Hello GI nurses!

I work on a general med/surg floor but often care for GI pts. One pt came in with nausea and failure to thrive. He was on a clear liquid diet, had normal bowel sounds, no abd pain but some abd distension, nausea, and vomiting, and his ileostomy (not new) was not putting out much. He was on a clear liquid diet but had little appetite and frequently vomited after eating. I noticed that he wasn't keeping anything down and the abdominal distension/ low output, but did not notify the MD because he had just been in to see the patient and examine him. In report I told the next nurse about the low output and N/V. I found out that not that night but the next night the patient passed away after vomiting bile and aspirating. The nurse from that shift said his abdomen became much more distended and painful and she called for an NG tube but the MD refused and said to stop giving the pt any narcotics. I am wondering if there is anything I could have done differently, such as call the MD earlier to ask about the NG tube. I know the patient did not die on my shift, but he died 3 shifts later and I feel like I missed something because he seemed very stable to me. Can an obstruction develop and/or worsen quickly? If the pt is admitted for nausea is it necessary to inform MD that nausea is worsening/ pt cannot keep down PO intake? Thank you for any advice you can give me!

History of SBOs?

There are occasionally strictures at the anastomosis site with ileocolectomy patients that results in recurrent SBOs.

Sounds likes you did what you could though.

thanks for the reply! no history of SBOs but very extensive medical history. the nurse who had him when he died said it seemed like his GI tract just got so blocked that everything came back up because it couldn't get out. I was wondering if this could develop quickly or if it was developing gradually and I missed something.

Can happen either way.

Abdominal distention, nausea, vomiting, and low stool output = CT for SBO order for me. Any signs of stool in emesis is immediate NPO and surgical consult.

This isn't your fault. Can you spot it earlier next time? Maybe. You did what any reasonable nurse would have done.

Thanks for your help! I did see in MD's notes a KUB was ordered and he was waiting for result. I guess things progressed before he was able to get the result. =( The other nurses were wondering why he didn't make pt npo and order NG when the distension got worse, but I guess that's up to the doctor to decide.

Thanks for your help! I did see in MD's notes a KUB was ordered and he was waiting for result. I guess things progressed before he was able to get the result. =( The other nurses were wondering why he didn't make pt npo and order NG when the distension got worse but I guess that's up to the doctor to decide.[/quote']

Ultimately it is.

Next time you can put some pressure on the provider (not always an MD!) and perhaps get the order earlier; that's whet nurses really save lives in my opinion, making providers order the right things at the right time when they are convinced they are either.

Great advice! And if I have a situation where I think I may know what the pt needs I won't hesitate to recommend it to the MD (or NP of course!!) Thanks so much =)

Great advice! And if I have a situation where I think I may know what the pt needs I won't hesitate to recommend it to the MD (or NP of course!!) Thanks so much =)

Also if the doc isn't taking your concerns seriously and you are seeing the pt deteriorate, don't be afraid to go up the chain of command. If you are at a teaching hospital page the attending. At my hospital you can even call an ICU nurse that will get the ICU attending to come see the pt immediately if necessary

Good point! The nurses who had him the day and night shifts on the day that he passed said they felt it was a big change in condition that day and MD didn't take their concerns seriously. They eventually got the code white team (team of critical care nurses, respiratory therapist, and house supervisor) involved but by that point pt was close to coding. They said they wished they had called the team earlier rather than paging the MD multiple times with no result. =(