That nagging feeling...

amoLucia · Apr 25, 2015

Many years ago one of my pts was a young gal I knew as a coworker from another job. She was now hospitalized on my unit with a serious diagnosis. She was an 'angry young pt' with an attitude and poor lifestyle behavior issues and was 'quite animated'. But not that nite!

I knew her and she just wasn't right. Nothing specific - just drowsy and not really talking, denied any problems. VS and other assessments were unremarkable. I knew she wasn't right but had no clue what was wrong. I struggled to get her evaluated for the unit - to the point where I wheedled the house doc to 'just believe me' in frustration. Well, he did and I got her out just at the end of my shift.

When I came in the next nite, I learned she coded 2 hours later in the unit and died.

I have a motto - 'when in doubt, err on the safe side'. I did what I needed to do.

dudette10, MSN, RN · Apr 25, 2015

Many years ago one of my pts was a young gal I knew as a coworker from another job. She was now hospitalized on my unit with a serious diagnosis. She was an 'angry young pt' with an attitude and poor lifestyle behavior issues and was 'quite animated'. But not that nite!
I knew her and she just wasn't right. Nothing specific - just drowsy and not really talking, denied any problems. VS and other assessments were unremarkable. I knew she wasn't right but had no clue what was wrong. I struggled to get her evaluated for the unit - to the point where I wheedled the house doc to 'just believe me' in frustration. Well, he did and I got her out just at the end of my shift.
When I came in the next nite, I learned she coded 2 hours later in the unit and died.
I have a motto - 'when in doubt, err on the safe side'. I did what I needed to do.

That's the kind of story I'm talking about! Thanks for your contribution.

Did you ever find out what was wrong that caused her to code?

amoLucia · Apr 25, 2015

Yes, I do. But HIPAA is around even though this occurred some 35 years ago. I hadn't thought of her for a long time - I even remember her name and how I first knew her history. Some pts you do NOT forget. She was only 23 y/o - younger than me.

You'll find that as the longer you practice, you'll run into more of these type of situations. You have to believe in your own ESP warning system.

Home Health Columnist / Guide · Apr 25, 2015

Thirty yrs ago was LPN in Senior yr BSN progam, only nurse on 14 bed Respiratory telemetry unit on night shift -no aide. Had COPD patient with terrible gases all night, RT up numerous times. Only new intern in to see patient. In those days, operators had to have permission of Nrsg Supervisor to contact attendings --Sup stated "intern has to learn how to manage patient". Called ER doc at 5AM and told her if she didn't come up, patient would die. Doc saw patient, told to give IV Solumedrol, started another neb TX and doc left room. Upon me leaving room to get med, patient said "I'm just so tired, laying down to get some rest" -- ran to med cart as nagging thought about that statement. Upon walking back in room 1 minute later, patient not breathing, code called + transferred to CCU, died 2 day later. I had documented hourly notes: assessment, intern/RT calls, nursing supervisor refusing to call attending.

Attending was pissed--Pulmonologist in charge of unit gave me his home phone number which I taped to back of narcotic cart for future use; Doctor reassured me I did all I could.

---

Same unit, several years latter had another elderly patient that I fretted about as just didn't have same demeanor as previous admit, quiet + passive. Labs Chem 7 and CBC done = normal. Told intern thought patient was dying "labs normal" he stated. Told him over past 5 yrs, had seen similar patients die with normal labs. 2 hrs later coded and died: proof you can have normal labs and still die.

Emergent, RN · Apr 25, 2015

I had a pt who appeared stable, mild SOB, stated "I think I'm gonna die".I called the doc, got pt transferred to ICU, he coded as soon as I returned to floor.

Always take seriously a pt who says he's going to die.

BrandonLPN, LPN · Apr 25, 2015

In LTC it can get to the point where staff is able to pick up on extremely subtle behavior changes that indicate UTIs or even sepsis long before any "real" changes in LOC or vitals present. We just get to know them that well. Whether or not someone is A&OX3 becomes meaningless when dealing with severe dementia. And I have seen many elderly residents have positive blood cultures without any appreciable change in VS, or any observable clinical symptoms. "They aren't acting right" is almost very literally all we are able to tell the doctor, and if the doctor is smart, that will be enough for him to order a battery of tests to find out what's going on.

