catheter/retaining urine/bumex gtt question

  1. Hello, I am really new and somewhat baffled by this, any insight appreciated.

    I was assigned a pt today, DNR/DNI, who was waiting placement in hospice. He has lung CA, pnemonia, and exacerb CHF. His LS coarse. Eve shift day before had low UOP, nurse did bald scan, 400 cc, removed catheter and ut in new one. Overnight c/o vague abd discomfort. Pt really weak, cannot talk very well. also overnight was placed on face tent at 15L.

    when I came on in am, sats 100% face tent. so I placed him back on humidified NC 6L and his sats remained 95% (I did this partly so he could drink/eat without mask, and if he was sating well, he didnt need the mask, and all that O2). gave him his meds, checked/changed gtt bag. He denied pain. went to see other pt.

    New order for Bumex gtt to be changed to 2.5 mg/min, went to changed rate (it was to be titrated accg to UOP, which was minimal. Pump had warning that this dose exceeded safe level. Went to drug book, recommended max 10 mg/day. called pharm, they confirmed. Went to resident, he changed to 2 mg. asked him if he wanted if still titrated, as it would be titrated up still as low UOP. He said yes.

    team in room, along with nervous distraught crying family. family asked team about pt c/o pain to abd/catheter. team told me to pull catheter. team left, family asking me all sorts of questions, esp about pt pain. I said pt denied pain earlier to me, that there are PRN meds, and that we assess regularily, is pt stoic about pain? there is also the option of scheduled pain meds as oppsed to PRN. they went to team and requested that- sched, pain meds.

    Contacted RT to give pt neb, pt unable to effectively cough, LS coarse. RT gave pt ned and suctioned, said they did the best they could buy LS still coarse, still sating 95% 6L NC.

    Went to pharm, explained situation, they said no, it would cause more probs if up from 2 mg/hr. Went to Dr, he said he discussed this w/ team, they felt up to 4 mg max/hr was ok, he wrote order. Went back to pharm, they said they would call Dr.

    I also was concerned about pulling pts cath when his UOP was so low and he was on bumex gtt. tried to talk to DR about this, but he was exhaused, caught up in another pt, and basically waved me off (you know the feeling). Went to talk to my charge nurse. she said why not try it, and monitor if he goes in depends/briefs, if not we can put catheter back in. discussed this with family who agreed, afer sharing my concerns about pulling catheter.

    New order for Bumex to be max 2 mg/hr. Pulled cather. Pt couldnt void. New shift coming on. New RN did bladder scan and 743 ml retained. she decided to put in new catheter with lidocaine. I ws finishing up charting on my shift.

    Question: I feel really bad I didnt do bladder scan initially on this pt. should I have?? I am so new, I feel I am really missing things!! Also, pt said he had no pain in am....dot dot dot...

    Also, pt will be sent home tomorrow since family didnt like hospice facility that was set up today...with this bladder issue, I am scaed for the situation...Also, should I have really pressed the Dr who didnt want to deal with me? I was really caught up initially in the whole Bumex dose issue, and didnt even really get to the bladder output issue yet before 2nd shift was coming on. Also what can cause retaining urine when a foley is in? he has generalized edema from CHF (I believe). His urine was very concetrated as well. I feel I had little time to deal with all this, and search for this mystery!

    What should I have done differently, what did I do wrong. I would like to learn so that I can be a good nurse, not an incompetant one.
    thanks to all experienced nurses out there who take the time to respond!PS please feel free to ask additional questions.
    Last edit by hollyberry678 on Dec 15, '07
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  2. 6 Comments

  3. by   BBFRN
    It sounds like you did a great job. I'm assuming this pt has a really low EF & LV dysfunction? Add to that the lung CA & PNA, you've got a trainwreck.
    You were right not to give any more Bumex. Giving more can cause even greater renal failure than he may already have. A loop diuretic will also only work as well as the renal circulation allows. I'm hoping this pt was also getting some HCTZ- it can help. Did the MD want the F/C pulled because the family was freaking out about the UOP?

    I know when you're a fairly new nurse and you're confronted with a very scared family, it can feel like you're not doing enough. I think you did a great job. You don't sound incompetent at all. I'm hoping the family will be getting hospice assistance at home?
  4. by   hollyberry678
    Thanks for the reply. I am not sure of the EF because I didnt have time to search the H&P or MD notes today, they are not set up via our new really confusing and redundant computer program yet (redundant mega charting). Labs for this pt were actually pretty good, plus overheard the Dr tell family renal function "good", despite the increasing concentrated urine, ect. Maybe my bad nursing for not communicating this clearer to the DR's. I did tell the resident there was very little UOP while discussing Bumex/titration. IS that sufficient? Should I have been clearer?

    Yes, the family was asking me all sorts of medical questions, i referred them back to Dr, but they kept asking, like I was supposed to be an expert (or so I felt). I did feel very bad for them, they were drowning with being overwhelmed with this situation. I did get some 'free coffee' coupons we can pass out as needed (for good relations, can be any situation).

    Anyway, why the heck didnt I bladder scan him initially? I barely got time to do assessments, pass out meds, figure out my other pt's OR stuff, prep her, then come and they want the cath out BECAUSE THE FAMILY FELT IT WAS CAUSING HIM DISCOMFORT. I was trying to firgure out the Bumex dose, because the pump had a warning about going higher...and I didnt want to do that unless it was safe.

    The DR did tell me to go to 4 mg/hr/ max. but he didnt give me reason or rationale, which I was seeking. This past night while worrying I called a pharmacist who had time to look and recommended dose is 2mg/hr, beyond that it loses effectiveness, but said one study says it can go to 4mg for CHF pts. So that would have been all I needed to hear, but didnt at work...Am I bucking DR's orders now, or is it right I get an answer before upping to a level not generally deemed safe?

    anyway, I should have bladder scanned, and feel terrible I didnt first. I am beating myself up about this, but feel like an idiot.

    what exactly did I do right? I need to hear this.

