Lessons on why not to "Assume" things.

[TigerxLiLy]

Got to work at 11AM and read over our facilities "Communications" board. Noted that one of the Part A residents had a medical decline over the weekend according to some of the notes ("Ms.X is noted to be more lethargic", etc)

I went and read some of the nurses notes for over the weekend.. "11/29-Ms.X refused to eat/drink. Scheduled med pass bolus via peg tube and fluid flushes provided. Resident is noted to only respond to tactile simuli at this time, noted increased tremors in extremities due to Parkinsons"

"11/30- resident continues to be lethargic, vitals 130/64,89p, 19r,97%o2 sats, 97.9T, no changes in residents status."

I say to myself "No MD was notified!? maybe she isn't that bad..."-- went down to look at the patient myself..

1. The resident does not have a active Dx of Parkinsons, Her tremors were only noted to be in her BLE when she was sitting up in her w/c most of the time prior to this weekend.

2. Resident is usually very vocal, yelling at staff to empty her colostomy constantly-- if not the colostomy always pain or to tell staff to "go away" after she calls them in.

The patients baseline is vocall. -- just for background.

I called the residents name, no response-- she is supposedly "HOH" yet, hears perfectly fine when you say "How is your pain". So I say "Are you in pain?" No response.. resident is just looking up at ceiling. Touched residents arm and shook her a little. No response. Did the sternal rub, she turned her head- stated "Ow" and looked at me, but then went back to looking up at the ceiling with a vacant look. Did note that she was twitching in her BUE, which I did not think was her normal. Asked the charge nurse what she thought was going on, Charge nurse was clueless "What you mean? She looked like that all weekend." I told the charge nurse, "Yes.. but that is not her baseline...What have you guys been doing differently for her?" "Oh, Well I just got in report they just held her scheduled pain meds due to lethargy Friday, so That should be going away soon." ..me: "have you took her vitals yet?" .....charge nurse: "yeah, They were WNL, nothing to worry about."

Go to the computer to look and see if the MD/NP saw the patient recently. MD saw on 11/26--Orders for RFP 12/1 ( today! yay! ) Our lab draws on Mondays/Thursdays. So I go and check the lab results in the computer..big "CANCELLED" on the RFP. Look for the reason why ( not enough blood? couldn't get the stick? hemolyized? ).. Go and check our lab book to see what the lab sheet said... Technician signed that she got the blood..hmmmm... weird.

Call the Lab, Ask "Why did the RFP on Ms. X get cancelled?" Lab tech response, "Well, It looks like the blood was obtained through a line, or something other then venipuncture, because -- well the results are incompatible with life, so we cancelled this one and scheduled lab to draw on Thursday instead.." *pause* *blink blink* I state, "Well, Ms.X does not have any "Lines" on her, the only other way to get blood, and I'm assuming that your tech got blood, is through a venipuncture .. My patient looks pretty ill over here, Why didn't you call us first to make sure that the patient wasn't in distress or just notify us that we needed to redraw the lab?"

So, I notify my DON of the issue, I notify the supervisor of the issue and the supervisor states she is going to draw stat labs. Attempted to get blood 2x, She would Twitch/jerk even with someone else holding her arm still and dislodge the needle. So the supervisor gets her vitals. 84/56, 113 pulse, 79%- cant remember the rest.. but those were the ones that stuck out to me..

Supervisor calls MD and reports the vitals, current situation, and regretfully tells MD that we were unable to get any blood to run a RFP panel, that Lab drew blood this morning but is reporting that the numbers are wacky and incompatible with life. You can hear the MD cursing on the other line, literally. So of course we send the patient to the ER. They get the blood with their bad selfs :).

BUN= 235 ( baseline for resident is 35), Cr= 8.9 (BL 0.9), Chloride= "

The supervisor then had the nerve to ask me, "What made you look into all this? I looked at the patient at 8am and didn't seen anything wrong with her." ARE You Kidding me!?

[TigerxLiLy]

I just wish that our PCC system would make the alerts pop up on the nurses MAR - forcing them to acknowledge that the patient "hasnt voided in 8hrs" or "no BM in 48hrs"--- instead of relying on the nurses to click a box to see all the alerts..

A PRN nurse isnt going to be aware to click in the alert box...

Funny how PCC doesnt even have the "No void in 8hrs/shift" alert at all... (guess diaylsis patients may trigger )

[Nienna Celebrindal]

Oh wow, that's just ugly. Good catch.

