In nursing school, we were taught that most of
the time, good nurses know when something is wrong with their patients before
it reaches the point of serious damage. We learned it is important to be
advocates for patients that we know are not doing well, even when the doctors
do not agree with our assessments. However, there are many times when
there are no warning signs when a patient starts to decline. And it is
these declines that have the potential to be the deadliest if the nurse is not
paying close attention.
One night my orientee and I were planning on admitting
a patient from the emergency room. As a way for the orientee to learn,
she was caring for the four patients we already had and was going to take the
new admit as well. This night I was just there as a safety net, to answer
any questions or concerns, or to help out if she needed anything.
She took report on the patient, and was cluing me in a
little bit as to what was going on with the patient. She told me he had
come in for multiple chronic and acute deep venous thrombosis or blood
clots. She told me he was on a heparin drip to thin out the
blood. She informed me she had never had anything to do with a
heparin drip before so she would need my help.
The patient arrived and we went to assess the
patient. After showing her the heparin drip and explaining the how, why
and what, I quickly assessed the patient. Nothing seemed out of
sorts. I left my orientee to finish her assessment. When she came
out of the room, we discussed the patient and how he was doing. We both
agreed he was fine and the heparin drip was correct.
A few hours passed and the tech came out and said the
patient had vomited and needed some Zofran. We gave him some Zofran and
thirty minutes later, my orientee went into to draw his labs. She came
hurrying back out and told me there was something wrong with the patient.
As we went in the room, she told me she thought he was vomiting up blood.
When we arrived in the room, we found the patient
sitting up in the bed with a tub of blood sitting in front of him. It was
a lot of blood. We grabbed the dynamap to get his vital signs. Of
course his blood pressure had dropped and his heart rate was starting to
increase. We called the doctor and rapid response. As we waited for
the doctors to arrive, the patient continued to vomit blood. In total the
amount of blood was 1.7 liters. Usually if a patient was losing that much
blood and their blood pressure was bottoming out, the patient would start to
have changes in their level of consciousness. This patient however, sat
there and talked with us while we were drawing labs, placing a nasogastric
tube, turning off the heparin drip and preparing him to be moved to a different
floor. The doctors were commenting on the fact that he was not showing
the normal signs and symptoms of a GI bleed. The patient was moved off
the floor. After an hour one of the doctors came back up to update us on
the patient. During the transfer the patient lost consciousness and they
ended up having to intubate the patient to protect his airway. The
doctors commented to my orientee that if she had not caught it when she did or
if she was even 20 minutes later then we would have been coding the patient and
he probably would not have made it.
After the doctors left we went back and looked at his
vital signs from the ER to see if there were signs that we missed. His
vitals were stable, but his heart rate was lower than it had been when he
arrived to us. However, there were no indications or anything that we had
missed (which was a great relief).
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