Poor ICU Nursing Care

[nursesbca]

Today had to be one of the most stressful situations that I have had to deal with lately. I worked a shift in ICU (small 3 bed ICU) and myself and another nurse were taking care of 3 patients. 2 of these patients were fresh MI's and the other was pneumonia, sinus tachycardia and septicemia (really sick). So we sit down and get our report at 730am and the 3rd patient described above had had a horrible day yesterday (very restless, aggressive. etc) and overnight had received 2 doses of IM Haldol. In report the nurse working nights had said that she let the man rest the entire night as he had been through so much the day before and was fine this morning. So the other nurse and myself decided between us that we would take care of the other 2 patients (do assessment, vitals, etc.) and attend to out 3rd patient last (we figured we would let him get a little more rest. Upon entering the room the patient looked a mess, bedclothes messed up, looked like he hadn't been touched all night. In checking his vital signs he had a temp of 33.4 and BP of 66/33, no urinary output since 6am. We immediately checked his chart from last night and not a single BP charted, not a single temp charted. In reading the night nurses notes, the patient's spO2 had dropped to 70% on 5 L of O2 and the doctor was not even called. I called the doctor to inform him of the patients condition which was poor, low BP, no urinary output, unresponsive, etc. The orders given to me was to D/C the Haldol and give a 250cc bolus of NS over 1 hour. About 10 minutes later the doc calls back again and tells us to hold all of his po meds (the patient was not alert enough to swallow them anyway). By this time our gentleman in Room 3 developed chest pain and we were in the middle of doing EKG's, giving NitroSpray, taking BP's, etc. The doc calls back once again and asks to start our sick man on a dopamine gtt and to give some more boluses. By this time the man is having 5-10 second periods of apnea, becoming bradycardic and eventually having periods of asystole and expires on us while we are right there in the room (he was a no code thank goodness). Finally about 10 mins after the man passes, the doc comes in and gets all upset saying that we were too late in calling him with the low BP, more or less implying that he died because of our negligence to call him earlier. This situation upset me for 2 reasons, in that the night nurse gave us a false impression of the patient status (how could she know his BP was in his boots if she didn't even bother to do one!) and the doc not giving proper orders the first time that he was called regarding the patients status and having the nerve to say that we were not doing our jobs. Our nurse manager was informed of the situation and we were told that we followed the correct steps, apparently this doc gets upset when he loses patients and tries to blame everyone else. He should have come in to assess the patient after the first phone call! Sorry this post is so long but I need to vent!!! I'm probably going to be working ICU again tomorrow. :uhoh21:

[cursenurse]

i think that a lot of the blame goes to the night nurse, who wanted to let the pt "rest" all night and didn't seem to properly assess the pt. i am concerned that you or the other nurse didn't go see that pt first. he should have at least been eyeballed and v/s taken. if i had gotten in report that an rn had not tended to a pt all night, i would want to see that person immediately to see what's going on. i believe in letting pt's get "rest" but my assessment will get done whether they are resting or not. i thought in the icu pt's were suppossed to be continuously monitored, not allowed to lay there for hours on end with no assessment or vitals.

i don't think the dr was overreacting, i believe there was serious failure to monitor on the part of the nurses.

[Dinith88]

Ummmm...sheesh, where to start...

...Although that patient was in an "ICU"...he was not receiving ICU-type care. That whole scenario is an embarassment(sp?) not only to the nurses, but the whole unit and hospital. The doc was right in being so upset...even if he's normally a dick.

[finchertwins, BSN, RN]

Wow, where to start. Vital signs are so important to take no matter what is going on with the pt. I understand the doctor's reaction they had a right to be upset, even if it wasn't meant for you. The night nurse fail the pt and neglected their duty. No matter the size of the facility you work in a ICU pt is considered in need of the highest level of care that the facility has to offer. Without doing a hands on assessment q1 or q2 hours serious clues as to the pt's perfussion, mental state, sedation, respiratory function, renal function will be missed. Learn from this and understand that it may seem nice to let a pt rest but in the end they could be the ones that pay the price for the peace and quiet. If I were you I would never take another pt from this nurse without doing a complete assessment of the pt's and having the nurse correct any defiecenies prior the taking over care of their pts. Protect your license and protect your pt's, review of this employee's practice seems to need t be done by the charge nurse/DON/nurse manager!:uhoh21:

[begalli]

This sounds unreal!!!