    By the way, I also should have communicated to the SW who was coordinating hospice about this bladder issue. Pt was supposed to go to hospice facility, but family went there in early afternoon, came back, and said no, just prior to the end of my shift. so it was decided that pt would go home. they are too distraught to care for pt at home, i feel, and I should have communicated that. SW was aware of that piece however. she said there was an opening at a preferred site on Tuesday, and that if home 'fails' they can go there then. I do hope they will get some home care assistance.

    I dont know, I have no idea. If I had known this pt for even one other shift I could have been more 'together' about it.
  5. by   BBFRN
    What you did right:

    1. You caught a med error before it started via the pump warning. Regardless of what 1 study says, you don't have the time or inclination to verify the veracity of that study. You have to go by policy and standards set for that med.

    2. You were closely monitoring the UOP, and notified the MD when it was low, despite the Bumex drip.

    3. You notified the MD that the Bumex dose he ordered was too high. Don't think of it as bucking his orders. Think of it as saving his butt in a possible med error suit.

    4. OK, so you didn't do a bladder scan, but you did all you could with what you had to work with in a very busy 12 hr shift. Nursing is a 24 hr job, and the pt had < 1 L urine retained. The doc ordered the F/C removed based on what the family was saying. He didn't think to order a bladder scan either.

    5. I'm thinking that the family's freaking out affected you and the doc both. It seems you and he both changed the direction of what you were doing with the pt based on their concerns. That's not necessarily a bad thing when a pt is near the end. That can be the time when your focus will be pointed more at the family and their concerns. This is the time where patient comfort becomes the primary concern, and you seemed to get that by assuring that his pain meds would be given on a scheduled basis, and by changing his O2 to nasal cannula as tolerated.

    I'm assuming you are a fairly new nurse? Give yourself a break. You will get a bladder scan the next time this happens. You can use this as a learning experience, and add it to your knowledge base for the future. Unfortunately, any experienced nurse (including myself) will tell you that a good nurse is one who cares enough to learn from the things that have gone wrong, and uses those experiences in subsequent situations. Judging from you posts, it seems you are that kind of nurse.

    From what I can tell, you did a great job. You were sensitive to the family's needs, and you cared about their concerns. You can't save everybody, and this guy is failing no matter how many meds you give him, or procedures you perform on him. Yes- a new cath would've helped, but his bladder distention probably wasn't the main cause of his discomfort. Ya did OK.
  6. by   hollyberry678
    Thanks so much Baptized, I really DO want to be able to leave each day and KNOW I did a good job...the best that I could have. I HATE leaving and thinking I couldve done better. I would want the same for myself or anyone counting on the medical system. but being new is really really tough.....thanks for your support/knowledge.
  7. by   BBFRN
    Quote from hollyberry678
    Thanks so much Baptized, I really DO want to be able to leave each day and KNOW I did a good job...the best that I could have. I HATE leaving and thinking I couldve done better. I would want the same for myself or anyone counting on the medical system. but being new is really really tough.....thanks for your support/knowledge.
    No problem! You will leave feeling like this a lot in your first year. That is normal in nursing, and nursing school doesn't do enough to prepare you for that, unfortunately. The best thing you can do is to find a mentor on your floor, and ask for help or input when you're not sure of what you should do. We've all been there!

    I had a shift like this not too long ago on the ICU. I've been a nurse for a long time, but hadn't been in critical care for a year yet. I had a pt go bad because of a med reaction. I fought with the cardiologist, and didn't give the med again. I left at the end of my shift with an intubated and paced pt, who had been sitting up and talking earlier in the day, with an angry cardiologist breathing down my neck. I thought I had done a terrible job by not preventing this patient's decline. When I came back 1 week later, I had thank you notes from the family (one from the dtr, who was a PACU nurse), and a pat on the back from the cardiologist, who said I had been right to hold the med. She had rapidly improved after I had left and the med was out of her system, and was not given that med again.

    The moral of the story: I had done a good job after all, and I asked for help from my more experienced critical care colleagues when I needed it. They were right in there with me, helping to code her and suggesting interventions to me. Sometimes doing a good job means getting help from your coworkers when you need it, and pissing off a doc or two. Because of this, the patient walked out of there less than a week later in good health.

    The 'woulda-coulda-shouldas' are only valuable if they enable you to learn. Otherwise, you'll only eat yourself up and take it home with you. Use this to your advantage, and you'll be fine. I'd let you take care of my family members any time.
  8. by   ted53
    Hi Hollyberry678. First of all let me say I am Scottish so I don't fully understand your drug names or all your abbreviations, I am experienced with cancer patients and very experienced with catheters.

    Second point, don't apologise for being new, everyone was at some time in their career and survived with the help of others.

    The fact you spoke to pharmacy and a doctor shows you care and are professionally thinking about your work.

    Everyone has been flustered by relatives at some point in their career. By being confident in your ability(not arrogant) you will be able to deal with these situations and relatives will relax after hearing confident explanations from you.

    Catheters; with an indwelling catheter the most common cause of blockage is a bladder infection. Very often small amounts of pus/debris block the eye of the foley preventing drainage. Inserting a new catheter and commencing antibiotics is an acceptable treatment, because if the infection is not treated the catheter will block again. A specimen should be sent to the lad to confirm infection and check the correct antibiotic is being prescribed.

    The next time you change a catheter keep the old one. Take it to your dirty area and using a scalpel blade slice the catheter down the middle. You will be surprised at the amount of debris that can collect in an indwelling catheter. This a very good teaching exercise.

    Good luck

    Edward

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