Did I Do Something Wrong? - page 2
by rnccf2007 3,655 Views | 18 Comments
I came home and cried feeling like a truly incompetent nurse. I work on a very busy SDU/Tele unit taking overflow from med surg. I had a patient who was being diuresed r/t chronic bladder retention and mild pleural effusion and... Read More
- 1Jul 10, '11 by rnccf2007Sounds like in the end the MD needed to put a parameter on this medication. Also how aggressive was the diuresing? 20mg, 40mg, Q6, Q8, Q12?
The dose was 40 mg q12. The patient had been given this dose for two days prior and his SBP was trending in the 90s which was WNL for the patient. However, lesson learned. I thank everyone for their comments.
- 7Jul 10, '11 by GrnTeaif he'd been getting it q12h for two days, he might have diuresed out the chf he came with, and so the last dose pushed him too far back on his starling curve-- insufficient diastolic fill to generate a good cardiac output. before you give any meds, it's sometimes worth it to give a quick look at not just the bp (which can, after all, have some component of compensation in it) but the hct (going up?), hr (going up?), i&o (net losses? making much urine since the last dose wore off?) and weight (how real were those losses?). (ideally all these data points are easy for a clinician like you to access in a quick moment. if not-- well, maybe you can get them to do something about that. a better flow sheet?) if all those together tell you he's getting to the dry side, think twice about the iv diuretic.
i agree, though, it's not intuition that tells a nurse these things, it's education and experience. you'll never make this mistake again.
and btw, good on ya for checking the bp after the tech did it c a machine. you're right, often those are inaccurate due to user error/poor technique.
- 2Jul 10, '11 by NurseyNurseKRNI do re-check blood pressures before I give IV diuretics and IV/PO antihypertensives. Remember, too, that if you are giving a medication at 0600 and the last BP was from 0400 then it is 2 or more hours old...and BPs can definitely change in that length of time for a lot of reasons. I will say though that it was very good that you looked at the BPs as a trend and not just as a single occurrence. In general, if the SBP is trending under 100 then I look back at the last time the medication was given and what their BP was then. I also use my coworkers as resources and look at their reactions and get an idea of what they would do. Lasix 40mg IV Q12 is a standard dose for diuresing, I am glad it was not 80mg! I think MN-Nurse said it very well, everyone who is a good nurse was at some point in their life clueless, no one is born a fully competent nurse! Everyone has had to learn and make mistakes! Do not beat yourself up over this. The good news is that the blood pressure was re-checked within 50 minutes and you were able to intervene appropriately. I think any nurse who will tell you they have never made a mistake would be lying to you. As far as I am concerned, its only a tragedy if you take nothing from the experience and let it repeat itself, which I am sure you won't =)Last edit by NurseyNurseKRN on Jul 10, '11
- 0Jul 10, '11 by tyvinCheck the BP when giving push/IV lasix; just something they taught me in school. I have run into other nurses who do not and it makes me nervous. If I say something it's not acknowledged as serious in this matter.
Experience is the best teacher. I also check the BP for myself just to be sure. It's not a diss on anyone, ultimately you're going to get the charge or doc who will ask if it was double checked.
- 3Jul 10, '11 by belle005I think you did great. Prior to admin, you looked at the BPs, noticed the trend was low, you thought it would be ok. The BP was rechecked when you learned it was low, you made sure the patient was asymptomatic and you called the doctor. I'm a new nurse, but that all sounds pretty reasonable to me. And now you'll do even better next time, because if you're giving IV lasix, you'll check the BP just prior to admin and you'll watch the patient even more carefully. I don't see any reason for you to beat yourself up here. Good work!
- 0Jul 11, '11 by Been there,done thatYou gave the lasix based on a BP taken within 2 hours. Acceptable, especially on that kind of a unit.
He had a borderline pressure to begin with. The drop in pressure was a RESPONSE to the med.
If he was asymptomatic, I would notify the doctor, watch closely and have just given the situation a little more time. I think the fluid bolus was the error here.
Let the body do what it can to adjust, we can't fix everything in a few minutes.