I can't imagine not obtaining and documenting vitals in an ICU. The night nurse, as you describe, was definitely in the wrong, but when you get report do you not go over vital signs - the basic yet crucial assessment data!? If you did you would have found out that the vital signs weren't done for hours. That would prompt me to see that patient first, even before report was finished!

That doc was justified in being pissed off.

That was a sentinel event if it occurred as you describe.

What about monitors?

My goodness.

[actioncat]

What a horrible situation to walk into.

[UM Review RN, ASN, RN]

What about monitors?

I only visited ICU as a float, but patients like that have an auto BP cuff on and we can take it at the push of a button from outside the room. The temp being 33.4 (92.12F)? No urinary output all shift?

Even if the patient was a DNR, I'd have been too upset to leave without at least calling the doc!

[ZASHAGALKA, RN]

somebody should be fired and reported to your board

A sentinel event (if canada uses JCAHO) should be reported.

Your hospital governing board should be notified.

In the CCU that I work in, we keep NIBP cuffs on and set to Q1H vitals ALL THE TIME FOR EVERY PATIENT. It's considered a standard of care. So is continuous sat monitoring for the most part. So are frequent 'hands on' evaluations. You can't sedate someone and then just assume they are resting. Sedation requires evaluation. DUH.

A sat in the 70's not addressed? No B/P's documented in Critical Care?

That's not critical care, that's funeral home care!

And you have a moral obligation to ensure that the powers that be (not just your supervisor - the hospital's accreditation board) know and investigate. Otherwise, you are not being a patient advocate. My nurse practice act legally requires me to intervene in such unsafe situations by not only reporting, but by ensuring that such practices are corrected.

This is a stand up and fight even if it costs your job issue. I'd much rather be suing your hospital because they fired me as a whistleblower than I would staying put and losing my license.

~faith,

Timothy.

[begalli]

The more I think about his (it has really hit a chord with me), the more I wonder how long it was until the day shift RN's got to this patient? And once he was found in the condition he was in, how much attention was he really given?

Just because he was a no code DOES NOT mean that he should not receive treatment. Sounds like he was a difficult patient to deal with when awake. Absolutely no excuse.

Plus, as the OP pointed out in his/her post, this was the sickest patient on the three bed unit - septic with sinus tach. Unless life sustaining measures where being actively withdrawn, he should have been watched like a hawk by every nurse who was assigned to him.

IMO, the night nurse is not alone in the neglect that this unfortunate patient endured.

[givadarn]

I agree with many of the other nurses' replies; you always want to eyeball the documentation of the last shifts' vital signs DURING REPORT so if everything is blank or something looks out of whack, you can address it right there face-to-face with the night nurse. It is all of our responsibilities to ensure that standards of care are upheld, and in the ICU q 1 hour vital signs are a minimum. Unfortunately, it sounds like this patient was too far gone by the time you came on shift.

It's definitely a learning experience; those night shift nurses should DEFINITELY be reported.

Also beware if a patient is acutely confused/agitated - this can signal an emergency like hypoxia, hypoglycemia, electrolyte imbalance, poor perfusion due to low BP. Only once all these things have been ruled out can you CAUTIOUSLY consider antipsychotics.

When I start my shift, I always think: which of my patients is the sickest/most unstable or needs to be assessed first? In this situation, even the MI patient comes second.

Hang in there; you're getting trial by fire but you'll survive!

[NoCrumping]

The more I think about his (it has really hit a chord with me), the more I wonder how long it was until the day shift RN's got to this patient? And once he was found in the condition he was in, how much attention was he really given?

Just because he was a no code DOES NOT mean that he should not receive treatment. Sounds like he was a difficult patient to deal with when awake. Absolutely no excuse.

Plus, as the OP pointed out in his/her post, this was the sickest patient on the three bed unit - septic with sinus tach. Unless life sustaining measures where being actively withdrawn, he should have been watched like a hawk by every nurse who was assigned to him.

IMO, the night nurse is not alone in the neglect that this unfortunate patient endured.

I agree, and further more..there were 2 of them for 3 patients!!!!!

[decoopa]

What's a DNR doing in the ICU anyway? You never know what you're walking into. That'

s a tough situation though.