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..

[clemmm78, RN]

If I may add something for the future. I do agree that it all points to a PE and there was nothing that likely you could have done. However, and this isn't a criticism but just an observation of what I would have done.

Had the CNA told me about the low BP, I would have gone to her then, not 20 minutes later. Why? Because although the CNA said the patient was asymptomatic, I would want to see that for myself. I understand why you did the patient turns first, but what concerns me is that you could get distracted or waylaid, making it even longer before you got to the patient. does that make sense?

[NickB]

Sorry for what you had to go through. Sounds like you did all you could. On a side note, as I read through your post, I couldn't help but keep thinking that your CNA is being given way to much responsibility. RNs need to be the ones who assess. I know that your CNA is trying to help by telling you what he/she saw, but I would make it a point to follow up on those observations as we have the training to assess and they don't. I was quite suprised that they are even allowed to do the BGMs at your facility.

[rnlately]

I agree with everyone else; I don't think there is anything you could have done differently. I see BS in excess of 400 frequently and these people fare well with the proper administration of insulin. I wouldn't beat myself up about it. Such is life.

[nursesaurus]

I dont know too much as I am an LPN but since it was a hip fx it very well could have been a fat embolism. but I'm not experience so I'm not really sure I just distinctly remember fat embolism with hip fx's.

[mmmc2]

I bet she had an emboli as well...The high sugar didn't factor into her dying...This is exactly why I work hospice. I no longer have to worry about my patients dying. They're supposed to die....oh the relief! So many people I saw in my previous position before hospice, where dying and put through so much because they and their family were not introduced to the benefits of hospice.

[nursemike, ASN, RN]

I've been in much your same position and agree with the concensus. Also agree with don't beat yourself up. But I do think you are right to think long and hard about it, as you obviously are. I don't think you're in trouble, and I don't think the constructive criticisms given would have helped your patient. People die, and 88 y.o.people do it more often than others. But I'm sure it would help you to be able to say with confidence that you had done everything you could, even though it's doubtful it would have mattered. Sorry for your loss, and keep up the good work. (You are doing good work.)

[RedhairedNurse, BSN, RN]

If I may add something for the future. I do agree that it all points to a PE and there was nothing that likely you could have done. However, and this isn't a criticism but just an observation of what I would have done.

Had the CNA told me about the low BP, I would have gone to her then, not 20 minutes later. Why? Because although the CNA said the patient was asymptomatic, I would want to see that for myself. I understand why you did the patient turns first, but what concerns me is that you could get distracted or waylaid, making it even longer before you got to the patient. does that make sense?

I agree with you. I would have checked that right away. In nursing we have to prioritize and this takes precedence over turning. We learn from our mistakes and I've learned from many mistakes I've made; thankfully no body has passed on during my care.

I think the OP did the best she could, but next time prioritize.

[Meema, LPN]

I am really sorry that you had to experience a pt dying. I'm still waiting for that to happen to me I have only been an LPN for 6 months. I work at a VA hospital in the ACU/ICU. I have had a few occassions when the CNA was busy and didn't get my BS done. I frequently check my BS myself. If one is forgotten by the CNA, I immediately go in and check it. I too am OCD and like to have things done a certain way. All of my paperwork is organized and I plan my day around my patient's needs.

So, I agree that it was probably a PE that caused her death. The BS didn't have anything to do with it. I have seen people get up into the 600's and not really show any symptoms, but everyone is different. She had multiple things going on that were not in her favor. This was probably going to happen whether you checked her BS right away or later. But because you waited, your always going to have that "what if" in the back of your mind.

[cherrybreeze, ADN, RN]

If I may add something for the future. I do agree that it all points to a PE and there was nothing that likely you could have done. However, and this isn't a criticism but just an observation of what I would have done.

Had the CNA told me about the low BP, I would have gone to her then, not 20 minutes later. Why? Because although the CNA said the patient was asymptomatic, I would want to see that for myself. I understand why you did the patient turns first, but what concerns me is that you could get distracted or waylaid, making it even longer before you got to the patient. does that make sense?

I second this.

I don't think anything you could have done would have changed the outcome, but a couple of things in your post do stand out to me that I'd like to address (not to criticize, but just to give you some food for thought as you move forward in your career).

First is the turning patients, and not going right away to assess this patient when the low BP was reported to you. A CNA may believe her to be asymptomatic, but it is really your assessment that needs to be done at that time. Since she was a new admission, you don't have a baseline established yet for what her usual state is (to call her "asymptomatic") or if her BP chronically runs on the lower side. I would have gone to her right away, and delegated the turning of your other patients to the CNA.

Secondly, I also don't think the blood sugar was a contributing factor, but I think it would have been a better choice to not wait until the next scheduled check, which was six hours later. If the order to check them was written at 7pm, had she had a blood sugar checked at all, since she had arrived on the floor? I disagree with the poster who is surprised that the CNA's do blood sugars at all, that is a task easily delegated and handled by a CNA, as all they do is perform the procedure and report the results. I would have asked the CNA that was supposed to do it what the result was (after all, you have to know if you need to cover them with insulin or not), and upon finding out that it hadn't been done, had the CNA do it as soon as you realized it. Is it a standard for your CNA's to report blood sugar findings to you whenever they get them, or do you usually have to seek them out to get the results? If it's the latter, a different practice overall might be called for.

Again, let me reiterate, because I feel it's important to say: I do not think either of these things would have changed the outcome. I'm not saying these things to come down on you, at all....I just think you can turn what was a difficult experience in to a learning experience, as well, so I hope you don't take it the wrong way. I also know how hard it is to lose a patient. It can be hard when it's expected; when it's a sudden turn for the worse, it's much worse. It's not something you ever get "used' to, but you will learn coping mechanisms as you see it more. Don't beat yourself up. It sounds like she failed quickly.

Perhaps seek out a coworker a chaplain to talk to, as well, to work through your feelings about it. You sound like a very caring nurse, don't ever lose that. :redbeathe