Just as a good nurse listens closely when a CNA tells her that a resident "just seems off", so a good physician should listen closely when a nurse tells him something similar.

Beverage · Apr 25, 2015

Last week I was on day 2 with a POD14 CABG, slow to progress. BUN 2.09, K+5.5, WBC 15 all trending up. Had a PICC extravasation 3 days prior which was d/c'd. LS Clear, no chest tubes, just pacer wires. BP 120's/70's, SB 55-59, 94% on 4L NC. Bipap at bedside for NOC and PRN. I held her AM dose of Coreg, amiodarone and digoxin. Pt had been chronic complainer, moans, pulls off 02, on the call light a lot previous day requesting coffee, jello, bed pan. 10:00 she's being noisy so I check to make sure her NC is in place. It wasn't and she had pulled off her gown and was incontinent. She tells me "I'm going to die". Recheck VS, BP is good, HR is 40's and Sats 84%RA. Replaced NC and cleaned her up, linen change and paged MD to update. Sats remained in the 80's so I put her on the Bipap with improvement to 94% on 40% 02. MD called back with orders to transfer to ICU. There were no beds so I called a RATT which will get the pt a "code" bed in ICU. My thoughts are she was going septic from the PICC issue. I keep wondering if she recovered. I hate it when a pt tells me they're going to die.

calivianya, BSN, RN · Apr 25, 2015

I had this particular patient multiple times - she was a frequent flyer. Another nurse had her that night. I stopped by the room to say hello and she stated she wasn't feeling right and was extremely anxious. Hx of anxiety but I had never seen her worked up like that. It was unusual behavior for her and both myself and her nurse were scratching our heads over it, but labs were normal (for her), we had PRNs ordered for just about everything imaginable, she was already in ICU, she was DNR/DNI, already on tele, so... nothing really to call a physician about that we could think of. ICU nurses can definitely smell blood in the water; the entire unit kept peeping in the room to look at her.

I was helping to slide her up in the bed when she shot into the 140s/150s (narrow complex, not VT) and freaked out even further, so we finally had an excuse to page. There were four of us in the room by this point, so her main nurse was on the phone paging the physician, another was calling the family, and myself and one other were hovering around her bed. I was trying to get her to relax because she had a death grip on my arm and was looking me dead in the eyes telling me she was scared when she stopped speaking, her pupils dilated, and she went pulseless. The nurse on the phone with the POA immediately told them she had lost her pulse. We ended up doing a few rounds of compressions on her per their request but it didn't get us anywhere.

I don't know if she threw a massive PE, had a massive stroke/MI, or what. The family vetoed an autopsy so we never got to find out. She had a pretty extensive history. I would have liked to know because it seemed like it happened so fast. I remember thinking about that "feeling of impending doom" my instructors talked about in nursing school. She definitely had that feeling plastered all over her face.

amoLucia · Apr 25, 2015

I had a pt who appeared stable, mild SOB, stated "I think I'm gonna die".I called the doc, got pt transferred to ICU, he coded as soon as I returned to floor.
Always take seriously a pt who says he's going to die.

Yes!

I've related this episode before but one of my elderly CCU ladies had been stable for her stay in the unit. One night she tells me "now time to call Son in Boston". All VS assessments were stable and she had nothing special to report. But her quiet, calm, serious seriousness made the hair on my neck stand up on edge.

If somebody gives you that kind of message, RUN! DO NOT WALK to the nearest phone!!! I called Son in Boston - he would drive down immed. I called family and Doc.

Son in Boston got to hosp about 6 - 8 hours later. Visited Mom just before she coded and died.

And as some one else commented - always listen to your CNAs (or other cowowrker)! Even if it's only minutes after your last check. They get the same feelings too.

Altra, BSN, RN · Apr 25, 2015

... you can have normal labs and still die.

How true this is.

macawake, MSN · Apr 25, 2015

Always trust that nagging feeling.

I believe it's a mix of instinct, experience and subtle/intangible signs. It has never steered me wrong.