Did I cause this rapid response?

Ultimately, when a patient wants to go south, I find that they are going to do it no matter what nurse they have. In the beginning as a new grad, it's hard because you might not treat the situation with the same sense of urgency a seasoned RN would. And then you beat yourself up and wonder if you caused it. The reality is usually the patient simply wanted to tank. Even with more experience, I will wonder if I overlooked something or could have done something differently.

Never trust a patient no matter how stable, constantly reassess and follow up, report to the doc if you are concerned even if you know your concerns will be blown off, and document all of it. The more experience you get the better you will be at this and you seem to already have a good foundation.

Nobody causes a rapid response, do not ever be afraid to call one.... that's what they are there for.

LOL, I actually have, when a patient vasovagaled due to an IV insertion. Completely normal, easy IV insertion but pt. was getting a CT and a PET scan which meant fasting and the pt. hated needles. I already had the patient laying down so not much more I could have done to prevent it.

My two cents: You didn't cause this. If someone is admitted with sepsis-all bets are off. Essentially you are playing a game against time and an infection going through someone's system and sometimes sepsis takes a turn for the worse. I would be more interested in his other vital signs (HR/BP/respirations) around the time when you place him on oxygen.

That said...what you could have possibly done is questioned the am 20 units of Lantus. Lantus is far better served being given at night in my mind. Officially they say Lantus doesn't peak. Or I should say doesn't have much of a peak effect. But I've seen it happen many times. And if he got the Lantus at lets say 8 or 9 am...around 4pm is just about right for it to catch up to him. Other question would be if he also is on any oral antidiabetic meds along with the insulin.

In any case, a good learning scenario and at least it was caught and he is in the ICU. You will be a better nurse because of this. :) I would be more worried if you weren't wondering what happened!

A lot of good comments above, I don't have much to add.

1) You survived your (assumed) first RRT! There is a reason Rapid Response Teams exist--to prevent Code Blues. Your patient didn't code, you called a rapid because you recognized the change in patient condition and realized you needed more resources to help the patient. The RRT does just that--it brings you the resources you need in a fast manner. NEVER be scared to call a Rapid because the worst that will happen is the team will be like: "AH, whaa?" and then go back to their day. The best that will happen is you will get your patient the resources the patient needs in a timely fashion.

2) Other posts talked about recognition in change in pt. baseline/increased SOB/need for oxygen. I don't know your facility protocols but in my facility the MD needs to know if oxygen is started. Mostly because oxygen is technically a drug and they're supposed to "order" it. I think of it as a checks and balances act instead--if you felt that the patient condition needed oxygen, that means there is a change in patient condition. You need to communicate that change to the MD which is why you're calling, not necessarily for the actual oxygen order, but to facilitate the communication.

For example, I had a patient receive IM morphine on my last shift by the float nurse while I was busy with a critical patient. I went to assess my patient after the critical patient was stabilized and she was desatting into the 60s. I placed her on a simple mask, ensured she was breathing and awake/alert, and told the MD. Not that I necessarily started oxygen, but that the patient is *very* sensitive to morphine along with her other drugs and we needed to be aware. MD told admitting MD, less morphine was ordered then standard dose and constant pulse ox was ordered for the floor.

3) Insulin is tricky. You have orders to check it q whatever hours, same with vital signs. For example q4 hrs. That is the minimum you need to do vital signs on a patient per orders. However, there is not a maximum number of times you need to do vital signs. You can do them as often as you feel the need. The same goes with BG. If you gave insulin and didn't see the patient eat lunch, you need to think: "what is the peak time of effect of that insulin? What time will that be?" and make a note to check the BG around that time, in addition to physically assessing the patient.

4) Remember that Rome wasn't built in a day. It takes time to learn what you need to know to be an educated nurse. What I still do to this day is ask questions and look stuff up. If I don't know something I will ask, and continue asking, over and over again, until I know enough to educate myself using trusty sources. Start with Sepsis, in this case. Ask your preceptor what your hospital's sepsis protocols are. Then read them and see if you can understand *why* they are in place. Why do we give broad spectrum antibiotics within X hours, why do we give IVF boluses, why do we culture everything, etc. Keep asking, keep reading, keep learning until you feel comfortable with that dx and then move on to the next.

