Lost my first patient - could I be in trouble?

[southernhospitality]

Hey guys, I lost my first patient last night and right now I’m filled with sadness, compassion, grief, and guilt all at the same time. I am filled with so many emotions I may be blowing this out of proportion, but maybe not. Please read and try to offer an honest opinion..

I’m a new nurse with 6 months of experience under my belt. I work on a surgical unit and generally we don’t have many critical patients. Last night I had 5 patients, and for some reason I was given an 88/f hip fracture patient that needed to be prepped for surgery in the AM (time consuming), and I also got a new admit right at the start of my shift who also had a tib/fib fracture. Of course the family of the pt with the tib/fib fx came in and weren’t sure what meds he takes at home (a ton). I reassured them that we need to know exactly what he takes, so a family member had to drive home and call me back (1 hour drive), meanwhile the patient’s BP is 210/100. Finally she got back to me and we got his BP under control. Once I finished his admission database with a huge medical history, I found out he had mrsa so we had to move him to a private room and get him out of the double bed room. Even later on, the surgeon came in and needed my help in applying a fiberglass cast due to the patient’s contractures. You know how it is, one or two patient’s take up all your time and it feels like your other patients get lost in the fray. Thankfully they were all stable and didn’t need anything during this timeframe.

Around 4AM the CNA I was working with reported that my 88/f hip fracture patient had a BP of 82/60 but said she was asymptomatic and was not pale. I then went and turned my patients, and 20 minutes later I was in her room to check her vitals and turn her. I checked her BP and it was 120/83 but she was moaning. I asked her what was wrong and she said, “I feel sick.” So I ran and got her some zofran. I then felt her temperature because she looked pale, she was ice cold but her bed was soaked in sweat. We ran, grabbed an accucheck machine and got her sugar: 333. At this point she was not responding to any stimuli, her RR was decreasing/faint, so I had the CNA run and call a CAT (critical assessment team) while I was slapping her arm to keep her breathing .

The CAT team came and in a few minutes called a code blue. The code then started, I struggled through giving a report on the patient as this was my first code. She had little to no significant medical history (diabetes, gerd, osteoporosis, severe dementia, breast biopsies). The code drugs were given, she had to be defibrillated, and I had to give compressions. They did a panic lab draw on her and found that her potassium was >6.0! Her last potassium from 9 hours earlier was 5.1. After 20 minutes of the code, she was sent downstairs to ICU, she had a faint pulse, her pupils were dilating, and she had a gag reflex. Later on I found out her daughters (the pt’s POA) decided they wanted resuscitation efforts to stop so the patient could be comfortable. The ICU nurses thought she either had a PE or DKA.

This is why I’m worried.. At 7 PM an order was written for Q6H accuchecks to be covered with low dose insulin. Another nurse told me that the CNA I was working with said he stated he was going to get the 11PM accucheck (I know, this is ultimately my responsibility to make sure this gets done), but I was super busy and didn’t make sure it was done. So we decided we would just get the 5 AM accucheck since she was earlier stable, and she would be fine. Keep in mind I am an extremely OCD nurse who makes sure all my orders are in the computer, everything is given on time, and I don’t leave anything behind for the next shift. This was something I should not have let slide.

My colleagues that were working with me said I have nothing to worry about and I did everything I could have, as a few units of low dose regular insulin would not have changed this situation. I wouldn’t imagine the family would try to press this situation as the patient appeared to have a lower quality of life in a nursing home with severe dementia, and the fact they didn’t want resuscitation to continue. However, couldn’t they have someone look deeper into the patient’s chart and see that an order for accuchecks was written and then check the computer charting and see it wasn’t even checked until it was critical? The house supervisor thought it was probably PE and so do my colleagues, however I was thinking it would be DKA due to the potassium fluid shift that caused her level to shoot up above 6.0?

Should I be worried? Please offer your insights..

[blondy2061h, MSN, RN]

A blood sugar of 333 is not fatal. Something else happened and I doubt very much that you could have done anything to stop it. It sounds like you handled the situation well. The first patient you have die is always difficult.

[heatheryk]

I don't think you have anything to worry about. I'm a new nurse too...have only had 1 code as a student. It was in the ICU, the ICU doc told me that the potassium will shift during a code because of acidosis and come out of the cells.

[PAERRN20]

A blood glucose of 333 doesn't really point me to DKA. I think the PE is more likely the culprit here.

Try not to beat yourself up over this...hugs to you!

[martymoose, BSN, RN]

i was thinking PE also- which I think would be quite likely after a recent surgery. That bg shouldnt have caused that much of a problem. (((((((((hugs)))))))))))

[southernhospitality]

i was thinking PE also- which I think would be quite likely after a recent surgery. That bg shouldnt have caused that much of a problem. (((((((((hugs)))))))))))

Thanks for your responses.. The patient hadn't actually gone to surgery yet, she was supposed to go for hip surgery today if medically cleared.

[Melody007_FNP-C, APRN]

Even though she had not had surgery yet, having a fracture increases ones chance of an embolism. Her symptoms sound like a PE to me as well. Don't beat yourself up it wasn't your fault.

[talaxandra]

A glucose of 330mg/dl (~18.5mmol/L) is low for DKA, which is almost exclusively associated with T1DM (your patient sounds like she had T2DM). Though you can get hyperkalemia in the early stages of DKA, the course you describe sounds a lot like there was something else going on.

Diaphoresis and pallor are associated with low BGL and so were likely symptomatic of another issue - in women and people with diabetes diaphoresis and pallor can be symptoms of an MI. I think your patient had an acute ischemic event, possibly precipitated by a PE and/or a fat embolism from the fracture and/or from the shock of the fracture.

For next time - on my endo (and other specialty) unit, if we miss taking a BGL when it's scheduled we check it as soon as this is discovered. Waiting until the next reading's due is only fine if there isn't a problem, but is too late if the patient's dropping. I doubt it made any difference in this case, but doing that may have put your mind at ease, and could make a big difference in another situation.

I hope everyone's responses have helped.

[Kyrshamarks, BSN, RN]

The key ois fx hip. PE is the culprit. That is the major complication from them. That is how I lost my dad when he fell and fx his hip, He was in the hospital and threw a PE. Do not worry about a lawsuit. There was nothing that was going to save that lady other than the doc taking her to the OR right away on admission and I doubt that would have even helped.

[resumecpr]

I have applaud you for thinking to check the patient's blood sugar. Most nurses forget about the simple things first. You did a great job and should be proud of yourself for your effective critical thinking! Losing a patient will never get easier with time. It's alway a loss, no matter what. Over time we as nurses learn to cope more effectively and are thankful we have places such as this to vent. Best wishes!

[ukstudent]

I'm with Talaxander with this one. The symptoms say it was an MI. Nothing you did or didn't do was going to change what happened.

[Miss Mab]

Pull the other and it'll play Jingle bells.....