What could've been done

allnurses Guide · Jan 6, 2017

What else could you have done? Not a whole lot, really.

You seem to have a very keen sixth sense about your patients,

and knowing when something is wrong, or about to go wrong.

That is a wonderful thing to have; always pay attention to it

and carefully assess and document, when you are sensing that

something is wrong.

One thing you could have done, if you didn't, was just alert

the oncoming nurse, that you feel that something is wrong

but can't pinpoint what it is. Alert them that the patient

needs to be watched more carefully.

Curious, what was causing the patient to de-sat all night?

RNattie · Jan 6, 2017

I'm not quite sure what was making her desat. She is an obese patient so the theory is that her weight was obstructing o2 flow.

allnurses Guide · Jan 6, 2017

Ah. Interesting. Well anyway, like I said, there really wasn't anything

you could do that you didn't already do. And like you said, there really

wasn't anything concrete to report to the doctor, so... :)

chare · Jan 6, 2017

If she was obese obstructive sleep apnea is a likely consideration. Did she have other nights with desaturation events? If so, they might consider a sleep study.

Regarding contacting the physician. If it is a patient that I know we'll, and I think something is going on, I never hesitate to contact the physician. Even in the absence of any adverse findings on assessment.

A&OxNone, MSN, RN · Jan 6, 2017

After being a nurse for almost 7 years, I've decided this - sometimes your senses go off that something isn't right, but your assessment is fine. Then all you need is TIME. Eventually, there will be more signs and be able to point you in the right direction.

I'm a pediatric nurse, so my patients can't usually tell me what they need, but sometimes I'll notice something that isn't explained yet - like they are a little more tachycardic than the rest of the day. They seem fine, so do they need to poop, do they need to vomit, are they in pain, are they getting a fever, are they getting dehydrated? Time will give you more clues about what it is. So I feel strongly that nothing could've been done, she just needed time to do what she was going to do. Hope this helps and makes you feel better.

KatieMI, BSN, MSN, RN · Jan 6, 2017

There are not many things you can do in such situations but here are a few I like:

- VSs before and right after ambulating the patient and reaction on exercise with SaO2 in process (providing you know the baseline)

- same 1 hour after a dose of opioid pain med (if it is indicated and, again, if you know baseline)

- changes 1 hour after dose of B- blocker, as above. Slight tachy/not decreasing BP which is not corrected by these drugs commonly tells something.

If reactions become more exaggerated, even if VSs still within baseline, there are reasons to watch for more. Say, if patient is normally SaO2 97-99 on 2 L NC and drops to 95% while walking with quick recovery but now drop in to 92% and took 15 min to come back with RR not returning to baseline in 20 min, it means that something is wrong.

- for patients "normally" SaO2 at low 90th, add O2 to max by device (6 L NC, etc) and watch. Lack of changes in SaO2 in 15 min or minimal increase almost always says something

- VSs q1 between 4 and 6 PM on days, between 3 and 5 AM on nights, with SaO2 and blood glucose. These are times of "physiologic max and min" and all new findings become more evident at these hours

- real good ol' school head to toe. Palpation, percussion, etc. You need time, goid stetoscope and good technique for doing that

- and, finally, it is totally ok to tell incoming shift that you do not know why, but the guy just doesn't smell right to you. Or call and tell doctor the same if there is trust between you and him/her.

Trust yourself and your guts. They can lie, but not that often.

P.S. "weight compressing airways" is basically OSA, which doesn't happen acutely. Unclear, vague changes in obese hospitalized patient with slight tendency toward respiratory altercations are most commonly either atelectasis (#1), small branch PE or HAP.

Sour Lemon · Jan 6, 2017

I had one that kept de-sating briefly all night, but her pulse increased at the same time. She was fine, otherwise. I wasn't sure what to think of it, but I put her on a continuous pulse-ox in an attempt to figure it out (or at least monitor it). She wasn't on telemetry.

My patient eventually had a CT of the chest and bilateral pulmonary emboli were discovered.

Guest219794 · Jan 7, 2017

I'm a new nurse that recently faced a situation I don't think I handled well. I would appreciate any advise as to how I can best handle similar situations in the future.
A patient was admitted to my unit for over two weeks with respiratory issues. I had her every shift I worked during those two weeks so I got to know her well. Two days before her discharge, something seemed off about her. I repeatedly assessed her throughout my shift. Her vitals remained within normal limits and she continued to read normal sinus rhythm. Her skin color was normal and warm to the touch. Capillary refills occurred in less than 3 seconds. She was alert and oriented times three, same as always. She verbalized that she felt fine and couldn't wait to go home. Still, something felt off about her. I wanted to tell the doctor but knew he wouldn't do much since my assessment did not reveal anything out of the ordinary.
When I came back the following night, the nurse I handed her off to told me the patient constantly desatted during her shift. The patient is stable now. However, I can't help but wonder if I could've done something more for the patient since I knew something felt off about her. In such a situation, what else could I have done?

You did nothing wrong.

What could you have done? You could have asked the doc to asses the pt, and explained that something just seemed off. He/she could have blown you off, or could have done an assessment and formed an impression.

As an ER nurse, I work closely with my docs. I work in an environment in which I can say "I have some concerns about room 7. I can't really put my finger on it, but something seems off." They can do what they want with the information. I suspect that at minimum, they are more attentive in their exam, and look beyond the obvious.

This strategy might not work all over.

CalArmy · Jan 7, 2017

I agree sometimes you just have to wait. You are developing your nurse spider senses.