Please help me figure out what happened to my pt

[Florence NightinFAIL]

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...

[canesdukegirl, BSN, RN]

Nerd2-

But she had an NG tube...and it was draining. Are you thinking that it could have become clogged?

[Jenni811, RN]

"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?

wondering the same thing :) ours are only 30 minutes

[Isabelle49]

Organ failure.

[canchaser, BSN, RN]

But she had an NG tube...and it was draining. Are you thinking that it could have become clogged?

Probably not lets look at some pathophysiology. The intestinal tract secretes a lot of bile per day, some of the bile comes in from the pancreas/ liver, downstream from the stomach, some believe that placing a NGT only decompressses the stomach and to decompress the bowel you really need a tube that goes in the bowel. " Absorption takes place in the small intestine, Do you think the NGT was really sucking all the bile off? Probably not unless you could over come the pyloric valve on the stomach. So there would be pressure building up in and around the bowel, this could lead to narrowing/ blockage of an artery to the bowel.

Once the narrowing in the above pt occured, the blood flow backed up causing this pt to go into failure. The pt could of had a bowel spasm, this could be a cause for failure/ lack of blood flow if it lasted long enough. If any of this happened you would not know till the external symptoms of SOB occured. You missed nothing that I could see.

[canesdukegirl, BSN, RN]

VERY nice, Canchaser!

[canchaser, BSN, RN]

VERY nice, Canchaser!

Thanks!

[casi, ASN, RN]

Here's my question, was the o2sat probe working? If her vital signs were WNL and she was breathing regularly and unlabored... were her o2sats really that low?

[nerdtonurse?, BSN, RN]

Love it, canchaser, that's what I was thinking -- I just had to stop and run to church. When I had the patient that did that, they went from fine to going down the drain in the space of 5 minutes -- I think they've already compensated, compensated, compensated and then they can't do it anymore, and they go bad very, very quickly. Mesenteric based ischemia is horrible stuff.

[Biffbradford]

Don't be shocked that patients admitted to the hospital for anything, can crump inside an hour, or even much less time than that. Just say'n.

They can be discharged, have their coat on, and are walking out the door with a big smile on their face, when BAM, down they go. CALL A CODE!

My Dad pulled that one. Heading home and *PLOP* down he went.

[Florence NightinFAIL, BSN, RN]

That's a very good explanation and something to think/research about further, thanks cancather.

Her breath sounds were diminished but she looked/sounded fine. Just very drowsy. The dinamap worked fine because it was used on the other pts in the room - and besides another one was used too just in case.

I'm sorry if my retelling made it sound like it took longer than it should - RT and the Resident were paged stat right after one another.

P.S. It was nightshift. We take all our breaks at once - so a two hour sleep break.

[Florence NightinFAIL, BSN, RN]

Here is the sequence of events:

1600 - Pt threw up. The nurse was with her when this happened and no apparent aspiration occured.

1700- NG tube was put in. Drained 100 cc right away.

2000 - My initial assessment *see 1st post* and med pass.

2430- Went on break

0130 - Covering nurse does vitals and discovers pt crumping.

Now - if she DID aspirate @ 1600 when she vomited - why would she show changes 8 and a half hours later? Her chest was CLEAR for 7.5 hrs and then BAM!

[cherrybreeze, ADN, 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.

Just because there was no documented history of CHF doesn't rule it out now. There is always a "first" episode that leads to said diagnosis, and this may have been it. The patient may have had every factor in place for it happen, and this was the opportunity for it to come to fruition.