I've been in OTR for 4 years now and have worked mostly in acute care. I
recently had a pt who had a minor procedure done (an I & D to
remove an abdominal wall abscess). Pt was seen on the 2nd day of
post-op and orders were written for ADLS & OOB. Chart review
indicated that pt was morbidly obese and lived a sedentary life. RN
Ok'd session & reports that pt was doing well including stable
vitals. Upon arrival pt was up & long sitting in a bariatric bed
& scd's were on BLE's. Pt was not on a cardiac monitor nor was
oxygen been used as he did not require it. PLOF was obtained, UE
assessment was completed & then pt proceeded to transfer to EOB
w/spv. Pt sat there for 2-3 min & denied any dizziness, sob or
adverse reaction to mobility. pt then transferred to recliner w/cga. Pt
was still conversing w/therapist & even initiated adls, however 2-3
min into task pt became unresponsive. I took immediate action &
called for help in which the nurses came running into the room. I
administered oxygen, & pt was then positioned to start initiating
cpr. The pt subsequently died from a PE according to preliminary
reports. I keep going over in my mind of what could have been done
differently. Pt was on DVT prophylaxis including blood thinners &
there was no apparent warning signs to indicate that would happen.
migo1
migo1