call to you. But on the other hand, sometimes protocol goes out the window in an emergency.

- There are certainly times when it is ok to give a CHF patient patient. Without seeing the patient's labs, xrays, etc, I couldn't tell you if this was one of those times, but the basic situation sounds plausibly like it could have been. The patient could have been over-diuresed and dry, or could have been going into septic shock and in need of fluid regardless of the chf. You can always intubate if you need to, but a patient must have adequate perfusion to survive.

- You are not really at fault for giving fluids if the patient decompensates after administration. Its really a matter of whether the order was so obviously incorrect that any competent nurse would refuse to follow it, and that wasn't the case here. Additionally, even of the patient decompensates after the fluid, there's no clear reason to think it was the fluid that caused the decline - the patient was likely declining in the first place.

- That said, you can be held liable for acting outside of your scope, so you were wise not to take a verbal order directly as a student. Be careful in these situations not to act outside of your scope as a student just because the bedside nurse or doctor asks you to.