Was this my fault???... just need to let it out

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Specializes in PCU/Telemetry.

Something that happened at work the other day has really been bothering me and I need to get it off my chest... I was taking care of a patient who came in with pneumonia/exacerbation of COPD and CHF. Elderly man, in his early 80's, doing pretty well in my opinion (no SOB, O2 sats were good, BP good, lungs had a few wheezes which cleared with neb treatments). I took care of this guy three nights in a row and he did fine. He had Ambien ordered for sleep which I gave him as ordered all three nights with no problem. Well, apparently he told his attending doc he was having problems relaxing and was anxious, so the doc ordered for him to have Xanax as well PRN. I administered the Ambien at bedtime (10 pm) as usual and maybe about 4 hours later he awoke and c/o anxiety and asked for the Xanax (about 2 am). All was well until an hour later when the guy (who had absolutely no confusion prior to the Xanax) proceeded to strip off his gown, his O2, and his tele leads and prance down the hall. So we dressed him, put him back in bed (bed alarm in place now LOL) and checked an O2 sat just to be safe (93% which was his baseline sat when off of O2- came up to 99% after a few minutes). He slept a few hours and then I found him naked and off tele again. Redressed him and made a mental note that I would never be giving him Xanax again. Well about this time, the doc came in (not his attending, but the doc covering for the weekend). Before he went in to see the pt, I gave him a rundown of the night's events (xanax, pts new onset confusion, etc.).... Doc went in and assessed pt, came out and didnt seem concerned about his status (other than the fact that he was bleeding, apparently had just removed his own IV), ordered to d/c the Xanax and just some routine labs and such for the next day. Well I started a new site on the guy, made sure his vitals were good, HOB was up, bed alarm on, etc. Well I come back the next night, and he has been transferred to ICU!!! So the nurse I had passed him on to says "Oh yeah, that guy you gave me was in respiratory failure, we sent him to ICU. You know, you never should have given him Ambien and Xanax, what were you thinking?" I feel so bad, was it my fault?? And why didnt I catch it? O2 sat was good, respirations were fine.... I just feel so incompetent...

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Specializes in cardiac/critical care/ informatics.

I don't think that you did anything wrong. Maybe it could have been the combo, but it was given 4 hours apart and he was awake. You did all the right things I wouldn't beat my self up over. I do have a question about the patient being on o2 when his ra sat was 93% and he has copd. That could have been the culprit, his co2 went up -confusion- then resp failure. Just a thought.

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Specializes in PCU/Telemetry.

That is a good point, but he'd been on O2 for days... and CO2 had been fine, could that happen suddenly after almost a week at same O2 setting?

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I personally don't think you did anything wrong. The ambien and xanax were given four hours apart so I don't think the medication was the cause esp. after you stated that his sats have been running within normal range the whole night. I think his respiratory failure was contributed to something else, don't blame yourself. I believe the other nurse was wrong for judging your decision like that, nursing is a forever learning experience,and no one is perfect.

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Specializes in Cardiac Telemetry, ED.

I would have done the same thing.

The respiratory failure could have been because of the pneumonia or the heart failure, or the combination of all of his illnesses. Sounds like he was compensating pretty well at first, but compensatory mechanisms fail after a time. CO2 narcosis happens a lot faster than a week. You'd have known he was a CO2 retainer a lot sooner, I think, if that were the case. I don't think you did anything wrong.

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well not really ur fault there..the DOCTOR ordered for those meds to be administered...but i think its contraindicated with a pre existing resp. depression which could be present in a pt with COPD and pneumonia...if ur pt was doing good during ur shift, it cud have happened during the other nurses shift..check the stats on the chart and review it again to see where u went wrong (probably) or the other nurse.. but dont feel bad about urself cuz as long as u know u havent done anything wrong, then, u probably havent..the respiratory depressiong could have been a result of the CHF or high O2 sat... ( u know the CO2-O2 reflex)... just thinking :thnkg:

xviii-xxv:nurse:

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...or ur pt had an AMBIEN overdose....???

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Specializes in Rodeo Nursing (Neuro).

It doesn't sound to me like you did anything wrong. Paradoxical agitation under benzos is not terribly uncommon in elderly patients. I'd be more worried about giving O2 with that history, but if he was doing well on it (sats and respers WNL) I would tend to think that a patient with COPD, CHF, and pneumonia is just a real prime candidate for respiratory distress.

Just checked my drug guide, and don't find respiratory depression listed as an adverse reaction to Ambien or Xanax. We give them a lot on my unit, and I've never seen it, either. CNS depression, of course, but I'd think it would have to get pretty severe to affect the brainstem. And, really, with those sats, I wouldn't think the reported anxiety would be an early sign of hypoxia. A blood gas might have shown that he was compensating, but he wasn't hypoxic when you had him.

I think he went bad in spite of your care, not because of it.

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