Sharpening skills and advocacy

[DjKaeDae]

It's been a bit over two years since I've written or logged into this website. I recall the last time I was on this page was right before my NCLEX and I was freaking out... but I passed. I'm almost one year into working nights on a medical surgical floor of a community hospital... and I LOVE IT. I have my moments where I'm super busy 12 hours at night from ensuring all orders have been carried out correctly, pt's are all stable, medicated appropriately for pain, clean, and safe from trying to jump out of bed and whatnot... However, I have moments where I go home and think about what I could have done to make a situation better for my patient.

Long story short, here it is... Two nights ago, my 55 year old patient was admitted for hypotension on neutropenic precautions. Hx of COPD and colon ca stg 4 with mets to liver. (trying not to give so much pt info out here) No hx of cardiac disease. 2 weeks into chemo. In ER, he was bolused 500ml NS. Patient was hypotensive at the start of my shift SBP:86 HR at 113. Called the on call MD and MD ordered 250ml NS + albumin. Administered it. SBP now in 80s and 70s with HR at 125s. Called MD again, MD ordered same thing, 250ml NS + albumin. I told this MD that this pt should be in ICU for that BP, but MD still ordered the same thing and said let's see how he is after this one. I told the MD that he has some labored breathing but has had it since start of shift (in which the pt is alert and oriented) and when asked states he's breathing fine with no difficulties. O2 saturations were maintained at 95%. RT has been in and out of the room for breathing treatments and suctioning.

After the second 250ml NS and albumin, pt's SBP was at 107 with a HR of 138. Called MD. Orders to transfer to telemetry. Transfered the pt to telemetry. 20 minutes later, I was told he was intubated and taken to the ICU. I was told his ABG's were all off and he was acidotic.

I felt horrible that night and morning. I kept thinking to myself what I could have done to make that situation better for this pt. I mean, I followed up with this MD frequently. I thought I was taking the right steps. He appeared fine to me prior to transfer. Pt stated he was fine and had no difficulties in breathing. Saturation was wnl. I was concerned about his BP dropping and his HR being tachy. I didn't ignore his respiratory status (at least I dont think i did) as I knew RT was there a few times, and myself and another RN was there a few times to suction him orally as he had small amounts of thick sputum in his throat, but not lower. The MD and I were concerned about overloading him on fluid and that was her rationale for bolusing him 250ml at a time. The only subtle change I saw was after the second order of 250NS and albumin where his breathing was a TINY bit more labored, but still denied any difficulty breathing. Saturation being 95 96%. Still alert oriented. When I transfered him to his new room on Tele, he was even asking us to put it back on the same channel he was watching...

I still feel like a piece of trash for what happened. How do I sharpen my skills from that situation? What could I have done or what should I have done to prevent him from going down like that? To me, he wasn't stable being on a medical surgical floor to begin with.

Thanks for taking the time to read this. Any and all criticism or advise and pointers is appreciated.

[NotReady4PrimeTime, RN]

What you've just described is almost a classic evolution of septic shock. If he didn't have blood, sputum and urine cultures in the ED and antibiotics right after, those fluid boluses weren't going to do much. There's not much more you could do with the situation. You stated the patient was neutropenic so there woudn't necessarily have been the dramatic spike in temp that often coincides with the tanking BP. As for the volumes of fluid used to resus this man, fluid restriction in the face of sepsis is the kiss of death. I've seen children in septic shock receive a litre or more per kilo and still be hypotensive... fluid overloaded with pulmonary edema of course but alive. What they benefit from is a Levophed infusion, antibiotics and any other supportive measures required by their evolving illness. So on the face of it, things with your patient progressed pretty much in the textbook pattern, right down to intubation and the ICU admission. All the little pieces of the puzzle that you've picked up with this patient are going to be in your head the next time you see it and you'll know better what to do and how aggressive to be with the doc. Nursing involves life-long learning. We're not perfect or superhuman and will never know everything. Stop beating yourself up for doing what anybody else in your place would have done. Good job!

[talaxandra]

I agree with Jan that this sounds like textbook septic shock in an immunocompromised patient. At my hospital a SBP under 90 is grounds for a medical emergency team/rapid response - since introducing them about a decade ago our code numbers have dramatically dropped, patient stays decreased, ICU stays shortened and morbidity/mortality stats massively improved. In the case of your patient an urgent review would have no only meant doctors clapping eyes on him instead of intervening by radar, but would almost have certainly meant commencing anti's (if he wasn't already prescribed them), monitoring far earlier, and probable transfer to ICU before he crumbled.

It sounds to me like you did everything you could with the resident you had and your level of experience. As an old bag I'd probably be more forceful than you'd be comfortable with, and maybe identified sepsis as a possible cause, but even so I've had my fair share of residents unable or unwilling to review downward-trending patients as quickly as I'd like, and that's with the MET protocol to support me.

Rapid response programs are well established - perhaps you could find out why your hospital hasn't got one and push for the adoption of this intervention, which saves money, saves lives, and prevents nurses feeling bad about not being able to work miracles.