Do I have to go back tonight?

5 Should have been in bed an hour ago & I'm just getting home because of a pt who was convinced no one wanted to help her, spent all night in & out of her room, hoping the other 5 pts I had were ok (they were). Then at 0330, she feels "funny" but only complains that it feels like fluid is building up in her legs. O2 sats 92% & since we had just log rolled & boosted her in bed (using trendelenberg's - she's 300+lb), I explained her sats may have dropped briefly. BP a bit high but she denies chest pain; lungs clear. She progressively gets more anxious (which she has been all shift & the previous shift as well), & demands to see her dr. Sats dip into upper 80's briefly, but she is starting to panic & basically hyperventilate because we "aren't doing anything."

Charge RN & then supervisor are contacted to come in, but pt is adamant that we aren't doctors & we're gonna let her die (only complaint still is that her legs are swelling up, but my observation is that they are no different than the start of my shift or the previous night when I cared for her). Call doc who orders lasix & ativan (whoops - allergy to diazepam & we don't give). Pt still isn't satisfied because doc didn't personally come in & see her & how does he know how she's doing? Nevermind the fact that he would be making rounds within about 2 hours. (She could die by then!)

Long story short, I feel like I spent at least 50% of the shift in her room trying to calm her down along with everyone else working the floor. And of course after the lasix, she was on the bedpan q30m & it just about takes all four of the staff on the floor to successfully place that due to her size.

Not trying to make light of what she was feeling & there were a few tests ordered to make sure she wasn't having an underlying problem that wasn't giving us the usual symptoms. I'm just tired & dread going back. Maybe I'll get to float tonight!

On a side note, it was kind of comical when the bipolar schizophrenic pt across the hall decided all the commotion was talk about him & came out in the hallway to start cussing at people who weren't there. Then, the lady thought someone was talking about her!
sats dropping to the 80s is significant, especially in the setting of increasing subjective feelings of anxiety. a sat of 85% is not the same as a pao2 of 85, it's more like a pao2 in the 50s, and this would be very bad. it would certainly be enough to engender a feeling of panic. generally speaking, whenever a patient thinks she's gonna die (and hasn't been saying this for years), it's a warning. most of us have seen it more than once.i wouldn't be surprised if you didn't observe a visible change in her legs if she's 300#, so that's meaningless. somebody like this is a classic for dvt and pe, which would give exactly this presentation. not all dvts originate in legs, so no swelling or pain in legs isn't a rule-out sign there, and of course pe can be severe with no change at all in breath sounds, since it's a vascular problem, not an alveolar or bronchial one.when you go in tonight, i hope you find her better. let us know what the work-up shows.

A chest x-ray and ABG needed to be done. If they are WNL, consult with pharmacy to obtain an appropriate anti-anxiety agent.No way would I spend half my shift on that... the doctor needs to know ... the patient requests examination now, not at his/her convenience.

I would have called the Rapid Response team if you have one. They will get the MD on the line and may even transfer pt to higher acuity unit or begin interventions.

Isn't there a house MD to come examine the patient???I am surprised the appropriate testing like a CXR and an ABG wasn't done. And the lasix, if they were so sure it was anxiety, why the lasix? Curious, what was this patients admitting diagnosis?

Obese + female + anxiety does not always = malingering. Once in a while, something really IS wrong, and it should be assumed as such until proven otherwise. Just saying.

I remember this guy in his 40's who was an HD patient who had other issues and had a bowel resection of some sort I believe and was on my unit. He took very high doses of pain meds at home and developed vascular steal syndrome from his HD access. He was in PAIN. he was wide awake on a fentanyl drip. He was also one of those demanding patients who liked to be babied. He started going a little cuckoo, hallucinating, all of that stud. Everyone including the MD's thought it was the effects of the opiates and ICU psychosis. Well......After everyone was pretty much ignoring him and symptoms, a nurse who didn;t know the patient before eland felt something wasn't right, his BP dropped and needed to be intubated. OOOPPPSSSS, this whole time he was hallucinating it was because his bowel perforated and he was septic and severe metabolic acidosis. He ended up on multiple drips knocking on deaths door, but luckily he actually came out alive and well.You never know.

Did anyone read the post? She was anxious at baseline. Briefly dipped into the 80s (not staying there, no progressive decrease in O2 sats). No chest discomfort. The doctor was called. Orders were received.there were a few tests ordered to make sure she wasn't having an underlying problem that wasn't giving us the usual symptoms.

Quote from VivaLasViejasObese + female + anxiety does not always = malingering. Once in a while, something really IS wrong, and it should be assumed as such until proven otherwise. Just saying.

my concern is for this poor pt. having to go through this ordeal

this possibly appears to be a LTC facility. sats in the 80's is not good for anyone. one of the worst feelings in the world is when you have trouble with a patient/resident and the next shift has to send them out and they are admitted. kind of makes you feel you didnt do as thorough of a job as you could have. advice- when in doubt, get the order to send them out.

I would have asked for an order for a Foley

No, I totally understand that a feeling of panic could be the only symptom to an underlying problem. That is part of the reason why we were all with her so much, why I called in my charge & then supervisor when she was becoming progressively anxious; PE & MI were uppermost in my thoughts; she was POD2 for a knee revision. I mentioned calling RR but both charge & supervisor did not feel it necessary & being very new, I pretty much look to them for direction when I have concerns with a patient. Sats did not stay in the 80's, they dropped to 88 for about a minute & then back up again to her baseline which is about 92. She had an inhaler prn which she refused. Doc was called within about 20-30 minutes from the onset, given her VS/symptoms & ordered the lasix. She was mad because we didn't get him to come in & see her right then. He came in near to shift change & I was in the room when he assessed; lungs still clear & he told her he would order some tests. I know he ordered a cardiac panel, but not sure if x-ray was ordered. I spoke to the family who also let me know that she does have anxiety issues & gets worked up easily. So, I don't know.....yes, it was always there in my mind that something serious could be going on but the general agreement with everyone I reported to was that it was not. There is so much more that I could say about her general attitude even before this happened & how she was pretty much convinced we couldn't help her & weren't trying. Just hoping that all testing came back ok & I'll post again later! Thanks for the input!