Too little too late

1 Hi everyone! I am in need of some encouragement here. I've only been a nurse for about a year and so I feel stupid like I missed something and can't forgive myself. On my first night working this week, I had an older adult female (patient A) 61y.o. that was assigned to me. The day shift nurse told me that the patient was somewhat confused at times (alert to person and place most of the time but couldn't tell you the date), and that she could walk to the bedside commode with assistance, but that she was a big lady and really needed persuading to get her out of bed instead of using the bedpan like she prefers. She had a colon resection the day before and did have SCDs and TEDs on. Upon entering the room at the beginning of the night, the lady demanded (not asked) that she have some Ativan because she was feeling very anxious, so, after assisted her up to the BSC and back to bed, I gave her 1mg to help her anxiety. Anyways, as the night progressed, the lady tossed and turned in bed, and tried to get up a few times unassisted so I put her bed alarm on and continued to check on her frequently throughout the night (at least one to two times an hour). I checked her vitals around 0400 and I had a little difficulty obtaining her bp, but that's no surprise because our vital machines malfunction frequently (old pieces of crap), so I got her vitals manually and didn't note anything unusual for her. I gave her bath around 0600, and checked on her again around 0650 She made it fine until the end of my shift and after I had passed off report at 0700 and got ready to leave, a nurse tech went to go check on her and do the morning vitals and found patient A unresponsive and blue. After calling a code, we tried to resuscitate her and managed to long enough to get her down to ICU where they put her on a vent. When they did a CT scan they found that she is severely brain damaged due to hypoxia and her family decided to remove life support. Now, it's been three days since this event and I keep replaying events in my mind over and over, trying to figure out what I missed. I had just thought that the lady's agitation was related to possible sun-downers or that she had reacted strangely to the Ativan. Now maybe I think she was in distress and I didn't even notice. I feel so stupid and inadequate. The doctors said that they think that she may have had a PE and said that there was not much I would have been able to do anyways, but I still feel terrible. The family came up to our floor and thanked us for trying our hardest to save her. I just keep thinking wouldh've/couldh've/shouldh've and it's hard for me to let it go. Now I'm scared to go back to work for fear that I'll miss something again.
Just some thoughts: (without knowing much of the specific situation)The confusion, new onset or baseline-could signal hypoxia or a TIA/stroke. But you stated that the VS were normal for her, but did not give specifics. Also, bathing can place a high demand on the CV/pulm system especially in a post-op/critical patient. In the ICU you can watch a pt's oxygen sats/SvO2 drop during a bath.Ultimately, the death is not your fault, in my opinion. People live and they die. I think the bigger tragedy would be the family not removing the life support and allowing her body to suffer the futile long-term care.

Meg, she was not in any cardiovascular or respiratory distress when you assessed her before and after so you did everything right. My question is, when you bathe her did she expressed that something didn't feel right or her behavior seemed unusual besides demanding the Ativan? Nobody is perfect and nursing is a source of constant learning. Like you, I beat myself up whenever I think about the should'ves. That means that you do have great compassion for your patients and you take your job as a nurse seriously. Most importantly, you care.

PE's happen, fast and furious. I barely survived mine; there was nothing you could have done. Give your heart enough time to catch up to what your head knows. The fact that you were with her only a hour before, providing care, and then again at 0650 means you would have seen the distress if it was there: I was gasping, in sudden severe pain, and complaining of not being able to see suddenly.Take heart

Quote from JBuddPE's happen, fast and furious. I barely survived mine; there was nothing you could have done. Give your heart enough time to catch up to what your head knows. The fact that you were with her only a hour before, providing care, and then again at 0650 means you would have seen the distress if it was there: I was gasping, in sudden severe pain, and complaining of not being able to see suddenly.Take heart

She was high risk for surgery anyway and the abdominal surgery made her a higher risk for bloot clots. Hind sight is ALWAYS 20/20. When reading your story PE was my immediate thought. Obesity, restlessness, anxiety.....a sense of impending doom....a restless they can't explain is the body's way of expressing that something's not right( some researchers call it Irukandji Syndrome as it causes the same physiological responses caused by a jellyfish bite) You assessed her and Her vitals were stable she had no complaints of SOB or pain....PE's are swift and deadly. I have had surgical patients getting dressed to go home and drop dead from massive PE.Patients just sometimes die dispite our best efforts and it's ok to feel bad, but I don't think you "missed" anything. The next time a patient acts like that it may alert you but it still may not change the outcome. Learn from this experience and forgive yourself for not being psychic and pat yourself on the back for being a good nurse and giving her good patient care.Now go back to work and be a nurse.....

I had an experience similar to yours when i was a new grad. I had built a rapport with this patient. Vague symptoms that started with having an episode of syncope at the doctors office was the reason she came to us. Though she wasnt a surgical patient, she too felt "anxious" but it was more of not being able to sleep and wanting something for it. Checked on her frequently through the night. Vitals at baseline for her. Next morning she is less responsive for day shift. Turns out she had a massive stroke. Then proceeded to have multiple strokes and passed. Doc couldnt figure out why. I was shaken up completely. What did i miss? Should i have awaken her before 6 o'clock report? As previous posts state, unfortutenly some things are out of our control. The most important lessen i have learned as a nurse is I am only human just like everyone else. On to the next one...

It sounds to me like you gave her exceptional care. She was just unlucky, but lucky she had someone who cared so well for her on her last night.

OMG! The exact same thing happened to me on Thursday. Except everything happened around 6 am before I got there for day shift. Well when I got there her vitals were stable and she was eating breakfast. I even called her MD to let him know what was going on! I went back later and she was cold!!! I called a code and we never got her back. I keep re-playing in my head what could I have done differently. This all happened within 30 minutes. Oh and I'm also a brand new nurse (2 months) so I REALLY know how you feel. As long as we do what we are supposed to do, that's all we can do.

The first code I witnessed was that of a gentleman shaving in his bathroom for preparation for discharge the next day. He threw a clot-->PE and dropped on the spot.No warnings, just died on the spot.Mayor Daley I of Chicago had just left his Drs office, getting a clean bill of health, and had a massive heart attack in the lobby and died.Sometimes people will die, sometimes without warning, in spite of our best efforts.

Learn what you can from it and move on.A lot of people believe, if it's your time to go, you're going to go, if it's not your time, you're not going.It was her time.

Never 'shoulda' on yourself. My first thought was a PE, but even if you had known earlier, there probably was not going to be a lot of hope. When it's your time to go.....

Don't beat yourself up. I'm assuming that here SpO2 was fine, which is one of the first things you check with increased confusion. It sounds like you provided excellent care. In the ICU, patients do die suddenly of PE's, often with few s/s... their heart, SpO2, and respirations are constantly monitored and they just suddenly code, and many times there is nothing that can be done. Take away from this the importance of DVT prophylaxis, the heparin, lovenox, SCD's, and getting patients out of bed, into a chair, ambulating them. It's all theoretical and just another task until you witness the worse case scenario.