[daretolive]

Urine output in 16 hours postop was 200 ml. I know, way below recommended 30 ml/hour. Pt was not edematous, had IV fluids running at 125/hour, patient didn't seem to be dry, vitals were good, no complaints or dry mouth, had had morphine PCA, but that was discontinued on pm's due to N+V. Foley manipulated, balloon secured, patient turned on side, foley in was a 16 french, only minimal output. We took it out, put in 18 french. Still no urine output, just a small clot, another nurse took that out, ouch, put in a 20 french, still no urine output, just a clot. It appeared that bladder was full of clots from initial traumatic insertion down in preop. So this patient had spinal block for surgery, ortho doc did not want to address it, medical doc said she didn't have the rights to this patient, because she was never told to follow in the hospital, called crabby surgeon back, got order to consult the medical doc, and "I can't do anything about his bladder". Medical doc TKO'd the fluid rate, to remove current foley to see if he could pee on his own, which he hadn't after 2 hours. Is he just dry? Was the nerve block doing this? Is he blocked ? Is it just the general trauma of having a tube shoved up where it doesn't belong, multiple times? Well, medical doc ordered a bladder ultrasound, which showed NO urine collected in bladder, per the tech, unconfirmed by radiologist when I left. So, now, they say, lets check his chem panel for kidney function and electrolytes. My shift was over, I don't know how those were.

But, being a new grad, I have no idea how a post op can be getting maintainance fluids like that, with meager UOP. Oh, the last order I heard was that they were trying to get some doctor, that would be able to do a cystoscopy. (Long story, small hospital, only urologist is out of the country until next week,) the general surgeon said he didn't want to touch the guy, but he did say lets call the gyno(!!) and since he does these on women, would he be willing to attempt on a male. Or do we need to look far above the bladder. Figure out fluid balance, figure out other fluid losses, so maybe he just didn't have urine to pee. Hemovac total was 280 ml, and a 300 ml emesis on PM shift. So, that is 580 right there, and the hemovac output happened after the 4 hour cutoff, so we couldn't reinfuse.

Knee's are great when they go as planned. But, this one isn't, and being a young nurse, I am petrified they are going to come back on me and blame me for the way things were handled, and their medical staff that were too busy being unavailable to be able to decisively know what to do with this patient. I hope day shift isn't ready to hang me.....

Any words or encouragement or advice, or personal experience would be greatly appreciated.

[RN1989]

Waiting 16 hours before reporting a urine output of only 200 cc goes against standards, particularly for a post op pt.

The floor nurse receiving the pt from PACU should have received the I/O totals from OR and RR and passed this on to everyone else. This would have alerted everyone much sooner to a problem.

It is conceivable that the pt was very dehydrated from being NPO preop. It is also conceivable that a relatively healthy person was thirdspacing and just not showing s/s yet.

Since you do not have definitive answers at this point, you will not know if your inaction caused any problems. Take this as a learning situation and report abnormalities ASAP. If the doctors do not want to write orders and you feel orders are necessary, use the chain of command to go over their heads. You should have a policy on that in your P&P book. Do not let a doctor's or another nurse's lack of concern for a problem shadow your judgement when you know that there is a problem. Do not be afraid to contact docs even in the middle of the night for an abnormality. Your license depends on this.

[daretolive]

PM's documented their 150 ml of the urine output-yes they should have reported it to me, at the very least, called the MD to report it, but they didn't, but my watching it for the first few hours of nights, and there was only 50 more ml, then I did act. I did do what I thought was within my capacity, including consulting 3 more experienced nurses. And 3 MD's, who didn't want to take responsibility and tried to say it was the other doc's responsibility. The whole system broke down. But, in a small community hospital, with no ancillary staff on at night, the US couldn't even happen til 0600. And the surgeon was without common sense, and lets just say, my first two phone calls trying to reach him, I found myself talking to his EX-wife, very scorned, saying we needed not to reach her in the middle of the night, and that he moved out last fall. God forbid would a doctor care to actually have the correct contact numbers for us. The surgeon left her last fall for a 22 year old surgery tech, and then left that person for "a 28 year old bar maid". Oh the drama. TMI Just hoping that this patient was dry, and it was nothing more.

