Nurses responsibility

Esme12, ASN, BSN, RN · Oct 8, 2014

Patient decline with or without interventions sometimes we have very little control.

What was the BUN? What other meds were they on? What was the O2 sat? What did the lungs sound like? Why were they admitted? I don't think the MD was pointing a finger at you...just hat the patients combination of meds might have contributed in the presence of renal insufficiency

trinay30 · Oct 8, 2014

I don't remember the exact number for the BUN and I think Creatinine was like 2? Just know that these values had been trending up for the last few days. The patient is a 70+ y.o. s/p two Heart Caths within two days and comorbidities, CHF, Lung Disease, Diabetic, CAD. His O2 sats were in the 95-97% on two liters of oxygen. The kicker is, that he night RN had called Rapid Reponse on her shift, due to the patient c/o SOB and Chest pain, which she had administered Morphine.

trinay30 · Oct 8, 2014

Patient decline with or without interventions sometimes we have very little control.
What was the BUN? What other meds were they on? What was the O2 sat? What did the lungs sound like? Why were they admitted? I don't think the MD was pointing a finger at you...just hat the patients combination of meds might have contributed in the presence of renal insufficiency

Lung sounds were clear, O2 sat 95-97 on 2 liters of O2. Only meds I gave were BB, Stool Softner and 81mg ASA. Don't remember the BUN, but the Creat was 2 and these values were trending upward for days s/p two Heart Caths within two days. The patients comorbids were CHF, Lung Disease, DM, OSA, CAD

MunoRN, RN · Oct 8, 2014

From your description it sounds like the problem was CO2 retention (decreasing LOC and ABG's that prompted BIPAP and then intubation).

It sounds like the physician was noting that morphine could have exacerbated the patient's OSA leading to hypercapnia. That doesn't mean it's necessarily wrong to give morphine to a patient who is SOB and has CP, sometimes that's just how it goes, particularly in patients with multiple comorbidities where the treatment for one can worsen another.

Esme12, ASN, BSN, RN · Oct 8, 2014

I also would have done a finger stick glucose just to be sure. with two heart caths in two days they need to watch those kidneys.

firstinfamily, RN · Oct 9, 2014

Could be the combination of medications in addition to the co-morbities led to the pts demise. The MSO4 would have helped with the chest pain and improve oxygenation. The renal insufficiency could have caused the initial AMS or combination of medications that he had been taking. I don't think the MD was implicating you at all. He has to look at the entire case and giving the MSO4 most likely helped the pain and breathing, it may have added to the confusion but not the only factor.

jadelpn, LPN, EMT-B · Oct 9, 2014

Depending on the level of renal insufficiency (which if diabetes was uncontrolled for any length of time, this can be a large contributor) I certainly have seen that be a huge factor in AMS.

The Lasix would get rid of any fluid...did he have edema? And again, this could all be contributed to the renal insufficiency as well.

The morphine could have been some sort of factor in the quality of breathing--but only one possible factor. Or if the patient was on medications that could be filtered through kidneys, (and I am thinking along the lines of some IV antibiotics) which could alter the level of the medication that is being metabolized.

Interesting case. However, that you gave his morning meds as indicated/ordered I am not seeing the nephrologist's comment as meaning you caused this decline by medicating him. And the MD was aware and did not order a hold on the patient's meds....

Been there,done that, ASN, RN · Oct 9, 2014

Think you're focusing on the wrong system.

CO2 retention most likely caused the decreased LOC. Was he using his CPAP?

Wile E Coyote, ASN, RN · Oct 10, 2014

Yup, this strongly points to hypercapnia and perhaps the kidneys' acutely impaired ability to buffer with enough bicarb. The morphine, the IV contrast from the heart caths along with any other nephrotoxic and sedating meds not mentioned are likely what the nephrologist is referring to. If you'd failed to intervene when you did and instead the patient arrested, then there would be room for criticism.

Laurie52 · Oct 10, 2014

A patient that I took care of was steadily exhibiting an increase in AMS. The attending was notified and orders were placed for a neurology consult. No patients vitals were stable for the exception of low temp and abnormal BUN and Creatinine steadily increasing, for which Renal was also on the case, Attending was aware. No orders were given to hold any morning meds. By the afternoon I had to call a Rapid Response because of the patients increased AMS, he was almost catatonic. The team drew ABGs and put him on bipap. He was transferred to ICU and intubated. The next day when reading the Nephrology notes as to the incident he wrote (presumed medication induced)? Just wondering if he was implicating me for administering the patients morning meds? He also wrote an order for Lasix IV which was given prior to the patient being transferred to the ICU. Were my actions or judgment the cause of the patients decline?
Very worried!!!!

How do you know what was written in the note after he was transferred to one ICU?