could use alittle help with my case study

  1. hello there

    Im a nursing student and i have to write a paper regarding a nurses professional values, the ANA code of ethics, the NPA and how all these things relate to this case study.

    in order to help me write it, i was hoping to get a few profession opinions on what the RN should have done in the following situation (specifically, did the patient belong on the unit in the first place? or at what point should she have been moved).

    68yo woman admitted to intermediate care unit with SOB for one day. history of COPD, CHF, and diabetes. she was alert and oriented but couldn't complete a full sentence due to lack of breath, her resp was 10 and shallow, diminished breath sounds in all lobes. her pulse ox was 84% on 2 liters ox, BP 135/90, pulse 110, 3+ edema both legs.

    the next thing it says is that the nurse called the admitting dr because she was concerned, he said "thats why i admitted her, increase to 4 liters and ill be there later"

    a half hour later her resp was 8, cyanosis of the lips, and couldn't be aroused. The RN called a code and the patient was resuscitated to her baseline admission.

    the RN requested the dr transfer the pt to the ICU but he left her on the unit. the nurse expressed concern to the charge nurse who said "we have to do what the doctor says so just watch her close".

    when the nurse came back the following day, the night nurse gave report that everything was fine and gave no other details. after report, the nurse found the patient confused, cyanotic, resp of 8, pulse ox 79% on 4 liters. the night nurse said the patient was fine at 0600 meds and that she told the PCA to monitor the patient and report any problems. the rapid response team came, intubated the patient, and sent her to the ICU with respiratory failure.

    so thats it, that pretty much sums up the whole case study. so was it wrong for the nurse to call the dr the first time? or ask that the patient be transferred after the patient coded? is there something the nurse, or charge nurse should have done? (NOTE - this is simply information ill use as a starting point for my paper, I'm not asking anyone to do my homework for me. but you can if you want to haha)

    anyway, i hope someone answers this. THANKS!
  2. Visit KyleG profile page

    About KyleG

    Joined: Dec '10; Posts: 5
    RN; from US
    Specialty: 2 year(s) of experience in nicu


  3. by   itsmejuli
    You need to read the information you were assigned and then read the case study again and analyze it. This is an ethics and critical thinking assignment. There are many errors that all of those concerned with the patient made.
  4. by   lovemaine
    Pt needs lasix for CHF and is probably receiving too much oxygen (CO2 retainer?) which is decreasing drive to breath resulting in low resp. rate and low o2 sats. The charge nurse should have encouraged the nurse to advocate for the patient....not just do as the Dr. your instincts and don't worry about "bugging" the Dr.....
    Last edit by lovemaine on Dec 3, '10 : Reason: more info
  5. by   GHGoonette
    Yeah, I agree with lovemaine, it sounds to me as if the instructor is looking for someone to pick up on the "patient advocacy" aspect. And documentation!
  6. by   nursej22
    Unfortunately this sort of thing happens way too often on our unit. The patient comes in or is brought to ED. Labs and imaging are done, treatment may or may not start, patients with a history of heart failure often get fluids for some unfathomable reason. The patient waits 6 hours, orders are written and the patient is transferred. In that time they have decompensated to respiratory failure on arrival.
    Our routine (it's sad that we have one) is to call a rapid response and then the doctor and request ABGs. If the MD won't listen to us, the stat RN is will usually back us up or request a consult by the intensivist. Respiratory therapy is present at our rapid responses and will press for a BiPAP, or vent. Even if the patient stays on our unit, they would have a continous pulse oximeter and if they can't maintain sats >90 on APAP, then to the ICU they go.
    We also have the option of going up the chain of command, to the supervisor or the medical director.
    Watch them close? What the heck are you watching for? Failure proceeds to arrest fast! You've already coded them once!
    The nurse may feel a dilemma between patient advocacy versus insubordination.
    Death, anoxic brain injury, lawsuit all beat out a reprimand.
  7. by   resumecpr
    4L is not a lot of 02 for a patient who's sats are <80 - whether she's got COPD or not. She needed Bipap first and a lot of ABGs. And I would have paged that MD until the patient got what she needed.
  8. by   Soulwindow42
    you have done things appropriately. This is a case management issue and i would agree that the doctor must have seen the pt. immediately. The patient is in impending respiratory failure probably secondary to CHF with Acute pulmonary edema.(Does the chest xray shows it?). At that time, giving of high dose lasix immediately might have a big impact on the succeeding management of this pt, together with biPAP. Your MD is well-informed enough that it will only take approx. 5-10 minutes of hypoxemia and you will developed encephalopathy, which might lead to irreversible coma. The patient should been admitted to critical care/Intensive care unit in the first place and aggressive monitoring and management should have been done earlier. If you think you are right, trust ur instinct and be assertive in a nice way. If not, always call your immediate supervisor and superior if this happens again. tnx
  9. by   KyleG
    hey thank you, this helped alot i really appreciate it
  10. by   KyleG
    thanks for taking the time to answer me your answer helped alot!
  11. by   KyleG
    thanks to everyone who commented
  12. by   KyleG
    sorry i think i accidentally posted some stuff twice im still new to forums
  13. by   Soulwindow42
    Its alright maam, ur welcome, and tnx too.