Rapid Response Team- Should I have called?

[BabyNurse13]

So I've been working on a Med surg unit for almost a year and last night, I had a pt who had hepatic encephalopathy. She was a/ox4 during the day, but as soon as I came on at 7pm (night shifter), the pt was already very lethargic and we received orders to put in an NG tube and give her Lactulose. She was also about to receive dialysis so I put in an NG tube, gave the lactulose and played the waiting game. Her vitals were stable throughout the night, the doctor was notified and I got orders to put her on tele monitor and cont. pulse ox and her O2 sat was 98-99% and her HR was sinus brady to sinus rhythm 50's to 60's. I had the charge nurse look at her and she called the ICU nurse to come look at the pt because at this point the pt was pretty much in a coma, barely responding to painful stimuli. We all agreed, including the MD that this was bc her NH4 level was >223 and she has a hx of hepatic encephalopathy, esrd, cirrhosis, plus she came in for rectal bleeding. She was about to go for a colonoscopy the next morning at 11 so after dialysis I had to finish giving her Miralax via NGT and in the AM I called the MD and he ordered for tap enema which I gave. She had several large BM's throughout the night and Throughout the night, her vitals remained stable but she remained very lethargic. At times I would see her move her legs or open her eyes esp when we turned her, sometimes she would push back and resist but that was the extent of it. Anyway, at 7am I handed her over to the next nurse and today I heard from a colleague that they called a rapid response on this pt at 9am. I don't know why they called an RRT, I don't know her outcome, I don't know any of the details except that one was called and now I can't sleep. I keep replaying the night in my head and I wonder... Should I have called an RRT? Was there something else I should have done? Did I miss something? Should I have transferred her to the ICU? Was I being negligent? Please help! I'm a new grad and I am so worried about this pt. I'm also dreading back to work knowing I may have failed her and been a bad nurse and caused another nurse more trouble. What would you have done??

[JustBeachyNurse, LPN]

You alerted your charge & the physician AND the patient was assessed by a member of the ICU nursing staff what more could you have done? Her situation, based upon what you wrote, could have easily changed after your shift warranting a RRT call through no fault of your own. If her physician, ICU, and your charge were not concerned about her altered LOC there isn't much more you could have done. Perhaps they wanted to try lactulose, dialysis, etc before moving to critical care to see if it would help.

[BabyNurse13]

Thank you for your response JustBeachyNurse. It makes me feel a little better. As an inexperienced nurse I constantly question my judgment. It's not to say my charge rn wasn't concerned, she was very concerned which was why they called the icu nurse to have a look and the icu nurse recommended that we just keep a closer eye on the pt. This put my

charge more at ease.

[sbostonRN]

I agree with JustBeachy. It sounds like the patient was unstable but you did everything right. Collaborating with your charge nurse and the doctor and involving the ICU nurse were all important steps that you took. If they felt the patient should have been transferred to a higher level of care, they would have voiced that. It sounds like they were being conservative and trying to treat the patient on the med/surg/tele unit. Encephalopathy patients can go downhill fast, and as you saw, the patient deteriorated throughout your shift. I would think that the patient simply continued to go downhill and that's why the RRT was called soon after you left.

[nurseprnRN, BSN, RN]

If they'd called a rapid response at 0710, then I'd feel less comfortable about it. 0900, not so much. The patient just slid down far enough to cross the RR threshold by then. You did fine.

[BabyNurse13]

Thank you all so much for your responses! I found that the RRT was actually called around 8 because the nurse was concerned about ALOC but the vitals were stable and no interventions were done, the pt was breathing fine on her own. They initially wanted to transfer her to ICU but when the MD came in, he found it unnecessary. The pt was basically obtained for 2-3 days, but she's back to her a/ox4 self today! Yay!

[Here.I.Stand, BSN, RN]

The treatment of lactulose and closer monitoring sounds appropriate. If she hadn't been able to protect her airway or if she'd been seizing she would have needed more interventions, but that wasn't the case. You got your charge, the MD, and the ICU nurse involved, and they all agreed that you were managing the pt just fine. You did well! Glad to hear she was ok!

[nurseprnRN, BSN, RN]

Obtained? Is this an autocorrect for "obtunded"? :)

See, we told you it was fine.