Should I have done more? Worried about a patient...

[Dani_Mila, BSN, RN]

I just started working in a telemetry/step-down ICU unit. It has been 2 weeks post orientation  I'm not a new nurse but it is my first time working at a hospital setting. I had a pt who was admitted due to COPD exacerbation (non-smoker, family members are) and PNA. She was scheduled to be discharged but was just awaiting a bed in a rehab facility. I've had this patient for about 2 days so I was quite familiar with her baseline. It was my third shift and after getting an update, her family ask for her to be changed. CNAs were busy taking their VS therefore I proceeded to change the patient. I laid the patient down and proceeded to change her, she asked for something to drink and her daughter immediately was about to let her drink fluids on a supine position. I immediately stopped her and gave education regarding aspiration precautions. 

After changing her, I sit her up, her O2 was at 3L NC starting in 92-93%. Pt baseline is confused, non-compliant at times, combative, and a very heavy mouth breather with non-compliace to using a BiPap at night. She sounded coorifice and diminished, but that has been her baseline for the past few days. She is very obese as well. Family left and after an hour, RT came to give her breathing treatments. She told me that pt sounded more coorifice than usual and more rhoncorous, audible without stethoscope, she started satting in 85% on 3L. I asked her to cough and take deep breaths but pt is very poor with coughing. We repositioned her and she placed a simple mask over her NC since she is heavily breathing through her mouth. She has asked me if she received any diuretics and I told her she does in the morning. I looked around the room and pt's family had at least 6 bottles of soda and 4 were empty, this was not there on the previous days I've worked. RT recommended that I get a BiPap PRN order and possibly a chest x-ray just in case. I spoke with the doctor and the x-ray results was "bilateral pleural effusions" which are considered new. Told the doctor about it and he ordered to stop the IV fluids and give her a IV Lasix 40 mg, pt started putting out a lot of urine that night. Pt kept removing her NC/mask and combative most of the shift, I had to put mittens on her in which she still somehow finds ways to remove it. Because of this, I kept getting paged because her O2 sat would be in the low 80s because of that. RT decided to place her on a BiPap setting 14/6  65%. Luckily, she was able to keep it on her. She was tachypneic at times in the 30s but it would go down to her baseline in the 22-25.  I gave an update to the MD and told him she still sounded coorifice and rhochorous, but is putting out a lot of urine more than 1000cc so far, the doctor said to just continue to monitor her. I was with this patient most of the night just trying to keep her mask on. She was hypertensive in 190s, I have her BP meds and she went down to 140s which is her baseline.

It was almost the end of shift, gave an update to the oncoming nurse who had her previously. I stayed for an hour just trying to finish up my new admission who came to the floor at 5:30AM. It was about 8:30 AM and Day RT came out of the room and told the oncoming nurse that patient might go to ICU because she was tachypneic, diaphoretic and is on high air pressure (BiPap). Oncoming nurse didn't want to call RRT yet and called the hospitalist instead to see the patient. Luckily, she came in immediately and I gave the doctor a brief update on what happened throughout the night and what interventions were placed. The doctor decided to keep the patient on BiPap and stated that she would start to heavily diurese her with diuretics. She was not concerned about sending her to ICU yet since pt was alert and awake and the BiPap is maintaining her O2 SATs at 93%. I showed the doctor the drink bottles that family were giving her during the days despite her being on IV fluids. I told the oncoming nurse that maybe nephrology can be consulted because her BUN and creatinine are elevated. Oncoming nurse called ICU to evaluate the patient just in case. I left the hospital so late thinking maybe I should have done more? Maybe I should have called RRT? What do you think I should have done differently? It was a busy and horrible night just dealing with pt downgrades, admission and an irate patient. I'm just lost for words and overwhelmed just trying to keep things together.

[Okami_CCRN, BSN, RN]

Based on the information you provided sounds like the patient may have aspirated, which could have been from the soda, dinner, lunch, etc. A CXR would have helped determine etiology of worsening respiratory status (worsening PNA vs. fluid overload). 

Your facility should have a list of criteria that would help you identify the need to call a RRT. Some of that criteria includes tachypnea, increasing oxygen demand etc. A patient who was previously requiring 2-3L of O2 (approx. 28-32% FiO2) who now was placed on BiPAP with 65% FiO2 should require further investigation. With that being said, you notified and periodically updated the provider regarding the patient's condition and response to interventions. When in doubt call a RRT. 

[AndreaH]

Hey there, it sounds like a very stressful shift! From my perspective, I believe you did a great job. As a nurse, your most important job is to keep the patient safe and communicate with the care team. First, give yourself some credit. This patient has multiple complex health conditions, is acutely ill, combative, and their family is hard to work with. First, you did a thorough assessment of the patient. You educated the family on the importance of limiting fluid intake. You listened to the RTs recommendation and communicated with the provider multiple times. You quickly completed orders. 

It's true, at the end of your shift the patient was in bad shape. This is not completely your fault. Nursing is a 24/7 job- the oncoming nurse can pick up where you left off. Of course, there is a lot to learn here. You could have called a RRT or entered an ICU consult or asked another nurse to assess the patient with you. My advice is to write down what you learned and what you may have done differently. Be kind to yourself, you are working hard and doing well!