Quadriplegics & shock

JustBeachyNurse, LPN · Nov 17, 2014

I work as an aide for a quadriplegic. I will be starting nursing school next fall and just need some experience.
Today I went to help him out and when I got there he was starting to poop (we do a bowel program). I tried to turn him so I could have a good view of his orifice/bowels. However, I could not adequately turn him and his right side kept falling, even with a pillow in place. He was very weak and his blood pressure was over 200. I called his wife and she said he could go in to shock and possibly die. I finally got him up high enough so I could start the bowel program, but he was in a lot of pain still the whole time. Eventually we called his wife again because he was not feeling well despite my efforts to lower his blood pressure by giving him milk and raising his head.
I just need advice for quads and how I could have prevented the spike in blood pressure, maybe advice on turning and bowel programs? I just feel really bad that that happened! I have only trained once with his wife for the bowel program, so it wasn't the best situation to be in for my first time, but I feel bad that he was in such pain and his life was endangered.
Thanks for your help...

Are you working as a home health aide? What does the plan of care state? What have you been instructed by your agency and supervising RN? Did you contact the RN?

Giving milk to lower BP? I've never heard of that.

I'm assuming by "have a good view of his orifice/bowels" you meant to visualize the perineal/perirectal area. While it is possible for a paralyzed patient to have a prolapsed bowel you should not be able to see bowels/intestines externally.

Honestly it sounds like you need more hands on education and training. If you are inexperienced and not working for an agency, reconsider completing a CHHA class and working via agency where you have the supervision and expertise of an RN.

HouTx, BSN, MSN, EdD · Nov 17, 2014

If you want to learn more about this phenomenon, I would encourage you to study 'autonomic dysreflexia'... it is life-threatening.

BUT - as PP commented, your appropriate response in this situation would be to immediately notify your supervising RN. This event is waaay beyond your scope of responsibility/knowledge level. Make sure that your supervisor knows exactly what happened. Your patient's plan of care should probably be revised to ensure that there is an appropriate level of response if this occurs again.

SopranoKris, MSN, RN, NP · Nov 17, 2014

I agree with HouTx, never give the patient something to eat/drink when there are adverse circumstances unless you've been specifically directed to do so by a physician or the RN. Sounds like they need to provide you more training. Please follow HouTx's advice about speaking with your supervisor. Your first priority is to ensure your patient's safety and you need to know exactly what that entails and what your actions should be if things go awry.

rdavis37 · Nov 17, 2014

I am not working for an agency; this is just the patient and his wife. I believe a nurse visits on occasion, but his wife does a lot of the nursing procedures (she has been trained). His wife is the one who told me to give him milk and raise his head. I did not make that decision.

I feel like I shouldn't have been placed in this situation when his wife was gone. Is this why HouTx you think that it was "way out of my scope of practice"? I know that his wife didn't know this would happen. I also will be watching a video about autonomic dysreflexia. I also have another question-with bowel programs, does the blood pressure raise more? Is there something I could have done wrong that would have raised his blood pressure?

RNsRWe, ASN, RN · Nov 17, 2014

If I'm understanding this correctly, you answered an ad (or were somehow otherwise notified of the job opening) and accepted a job for which you have absolutely no training, no experience, and no help available on the premises during the time you are there? You are fully in charge of a quadriplegic patient with significant risk for injury....and you have no way to respond to an emergency other than to dial 911?

Does this NOT sound like a recipe for disaster?

rdavis37 · Nov 17, 2014

I have training as a CNA, and I have been trained on the job for this. It is basic CNA work, except for this one time when it was the bowel program, which I have been trained for once. Usually I have help available, but when I walked into this situation, his wife was not there, and I did call her for help and she came home. I will definitely learn from this and know what to do next time, and I did not anticipate myself being in a situation like this because every other time I was there she was there.

SopranoKris, MSN, RN, NP · Nov 18, 2014

But you have not been trained adequately. The wife is not an RN and cannot teach you what you need to know. Giving milk does nothing to immediately lower BP. You haven't been trained to adequately anticipate what to do when an emergency arises, nor should you be working unsupervised. As RNsRWe said, definitely a recipe for disaster.

You have an obligation to ensure your patient's safety.

JustBeachyNurse, LPN · Nov 18, 2014

Your training is not sufficient. Giving milk for hypertension in a patient with autonomic dysreflexia is inappropriate and irresponsible. You are risking your CNA certificate and future potential nursing license. Even if in an agency environment I can guarantee that giving milk for autonomic dysreflexia would not be in the CHHA plan of care. Calling the RN would be, removing restrictive clothing or reducing physical strain or excessive movement (I.e. an inappropriately implemented bowel program). In many states CNAs & HHAs are not permitted to be delegated certain bowel programs.

I'm still hoping that you mistyped when you stated that you rolled the patient to get a better view of his bowels.

You need training from a licensed nurse. Not all private duty jobs listed on Craigslist are appropriate. The family may be trying to save money by hiring unlicensed aides directly but this is not always a safe choice for the family or the aide (in my state you cannot be a CHHA unless employed by a home health agency , and work under the supervision of a licensed RN, to try & prevent prevent these situations for the protection of the patient and aide)

I hope you have a current malpractice/ liability policy in place for your CNA certification and advised your carrier of your current job; to protect your current CNA cert & future nursing license.

JustBeachyNurse, LPN · Nov 18, 2014

I have training as a CNA, and I have been trained on the job for this. It is basic CNA work, except for this one time when it was the bowel program, which I have been trained for once. Usually I have help available, but when I walked into this situation, his wife was not there, and I did call her for help and she came home. I will definitely learn from this and know what to do next time, and I did not anticipate myself being in a situation like this because every other time I was there she was there.

Then clearly you were not adequately trained by a lay family caregiver. Do you even know if CNAs can legally implement bowel regimes in your state whether delegated by nurse or family?

There's an old saying "you don't know what you don't know".

And yes, a hypertensive crisis with autonomic dysreflexia can be fatal. A full bladder can also cause this syndrome as can excessive movement, tight splints or clothing, temperature fluctuations and more. This can be an emergency situation if the caregiver is not adequately trained.

rdavis37 · Nov 18, 2014

Okay, I understand. I will definitely talk to my boss about this. The original reason I took the job was the good learning experience, and that I know several nurses who have worked for them as aides and they have a good reputation. But you're right, it's the patient's life that is important.

rdavis37 · Nov 18, 2014

Also, JustBeachyNurse- I also just looked it up and there are some parts of the bowel program that CNAs cannot do. I should have checked on that. However, in that situation when he was already defecating when I got there, I did not know what to do. He did try calling the nurse that sometimes visits, but she did not answer. I probably should have called 911 instead. I remember that when he first told me that he needed a bowel program done, I hesitated because I had seen it done once, but had not done it supervised. I should have just not agreed to do it. I have another question-since he was starting to poop when I first got there one of the reasons his blood pressure went so high? Or was it because of all of the turning to try to get him in the right position? His hip has had problems in the past, and that's what was hurting at the beginning.

Also, one more thing to add-his wife told me that he has AD a few times a week. That is really scary, and they don't know how to reduce it. He is on medication for it and they will talk to their doctor to increase the dosage. I just can't help but feel scared that my actions endangered his life. I feel like we do make mistakes, and I don't know the true cause of what started the AD, but this was a life-threatening thing and I felt incompetent.