was not my patient but still learning!

[erin01]

So on my unit which is a busy tele unit, at night most of the nurses are young and inexperienced. Well one of the nurses who has been a nurse longer than me just not on this unit, had a confused patient. Now i stayed away for most of the night because i am pregnant and this patient at one point was trying to hit the nurses. He was pulling out his foley hitting and thrashing around in this bed. They restrained him and gave him ativan and haldol. The nurse kept calling the dr to get orders and by 5am she was a disaster, just exhausted and frustrated. I walked in close to 6 and the patient breathing was horrible, wheezing, abdominal muscles were being used. I asked her what his o2 sat was, and she said it was fine, and was at time trying to give him a breathing tx, by just holding the it over his face. IT was hard to administer because he was combative. He was not cyanotic, i looked at this finger nail beds and i have seen some one who really was not able to breath and i felt like he could. I asked if she thought maybe we should get a abg, like maybe he is hyperventilating? I felt something was off, but what do i know? One of the other nurses made a comment to her like about her doing nothing for this patient and his breathing all night! And i could tell how upset she got! I felt bad for her because i could see how it could happen, your so worried about his safety and and his behavior and thats what she thought was making him breath like that. Well the next day, the day nurses found out he was septic, fever of 103! Needless to say this nurse felt horrible, as did I for her. Especially because i would have done the same.. i think. I find it hard to be aggressive with patients like that, like i know something is off...but am not assertive to call a dr and say come see this patient now! I have seen these nurses who believe in how they feel and have no problem being aggressive in a situation like this! I am not one! I did pull this nurse a side and tell her not to beat herself up to much, because i know if she ever had a patient like that again it would go much differently!!!!!!!!! I just have had confused patients and its tuff, and its hard. She did mention that he was not confused at the beginning of the night and she thought maybe he was just sundowning. ITs so hard, we are not dr's and we are inexperienced! How to i become the one is confident enough to say something is wrong and get some one here now! Will i ever know when to do it? adv? thoughts ?

[ehooper80]

I'm assuming because the RN thought the pt was possibly having Sundowner's that this was an elderly patient w/ a prior Hx of dementia? If this is the case, the RN and yourself were not wrong to assume his behavior was dementia related... even the MD thought this or they would not have ordered restraints, Haldol and Ativan.

You can only learn from experience. Just FYI, the elderly (esp. those w/dementia) are commonly misdiagnosed/delay diagnosed because it is hard to differentiate the dementia (long term) from delirium (short term, r/t infection, shock, etc). Those coming from nursing homes often don't have a report to specify their baseline behavior or mental status... and nurses that have worked in LTC know that A&Ox1, A&Ox2, etc is not very helpful as the pt's cognitive status can change depending on time of day, mood, etc.

But for future reference, mental status changes are often the first sign of many conditions in the elderly... infection, stroke, pneumonia, even UTIs. The best rule of thumb I can offer is to NEVER assume a patient's/resident's behavior outbursts are due to dementia unless you ABSOLUTELY know that for a fact. Combativeness/hitting/crying/etc is often a sign that something is wrong. Have all basic needs been met (hunger, bathroom, hot/cold)? What are the vitals like (high/low BP/HR/RR, temp, O2)? The only thing you can do for a person that can't tell you what's wrong is a thorough assessment to try to find anything abnormal. Then report whatever you find, as well as the behavior, to the MD.

The other RN and you did your jobs... you've learned from the experience and next time you will know how to react. Don't worry about becoming aggressive... that's not always a good trait to have in nursing, and like my grandma always said, you catch more flies with honey than you do with vinegar. You can explain to the MD that you are concerned because your pt is acting very different than they were a few hours ago, is now combative, etc... but I would never tell an MD they needed to get there now unless someone was coding. Unless the pt was going into septic shock or V/S were very unstable, it's not really an emergency. But again, that is something you will learn with time.

Just a question... where was the charge nurse during this episode?