Don't beat yourself up, focus on what you did correctly and take time to acknowledge what steps you'd take next time, instead of what steps you took today. Think to yourself:

-- "Okay, I started oxygen today but I didn't tell the admitting MD. Next time I have a patient I need to start oxygen on, I know I need to either make a note of it to talk to the MD on rounds/page the MD/tell the charge and see if it warrant's a page or if it can wait for rounds"

-- "Okay, today I gave insulin but didn't see the patient eat. Next time I have a patient that seems confused I'm going to encourage the patient to eat and then give insulin (if time permits). If time doesn't permit, I'm going to ask a CNA to help the patient and then tell me how much of the meal they ate. If the CNA says they didn't eat a lot, I know I have to keep a closer eye on the patient and do more frequent accuchecks/FS"

As other's have pointed out, you missed a change in condition that you should have reported to your preceptor (or the physician) and you gave nutritional insulin when the patient was not eating. If the MAR said do not hold if NPO, you did not technically make a med error, but nevertheless any change in mental status should be accompanied by a finger stick. These are things your preceptor should be going over with you, debriefing with you so that you can perform independently at the end of your orientation.

When you receive a patient on the floor you should have a good idea on why they are coming in, the treatments they are getting and why, and what to look for in order to promote stability and improve health. If I had a septic patient, I would be looking for worsening s/s of sepsis, increases in HR, drops in BP, etc. Any new onset chest pain or SOB needs to be investigated. I want to know what's going on with all of my patients. If there's something I don't understand, I try to find out. When you are done with your orientation, you will be the safety net (one of them anyway). You will build a basic knowledge base during your orientation, learn who to ask for help and how you can get answers so that your patients stay safe and improve. Your preceptor is there to help you get these skills. I encourage you to use them as a resource.

I have made mistakes like this you describe in the beginning of my career and it is normal. What's important is you learn from them and don't feel like you have failed, but are motivated to improve and ask questions. It will be okay, you didn't cause this to occur, but moving forward will now know a few more things to look out for.

I'm more concerned about the respiratory status change not being reported. You should have verified the food was eaten, but honestly, stressed and sick diabetics typically run high sugars whether they have eaten or not. When realizing he didn't eat anything you should have checked his sugars more frequently and maybe gotten him to drink something if possible.

But anyway, back to the c/o SOB, that right there was his first sign of deterioration. His second sign was the fact that his SBP dropped from the 150s to 110. Third, he was lethargic before you gave the insulin as he didn't wake for lunch. You didn't cause the rapid to be called. You just missed early signs of deterioration that should have been reported to the provider. You are only 3 weeks in. Where was your preceptor during these changes? You are not expected to recognize all this so early in your career, but you are expected to learn from it. Next time you will be more diligent in recognizing and reporting changes in status.

Don't beat yourself up. We all have to learn. The fallout is im your preceptor not recognizing these changes either to guide you into better actions.

I agree. Please don't quit.

I love that you asked this question and was able to receive answers and rationales. But a big concern is what is going on between you and your preceptor that you couldn't ask her/him. That is what they assign preceptors for, and so even get a small pay raise to be a preceptor. He/She should have taken the opportunity to review this with you just as everyone has done here. I would chalk this up to a teachable moment for both you and her/him.

Keep at it don't give up. If your preceptor is inattentive and hands-off, discuss your concerns with the person over the preceptor program.

In addition to all the other comments/advice, I would add that sepsis lowers bs as well. I can't tell you how many septic patients I have coded in the ICU and when we check the sugars, we see they are as low as 30's. During resuscitition attempts, we give an amp of dextrose. This helps alot! Always check bs when coding any patient

You're not the first to make a mistake. You won't be the last. I was two weeks off orientation when I was given a female patient with "chest pain". ER MD determined it was epigastric, dc'd a nitro drip and sent her upstairs. She arrived to me with 2/10 "stomach pain", telling me she just needed her Nexium. That's all she said to me all night. I gave her the evening meds ordered for her. I gave her the mylanta ordered for her... still, she's having pain and discomfort. I call the house MD... he's gonna do a second round. Meanwhile, my charge nurse is overhearing this and she's like... you know women have other symptoms of chest pain. Right. But, the patient is literally telling me it's just indigestion and all she wants is her nexium, which I did discuss with the house doc. And, I am asking her what I think are all the right questions; when she came in it was after eating, and she said the pain was crushing. Reg flags, but she's telling me the pain is nothing like that now. She's denying everything except just needing her nexium because she usually takes two and only took one today. She has reflex, it's just an acid burn feeling and all this while she is burping a lot of air. Okay. Again, I discuss this all with the house MD. He ordered a GI cocktail. Well, my charge went and did an EKG. ST elevation. At this time the Patient is 9/10 "chest pain" because she was laying down for the EKG. I start subL nitro's, call the house MD to update him, meanwhile my charge is calling a rapid because the EKG says "STEMI" at the top, and does show ST elevation. The patient had shown ST elevation all evening tho, which I was told in report from the ED was from a prior MI 20 years ago. Even the house MD wasn't certain it was "true elevation" and didn't seem concerned about a STEMI. He even called cardiology and consulted with them while all this was happening. The patient went to the ICU that night, and in the AM cardiology did STEMI her.

