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...

[Krista09, BSN]

no offense but a 2 hour break to sleep on a night shift in my opinion is unsafe. Sleep before you come to work, only you truly know your patients and a covering nurse might not notice a change. Patients need to be monitored more closely at night secondary to having less staff, not left so their nurses can sleep. Theres a reason hospitals are open 24 hours, because people can become sick not only during the day, but at night as well. I've worked nights for 2 years and I would never dream of leaving my patients for an hour, never mind two.

[Cat_RN, ASN, BSN, RN]

I work night shift am I'm lucky if I make it to the bathroom once.

[DookieMeisterRN]

no offense but a 2 hour break to sleep on a night shift in my opinion is unsafe. Sleep before you come to work, only you truly know your patients and a covering nurse might not notice a change. Patients need to be monitored more closely at night secondary to having less staff, not left so their nurses can sleep. Theres a reason hospitals are open 24 hours, because people can become sick not only during the day, but at night as well. I've worked nights for 2 years and I would never dream of leaving my patients for an hour, never mind two.

It would be interesting to know what these hospitals mortality rates are if all the nurses are off the floor a good chunk of the time.

When I worked nocs we could only combine our breaks and take an hour off the floor but that left our buddy with 10 pts. That could be okay for 1 but not 2 or even 3 hrs. And if more than one nurse was off the floor? I wouldn't want to be sent to this hospital.

[DookieMeisterRN]

To solve the break issue once & for all!

Technically we are supposed to have 1 hour 45 min break in a 12 hr shift - but the unit/hospital culture is for 2 hrs. This is not just this hospital, but the three others in the city also. In fact, on one floor at the last hospital I preceptered, the nurses took 3 hour sleep breaks on nightshift on a surgical floor.

I can't remember any time where my break was cut short (unless I chose to or there is a code). I know I'm very lucky .

That's not lucky but setting you up for a lawsuit. Be prepared.

[Florence NightinFAIL, BSN, RN]

I can understand about the extra 30 mins, but some of you seem to begrude me my rightful 1.45 hrs of break out of a 12 hr shift.

I'm no martyr. Sometimes on dayshift I might not great all of my break time - but most often, I do during nightshift. And we give good report to our covering nurse (team based nursing - she has already rounded with me from the begining and has her own report of my patients). I don't see the problem. We take our nightshift breaks on the unit in the staff room.

Anyway - if you guys want to keep on talking about the break issue and discuss your own situations, maybe a new thread should be started.

Let's stick to the topic now. Thanks.:)

[Krista09, BSN]

We aren't talking about break issues; you asked what happened to your patient and we are simply giving an answer. The extended breaks could have been what happened to your patient. its not a matter of giving a good report to who's covering its a matter of staying with your patients. like it was mentioned before I would be interested to see the mortality rate of this hospital.

[Anna Flaxis, BSN, RN]

Anyway - if you guys want to keep on talking about the break issue and discuss your own situations, maybe a new thread should be started.

Let's stick to the topic now. Thanks.:)

I think that the fact that you were on break when this happened is relevant to the topic at hand. I don't begrudge anyone their breaks. I'm a big advocate of breaks. If we don't take care of ourselves, then how can we take care of others? Mistakes in patient care happen when care givers are fatigued, so breaks are really important for patient safety, in my mind.

However, I'm not a big fan of combining breaks into one long one.

Patients can turn on a dime, and no matter how good of a report the nurse covering you has, they still have their own patient load to take care of. While this patient could have just as easily decompensated while you were not on break, still that's a two hour window in which your patients are not being looked after by YOU, the nurse assigned. To me, that's a long time. A lot can happen in two hours.

Anyway, I'm still voting for flash pulmonary edema.

[MTRN13]

This was a topic of a staff meeting this last week. We are not allowed to combine breaks. We get 3 15 minute breaks, and one half hour break for a 12 hour shift. We were told if someone is covering your patient, and something happens we are both liable. Which means we give a through report, and a copy of the shift report before leaving. We check on the person who we are coverings patients. We would have nurses leave for 45 minutes to over a hour and half on break. It is not considerate or safe to leave 10 patients in one RN's care for that long especially if there are a few really demanding or confused patients. The other thing is certain nurses would take so long that it was hard to get in my short break. Which makes for a tense situation. I actually had to speak to my charge nurse to be able to take my second break of the night. The only other one being my 30 minutes break. I was only looking for 15 minutes. I was already not going to take 30 minutes worth of time that I am entitled to, but that was not going to turn into 45 minutes. I need my caffeine break somewhere around 3 AM or I start to lag. When someone else selfishly takes over an hour after their 30 minute dinner break. Sorry this turned into a rant. Unfortunately for us it turned into a problem of a few nurses taking advantage of the majority. I would urge all of us to be considerate of each other, and have each others back.

As for your patient, she should have told you during your break. Your patient is 02 sat's are in the 70's, there is a change in patient status from what you told me in report. What do you want to do....... If she did not call a rapid response maybe you would have. At least it would have been your choice. 2 hours break sounds very dangerous. One nurse with up to 10 patients for 2 hours it a receipe for disaster.

[Florence NightinFAIL, BSN, RN]

We will just have to agree to disagree.

Thanks for the insight guys.