But, if there was nerve damage from the epidural, how would that present, I thought that would be the culprit IF he had a full bladder and was unable to empty.

[daretolive]

He was dry. Nothing more. Copious amounts of urine since I left yesterday am until now.

[rn/writer]

The cardinal rule of scary stuff in nursing is to document the heck out of the situation. Record every measure you took, every phone call you made, every order, every action, every result. Leave a trail that shows you left no stone unturned in trying to address your patient's problem. Omit personal stuff (like the ex-wife's reaction), but do state that multiple attempts were made to impart information and obtain orders.

The goal in making a factual, objective, non-emotional report is to give the reader all the pieces and let them put together a picture. If that picture looks bad for someone else, it's the facts speaking for themselves, not you pointing a finger.

Your patient was fortunate to have you looking out for him. I'm glad the outcome was a good one, but had it gone the other way, the alarm you sounded could have made a big difference. If you are just beginning your nursing career and you have this kind of awareness and diligence, you will be a blessing to your patients and an asset to our profession.

Good job.

[P_RN]

I have even written telephone orders with a witness on the extension:

"Aware of uop of 200cc/ (whatever) I have no orders at this time"

to Dr. XXX/PRN
witness.......RN

and document, document x 1000 etc.

And I would never have such a procedure as a TKA in a small hsp with no ancillary MD coverage 24/7/365.

[NJNursing]

I also ran into a similar situation this week and in 2 years or ortho I'd never run into it. Got her first night PO. She had fluids at 125 all night (LR). From 11-7 the output was less than 200 cc. Granted she'd been vomiting a lot - she's very sensitive to narcs. Notified her MD at change of shift. He figured she'd "catch up." I get her again last night. Fluids were still running at 125, urine getting concentrated looking. Repositioned foley. 2500cc in in 24 hours, 500cc out. In 2 days she's had at least 5000cc in and less than 1000 out. Lungs sound good, diminished though. No s/s of third spacing. Vitals all stable. Her foley was supposed to come out today but I left it in because something didn't seem right and if they choose to lasix her, without the foley would have been a mess. Told the MD again who didn't seem all that concerned. Said he'd order a UA/CS and check her lytes to see how her BUN/Cre was doing. I was perplexed.

[iluvivt]

Do not forget about the stress response after surgery. The adrenocortical hormones kick in and hold on to water and Na+ and you may get a false picture of oliguria. So....you balance on a delicate tightrope here b/c if you give too much non-electrolyte fluids (ie D5W) you will get hyponatremia from expanding the ECF. So during this post-up stress period give conservative amounts of D5W and avoid excess infusions of NS (Usually one would see D5 1/4 or 1/2 NS) Then at about 48-72 hours post-op you start seeing that diuresis.

[MNmom3boys]

Originally Posted by iluvivt

Do not forget about the stress response after surgery. The adrenocortical hormones kick in and hold on to water and Na+ and you may get a false picture of oliguria. So....you balance on a delicate tightrope here b/c if you give too much non-electrolyte fluids (ie D5W) you will get hyponatremia from expanding the ECF. So during this post-up stress period give conservative amounts of D5W and avoid excess infusions of NS (Usually one would see D5 1/4 or 1/2 NS) Then at about 48-72 hours post-op you start seeing that diuresis.

I think this, along w/ pre-existing dehydration, is something that we are seeing in some of our total hip/ total knee patients. We run in D2 1/2NS at 75mL/hr for about the first 24 hours, assuming PO intake is good after surgery. The first couple times I had someone with a low output I, as a brand new nurse, was a bit freaked out. I still continue to clearly document I&O including the usually dark amber color, and let the next shift know about the concern. (I have not yet had one w/ no output.) But, inevitably the next day or so they are up to the commode peeing like the proverbial racehorse.