My first thought is the same as many others; where was your preceptor? I am pretty "fresh" off orientation at my new facility. When I was on orientation I had a couple different preceptors; a couple were like "alright, take the cart.. keep me in loop" and my primary was very "okay, what's going on" "what are you doing now" over my shoulder, and controlling. I loved them both. My primary loosened her reigns on the final couple weeks I was with her, but having the others who allowed me to develop a more team bonding and independence while with them was wonderful. I can't say enough how invaluable your preceptor is and if she isn't, ask for a new one. Ask her everything and anything. If you're unsure, flag her down. If you can't find her, grab another nurse. You're a team. You're all there to help one another. Or, at least you should be.

At my facility the AM coverage for breakfast is given at 630 by night shift. Day shift only gives whatever "set units" the patient may require. Your first meeting that morning with your patient should be your initial assessment. You don't need to listen to their lungs or give them the neuro pop quiz; but just look at them. How are they feeling? How are they breathing? Are they alert? Arousable? in pain? Ask a few questions on how their night was all while you are updating your board. That moment should have been your baseline; how was your patient's breathing right there.

Here's the red flag you missed. You put O2 on a patient who was otherwise on RA. That's a change in condition. That's a "I need my preceptor/another nurse/charge nurse" right now. Typically, you're always going to call your preceptor while you're on orientation. If you can't find her, get the charge RN, and if she's busy, grab another nurse. My Preceptor always carried an extra phone on her so I could call her. The doctor should have been notified. Usually during the day on my unit all the doctors are easily accessible. We have a texting service for if they aren't buzzing around up at the nurses station, which they usually are.

At that point, the insulin doesn't much matter. The patient got their insulin, and they ate their breakfast. As for his BP.. my first question is, okay.. what do they trend. I can't judge a SBP of 150 without knowing the patient, knowing what they run usually. I'd have checked what their BP was over night and the day before to see if this was a "usual" reading. Sometimes there's no data to go on. Evaluate your patient. What was happening or might have happened for the BP to suddenly go up. Pain? Ambulating? The patient just being woken up and now has a cuff crushing their arm? Are they on fluids? Do they have a hx of HTN? If there's nothing; go confirm the reading manually. If it's a one time reading, I give the DR a head's up that their BP is elevated and I am not sure why. I will keep them in touch with the next round of vitals (we're Q4 on our unit).

So, now you rechecked the patient after 30 minutes and increased the O2. Another red flag. Another change in condition. Again, here was a "get my preceptor, another nurse, or charge RN" moment. The patient had deteriorated. He went from being okay on RA, to okay on 1L, and now needed 2L. Additionally, the patient was now "sleepy" and jittery? Why? Does he have anxiety? Did anyone in report pass along he'd been anxious? He was calm in the AM, what suddenly had him jittery? Sure, he's getting a stress test later and that could cause him to be anxious, but Clearly, the patient wasn't fine. Everyone always says they are fine. Being in a hospital, no one is ever fine. Again, the doctor should have been called. On top of that the Patient's SBP dropped to 110. That's a pretty big drop, but again. Why? What is the patient's usual trend? Which bp was outside his usual range? The 110 or the 150. If the patient usually is around the 150's. That drop is a red flag. If the patient's normal BP is in the 110's. Okay, he dropped back down to normal, not so much of a red flag. But, the patient has anxiety? Usually this increases a persons BP doesn't it? There's that red flag again. However, you say this patient is there with r/o sepsis? A dramatic change in BP is a red flag all on it's own, not to mention there's still the other issue with his breathing.

So, now it's lunch time. Always, always ask if a patient enjoyed and ate their lunch prior to giving them the insulin. Don't lump insulin in with other meds if their meal tray hasn't come in yet and assume that because they ate breakfast they will eat lunch. Double back to them if you need to. Insulin is better given late than early in the grans scheme of things. If they didn't eat; call the doctor and ask "Hey, the patient didn't eat their lunch, they are set to get 5 units and 1 for coverage SSI. Do you want me to give this?" Granted, I don't think that 6 units of 'log with no lunch dropped this patient's BS down to 38 from 190. It certainly didn't help. A sudden decrease in appetite is a red flag. The patient ate his breakfast, but now had no interest in his lunch? Again, this is a r/o sepsis patient. Also you never mentioned if you tried to encourage him to eat anything, offered a snack, some juice, anything that would have helped elevate his BS after giving the insulin despite the patient not eating.

So, the day continues. You have other patients... and you keep checking on this patient, as you should. He's still anxious, and becoming increasingly anxious (jittery). Again, this is a r/o Sepsis patient. What's his BP? The last you mention is 11am. And the next is 4pm. That's a 5 hour gap for BP on a patient with r/o Sepsis. Also, what has his temperature been? Were labs drawn that morning? What did they show? And most importantly... what did you do during this time? It wasn't until 4pm your Preceptor noted the patient didn't look good, but not until she was already downstairs for the stress test...? Another question, why the stress test? I don't usually see stress tests on patients who are only r/o sepsis. And like someone else mentioned, why wasn't the patient NPO for a stress test? Maybe a facility thing.