[CapeCodMermaid, RN]

Yikes...my lab would have called to say they were coming out to do a redraw...I've never seen a BUN that high. We have alerts built in to our electronic medical record system....vital signs out of range, no BM in 3 days but there isn't an alert for no void. How is the resident now?

[TigerxLiLy]

Still hanging in by what I could read in the hospitals computer system. Still not voiding (GFR is 6 ). Still no complete indication of exactly what happened, MD notes pt had a history of the patient going in renal failure/metabolic acidosis?(think thats what they called it) and seem to think her colitis, partial colorectemy caused a dumping syndrome/losing electrolytes that were not replinished with h2o flushes and PEG boluses..Makes sense to me... still hypovolemic- but her BUN went to 163 and Cr down a bit to 6.0 and sodium ALMOST normal at 124-- but her potassium is lowering and her HGB is as well... but that is to be expected i would think. Nurses note pt is coming around and talking a bit.

[MattNurse, MSN, RN]

Just curious what her ABG looked like. Must be horrid as well.

Still hanging in by what I could read in the hospitals computer system. Still not voiding (GFR is 6 ). Still no complete indication of exactly what happened, MD notes pt had a history of the patient going in renal failure/metabolic acidosis?(think thats what they called it) and seem to think her colitis, partial colorectemy caused a dumping syndrome/losing electrolytes that were not replinished with h2o flushes and PEG boluses..Makes sense to me... still hypovolemic- but her BUN went to 163 and Cr down a bit to 6.0 and sodium ALMOST normal at 124-- but her potassium is lowering and her HGB is as well... but that is to be expected i would think. Nurses note pt is coming around and talking a bit.

[strawberryluv, BSN, RN]

Wow, that's an amazing story. Thanks for this anecdote, I'm going to definitely remember this when I'm an RN.

[No Stars In My Eyes]

I never heard of a lab getting wonky results like that and CANCELLING, postponing it to another day!!! It seems like at least one person should've said "HUH?" instead of "Oh well...."

Good catch, OP!

[TigerxLiLy]

Just wanted everyone to learn like we did at our facility. I wanted nurses to learn the importance of always looking at documentation if things are "abnormal" and to take action, not just wait for someone else to so it! For the CNAs- to PLEASE communicate with your nurse (you guys are a team) when you notice your patient not acting right, not eating, not peeing or pooping on ur shift-- that way thd nurse can see if they need to worry or not. DON had a talk with the hospital lab supervisor that day( yes, yes, it was the hospital lab that draws our labs... crazy huh?) "I really hope you get your staff together and let this be an example for everyone and tell them not to forget."

[SHGR, MSN, RN, CNS]

Just wanted everyone to learn like we did at our facility. I wanted nurses to learn the importance of always looking at documentation if things are "abnormal" and to take action, not just wait for someone else to so it! For the CNAs- to PLEASE communicate with your nurse (you guys are a team) when you notice your patient not acting right, not eating, not peeing or pooping on ur shift-- that way thd nurse can see if they need to worry or not. DON had a talk with the hospital lab supervisor that day( yes, yes, it was the hospital lab that draws our labs... crazy huh?) "I really hope you get your staff together and let this be an example for everyone and tell them not to forget."

I love the way you think- you sound like a great nurse, team player, and patient/family advocate. This is a great story- thanks for sharing. (I mean a terrible situation, but a great learning story)

[anon456, BSN, RN]

This is a very good case on why consistency in care is essential for our long-term and chronic patients. I have been seeing some of the same patients for years come in and go home again. Many are unable to communicate due to age (peds) or neurological status. The docs have learned to listen to the nurses who have been on the unit for awhile when they say the patient is not acting baseline. I just had a patient come in recently who was definitely not acting baseline and I was very concerned. I pushed for the patient to go to the ICU and so glad I did! They needed the advanced care.

[TigerxLiLy]

ABG after 12hrs sending over to hosp= pH 7.5, pCO2 32.2, pO2 116..

I have not read a ABG since school (been a nurse since 2008 but have worked in LTC since) Just know that is alkalosis... MD note states now in Resp alkalosis, however did have metabolic alkalosis due to high PCO2.. does that sound right?

K+ critical low today, but every other lab that WAS critical is stabilizing. Good news. GFR is 17, BUN 96, Cr 2.8... crazy

[psu_213, BSN, RN]

Still hanging in by what I could read in the hospitals computer system.

Good job advocating for the patient. Just be careful with how you are getting this new information. We don't want to see you get in trouble for looking through a unit's computer system that you have no business accessing.