Please help me figure out what happened to my pt

[Florence NightinFAIL, BSN, RN]

I had a 90 something patient admitted for SBO. She did not speak a word of english so I could only base my asessment on objective data. She was NPO, had NG tube that drained ~400 cc over my shift, IV fluid @75 cc/hr. She was drowsy throughtout the shift (had sleeping pill & antipsychotic meds), chest clear, VSSA, abdomen slightly distended w/ faint BSX4. Voided twice in bedpan. I checked on her regularly and she seemed fine.

So I went on my break and told my covering nurse to do a set of vitals in an hour. When I came back the nurse told me that when she went to do her vitals her sats were 70% on 2L O2 via NP. She had coorifice crackles thoughtout her lung fields and bladder scanned for 400 cc. Raised O2 to 5L and sats remained in low 80%. Throughtout this time her VS continued to be WNL, RR was 20/min. Breathing fine, not using accessory muscles. Rousable to speech. RT was called and she was placed on high flow O2 mask @ 80%. Sats slowly rose to >95%. Resident paged & ordered chest x-ray, abx, lasix, and something else that escapes my memory.

I was shocked that such a fast change would occur within an hour. I was also wondering what happened - I know that it could not have been fluid overload - she wasn't getting much. She was also peeing fine and her NG output was Ok. Someone said that she could have aspirated - but how with an NG tube? She was in semi-fowler's throughtout my shift and I can't really figure out what happened. I left before the results of the x-ray came.

What do you guys think? I can't stop thinking about her and wondering if I missed something...

[brandy1017, ASN, RN]

Most likely it was fluid overload, she was a 90 year old person her heart was probably not as strong as you or I, could of had a history of CHF. Also if she was septic from the SBO or if there was a perforation unknown to you she could have went septic with ARDS. Although CHF would be my first thought!

Well the resident covered the bases, CXR, lasix, antibiotics as far as the hypoxemia goes. What did the CXR show? Were they going to repeat a KUB anytime soon to check the SBO?

[Florence NightinFAIL, BSN, RN]

^I was discussing this with my supervisor & we went over her chart. No history of CHF or any other heart issues. Pretty good for 90+ year old.

This happened my on my last shift so I don't know what the results were or what happened to her afterward.

[RoyalPrince]

For future note I would have called a Rapid Response and get all those thins ordered stat right there and than after putting patient on a NRB

[thelema13]

Any resp hx? Older pts decompensate quicker, it sounds like fluid overload by what the doc ordered. The nurse covering for you should've responded quicker, rapid response should have been called, but these things happen. Why was she NPO and on NG suction? Dont forget sedatives lower RR, possibly allowing fluid to build up, adding to the already compromised lung status.

[nrsang97, BSN, RN]

Fluid overload.

[canesdukegirl, BSN, RN]

I like Brandy's response. It isn't uncommon for a SBO to perforate, however I would expect the classic signs of sepsis such as tachycardia, hypotension, oliguria and SOB to be apparent during your initial assessment.

It's gotta be fluid overload. Do you remember what her sats were before you went on break? What did her lung bases sound like? Were they diminished? Did she take deep breaths when you were listening to her lungs? How long had her NG tube been in?

Sometimes pts don't like to take deep breaths with an NG because it 'feels weird'. The NG tube coupled with the sedative in a 90 year old would make me think that she wasn't taking deep breaths, resulting in atelectasis.

[Cat_RN, ASN, BSN, RN]

I had a pt who did something like that.. stable on minute, circling the drain the next. ARDS was cause of death due to pneumosepsis. And NO, she didn't have any respiratory symptoms at all, nor was she febrile. Very bizarre.

[mama_d, BSN, RN]

I'm voting for fluid overload here too.

Although I have had a couple of pts go into flash pulmonary edema on me, CHF acting up (even if previously undiagnosed) is way way more common.

[Biffbradford]

"So I went on my break and told my covering nurse to do a set of vitals in an hour."

OKay, I gotta ask. How long are your breaks?

[nerdtonurse?, BSN, RN]

Okay, here's my thought. Small bowel obstruction -- you get GI contents backing up, you get pressure on the diaphram as the belly distends. You didn't mention any pedal pulses, but I've had a patient have a SBO due to mesenteric artery narrowing; resulted in sudden, full onset right sided heart failure.

[Jenni811, RN]

i work in cardiac/pulmonary unit so we get patients like this ALL the time. To mee, it sounds like she may have some CHF and had fluid overload with pulmonary edema.

I'd be curious to know what her EF is. But pulmonary edema/fluid overload can happen very quickly especially to a 90 year old who i'm guessing has some CHF. You didn't do anything wrong.