So at this point, the patient is brought back up to the floor, his BS is 35, his SPB is in the 80's. He's a rapid. He was sent to the ICU. Clearly, this patient is septic.

Did you cause the rapid and cause the patient to get admitted to the ICU? No. I think all that happened here was missed flags that maybe, MAYBE, would have prevented a trip to the ICU. I think an issue with this entire "case" is you seem to be chalking the events up to the insulin administration; but really the issue is the change in respiratory status and change in BP you didn't catch. Additionally, you're patient had multiple changes of condition that went unreported to the MD, or your preceptor, or the charge nurse. Remember, this patient is here for r/o sepsis. Signs of sepsis is what you should have been monitoring this patient for. Whatever reason the patient was there before and whether or not he was withdrawing from aside; he was here for r/o sepsis. If he did have something in his system he was withdrawing from, certainly that would have explained his anxiety and the developing jitters, but you still were short handed not to inform the MD.

Now, you're new. You're still connecting dots. And despite nursing school a lot of dots are missing. You need other people to help you connect those dots. So, the first thing you need to do is 1) stop blaming yourself, mistakes were made, we all make them, you missed things but this is on your preceptor as much as it is you; and 2) stop trying to find an excuse for what you missed. Saying "well, last time he was here" seems like you're trying to find a cop-out.

Should you quit? Of course not. You missed things. It should have been expected of you. There's a shared blame here but blame isn't going to fix what happened and beating yourself up over it will just hold you back. If you're worried about the patient's outcome, talk to your unit manage. Just know that you're already a better nurse because of this incident. Look at all you've learned from this incident and reflect on how you've already changed you're practice because of it. I bet you're certainly going to ensure a patient eats their meal before giving insulin, and call the MD if they haven't prior to giving it. You've learned that changes in condition can be very subtle and you're certainly going to call the MD when something appears to change or just feels wrong. You're going to rely more on your preceptor, your charge nurse, and the other nurses around you. You're going to start questioning everything. What's done is done. Learn, and move on.

It sounds to me like you feel responsible for the deterioration because his blood sugar happened to drop when you gave the lunchtime insulin for food he didn't eat. I think what really happened here is you had a patient who was developing sepsis, which caused the sudden drop in blood glucose and blood pressure. As a new nurse with a beginner's understanding of sepsis, you shouldn't be too hard on yourself. You did not cause this, and it is an experience to learn from.

My two cents: You didn't cause this. If someone is admitted with sepsis-all bets are off. Essentially you are playing a game against time and an infection going through someone's system and sometimes sepsis takes a turn for the worse. I would be more interested in his other vital signs (HR/BP/respirations) around the time when you place him on oxygen.

That said...what you could have possibly done is questioned the am 20 units of Lantus. Lantus is far better served being given at night in my mind. Officially they say Lantus doesn't peak. Or I should say doesn't have much of a peak effect. But I've seen it happen many times. And if he got the Lantus at lets say 8 or 9 am...around 4pm is just about right for it to catch up to him. Other question would be if he also is on any oral antidiabetic meds along with the insulin.

In any case, a good learning scenario and at least it was caught and he is in the ICU. You will be a better nurse because of this. :) I would be more worried if you weren't wondering what happened!

My son is T1D and we give his lantus in the morning. SO depends on the doctor for administration of Lantus.

First, I have been a nurse for a long time, but I can still remember my sense of fear and upset when, as a new nurse, I thought I did something wrong that hurt a patient. Don't quit. If every new nurse who experienced a similar scenario quit, we wouldn't have any nurses. This is the sort of thing most nurses experience in their first year, so you are not alone. Besides, the patient's problems caused the RR, not you. You might have been able to prevent some of the diabetic problems, but that respiratory distress is nothing you are responsible for.

As other respondents have said, take this as a learning experience. I think some key learning items here are: Feeling shaky and/or very anxious are both key signs of hypoglycemia in a diabetic. Now you know to run a glucose test if you ever see either shakiness or anxious behavior in a diabetic again again. Please "over-use" rather than under-use that glucometer. Better to know what the blood sugar is anytime you observe any change in a diabetic patient than to guess. You also learned more about dealing with respiratory symptoms in a patient. If I have to turn up oxygen for a patient twice on the same shift, I'm going to report that. Now you will too.

The deal here is that you are an awesome new nurse! I'm glad you are out there, you obviously care, and you have a boatload of great nursing knowledge. Please don't beat yourself up. This kind of experience, combined with the fact you are thinking about it and learning from it, is what will make you an excellent and experienced nurse in a little while. Hang in there!