Hey guys, so I had a patient recently admitted to my floor. She was a 80 year old female that was hospitalized after having multiple falls at home. She fractured several of her ribs and sustained a neck injury (had a Miami-J placed afterward) secondary to her fall. They diagnosed her with compressive myelopathy and she was sent up to my unit for further care. So initially when she was admitted, she was getting her medication PO in applesauce despite being diagnosed with dysphagia which was believed to be caused by neck swelling from the neck injury. She was getting TPN as well. When I did my initial assessment, I noticed the patient had a cough and was having difficulty expectorating. Her O2 saturation was around 91-92 on room air (no significant respiratory history). I contacted the doctor immediately as I did not feel comfortable giving her PO medications. She came to the floor and placed a Dobhoff and then subsequently had a chest x-ray ordered which confirmed placement of the tube. Several hours later, the patient's husband came in and voiced his concerns about how the patient looked. She had a noticeably grayish tinge to her skin, was lethargic, and exhibiting confused behavior (which I was told was not new since her admission). The patient was receiving Dilaudid which her husband said had caused slight confusion for her during a previous hospitalization. I took a set of vital signs which were all normal except for a low-grade temperature. I truly just did not like how this patient looked and let the doctor know. At the end of the shift, I went in the room and noticed the Dobhoff had migrated out significantly due to the patient tugging at it. I let the doctor know and she came up to the unit and pushed it back in. I asked her if she wanted to do another chest x-ray and she said "No it should be fine." Now THIS is what is eating away at me. I know confirmation is imperative after placement of dobhoff of nasogastric tubes and let the oncoming staff know this. Two nights later, the patient pulled out the dobhoff completely and a nasogastric tube was placed. The nurse taking care of the patient said she was talking to her, left the room, came back in and the patient coded and was unable to be resuscitated (had pulseless electrical activity). Mind you, her vitals had all been stable but she had been newly placed on O2. I just cannot stop thinking about this situation and it truly is bothering me. Should I have done more? Did the Doctor pushing the Dobhoff back in cause a tension pneumothorax or would the code have happened sooner? I also wonder if the patient had aspirated before the Dobhoff was placed as the nurses had been giving her medications PO. Her last CBC indicated a big spike in her WBC but she did receive a 1x dose of Dexamethasone. Did she have aspiration pneumonia? The wheels in my mind keep going. Sorry for the lengthy post but I'm trying to wrap my head around exactly what happened. Opinions would be greatly appreciated!
Document the heck out of the situation as you communicated with the doctor, what they said back to you, what you observed that they did, and how patient responded all the way through your shift. It covers your "assets" should your own actions be questions later.
This was an old lady with history of multiple falls. It's very possible she had been declining for days or weeks at home due to natural causes. I see this *all* the time in my area of nursing. Usually patient starts to aspirate at home due to natural decline/early dying process (which can take weeks) and they also start to fall a lot. I normally see them once they break a hip and family decides not to do any further treatments due to age/risks. It's very possible this patient already had aspiration issues, pneumonia, and weakness and this latest event was just the last step to her natural dying process.
As a nurse, of course, we want to not cause further interventions, but neither should we over-analyze things as long as you did your part correctly (including notifying the doctor, which you did, and double-checking policy on that type of tube and other interventions).
Hoosier_RN, MSN
3,968 Posts
Exactly what I was thinking (aspiration pneumo) as i read the OP