GI Bleed

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    Hi all,

    I had a patient come to the floor with an active GI bleed. There was a hx of a recent bleed - tarry stools and emesis. The pt had these symptoms while in the ER - stabilized with a BP of 113/56 in the ER and was moved to my floor about 6 hours later.

    His BP was 112/60 when he came to our floor. He was admitted - orders were to place an NGT, Foley and administer 2 units of PRBCs upon arrival. I had him sign the paperwork for admission and sign the consent for the blood transfusion. Pt was resting quietly. Three hours after arrival, the pt had a tarry stool and vomited 150 mL of bright red blood. I made a mistake in thinking I could monitor this - thinking that since the pt had demonstrated these symptoms in the ER, that the physician was aware and that if this continued, I would call to have the pt moved to ICU. The pt had no more episodes of vomiting for the remainder of my shift.

    The pt received 1 unit of PRBCs on my shift. His BP began to come up as he received the blood. I mistakenly thought that all was well with this patient and that I could continue to monitor him. At shift change, the physician came in wanting to know why I hadn't called regarding the bloody emesis. To be honest, I didn't know any better - thinking that she was aware of the pt's condition and also that I would continue to monitor the patient.

    She said there was an order to call if the pt's SBP was < 90. Sure enough, I missed that. The pt's BP was lower than that and, yes, I didn't call - because I missed that order.

    I just don't know what is wrong with me. It's been a while since I've written in and seem to only write in when I mess up. I am being told that this is a learning experience as I've never dealt with a GI bleed before - and yet - I there is no excuse for this. I do not feel like a good nurse and do not feel the least bit trustworthy. All I want is to do this well and it seems that no matter what I do - it's never enough or good enough.

    Thanks for listening.

    RiverNurse
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  3. 16 Comments so far...

  4. 0
    Hi Rivernurse,
    I'm sorry this is happening to you. It truly is a learning lesson though. Everytime something like this happens, you have to learn what you did wrong so that you're less likely to repeat it. When you find abnormalities, you have to ask what is being done about this. If you don't find the answer, call the doc. At the beginning of the shift, get a piece of paper and section it off by the number of pts that you have. Look at the orders and write down what has to be done i.e. dressing changes, qshift foley flushes , nurse blood draws, etc. Also, if you see an electrolyte that is abnormal and there is nothing done about it, include it on your list to follow up with the docs. Keep checking orders and labs and update your list as necessary and scratch off things that are completed. If while doing assessment, you find that a pt's has a complaint that is non-emergent, include it in the list of things to contact the docs about. Have faith, you can do it.
  5. 1
    Not to be hard on you but many a times gi bleeds are life threatening. It would probably be helpful for you to read up on gi bleeds and what could go wrong with them. You are always going to want to be concerned with their volume. Just because you don't see bleeding doesn't mean there isn't bleeding. Keep that in the back of your mind. If there is not enough volume well then you're worried about the kidneys and going into ARF. As a rule of thumb if my pt SBP dips below 90 you had better believe I am on the phone to the doc 99% of the time. In this case even if there were no parameters I still would've called.

    You might want to find out what is generally done at your hospital in regard to gi bleeds. Those patients should probably be in the icu the majority of the time esp if they're actively bleeding. On a med-surg or tele floor nurses may have a difficult time staying on top of their condition and they require a higher level of care. More frequent VS, etc. Plus they can give blood quicker in the icu than can be given on the floor.

    I'm assuming you're a new nurse. You learn as time goes on. Make sure you ask for help, even if just to bounce thoughts off of another nurse. Oh and one thing I have found is that just because the er deems a pt ok to go to a regular floor does not mean they are stable enough. Can't tell you how many times a pt has come up and been very unstable and needed to go to the ICU. Don't trust what they tell you til you lay your eyes on that pt. Just speaking from personal experience. The majority of admissions aren't like that but it does happen.
    blueheaven likes this.
  6. 1
    You are extremely critical of yourself (many good nurses are). I commend your pursuit of exellence, but please understand that this is an ongoing process and you barely had time to get your feet wet. You said it seems you only post when you mess up, but it had been a while since your last post, so obviously you're actually doing very well. I know "take it as a learning experience" came from a nurse with much more experience and there's a reason for this. While it is good to find areas in need of improvement, please also allow a little time to reflect on all the things you did for your patients. All to often we are ready to criticise ourself, but fall short on giving ourselves any kind of credit.
    Karley9336 likes this.
  7. 0
    Hi all,

    Many thanks - I have been officially written up for this incident - that was the recommendation written in the pt's chart by the attending physician. More importantly, the patient was transferred to ICU and has improved significantly.

    I am most upset b/c this pt could have easily died.

    More advice is certainly appreciated.

    RiverNurse
  8. 1
    I am not sure that the doctor should have written for you to be written up in the chart. that is a little extreme and can open you for a lawsuit by pointing a finger that you had done something wrong. that rates up there with writing "incident report written" in the pt's chart. Might check on that! We are all fallible. just learn and go on.
    Tait likes this.
  9. 0
    Quote from jayne109
    I am not sure that the doctor should have written for you to be written up in the chart. that is a little extreme and can open you for a lawsuit by pointing a finger that you had done something wrong. that rates up there with writing "incident report written" in the pt's chart. Might check on that! We are all fallible. just learn and go on.

    Absolutely. There is never to be any personal/work complaints in the chart. This would easily win a lawsuit.

    I don't think he could have "easily" died on you. I think it's odd that they put an NG down him without knowing where his bleed was. I don't recall that being a common practice on our floor. I need to look more up on that since it has come up in a few threads with mixed information.

    I think missing the BP was a issue, but if he was stable up until shift change than that last one (if taken by the techs while you were in report like it is done on our floor) was just a bad chance happening. (I missed a pt out put of 180ml at midnight the other day and felt like a total heel, so I know missing something can make you really feel bad). However, no one is perfect, put it away as a learning experience and move on! If you are even fussing about it proves that you are working hard on being a good nurse

    Was his NG pulling blood? Because him vomiting, depsite the NG, was a bit odd to me.

    :icon_hug:

    Tait
  10. 0
    At that point, the only order I had not carried out was the placement of the NGT. The pt had actively vomited, had just had a foley placed. I wanted give him a few minutes (literally) before placing the tube. His BPs were low - but were coming up due to the PRBCs being transfused and the additional fluids. Mea Culpa on that - I missed that order completely. I could complain about acuity here - the isolation pt I had... the two pts with peg tubes - one of whom needed feeding at the time this pt was going downhill... The pt in restraints that kept attempting to crawl off the bed and managed to dislodge her IV... The other "quieter" pt whose IV had infiltrated and was scheduled the day before that was "ok'ed for shoulder surgery" without a consent signed - nor was there any other specific instructions for this surgery... so that was missed... and two of my pts needing consents signed for EGD and peg tube placement...

    I don't have enough experience with GI bleeds and hemetemesis to know about placement of and NGT while vomiting is going on. I am glad to have heard more about this - and IMHO - I do not know why this pt was sent to our floor to begin with. Despite the fact that he had been in ER and was declared "stable" - I think in the best interest of the pt - given his recent hx of frank, red emesis - he should have been sent to ICU.

    Now I am concerned - I had no idea that a "recommendation" to be written up in a chart was/is akin to filing an incident report in the chart. I take it this means that in the event of a lawsuit - I would be named - and held accountable?

    Please - more feedback - and it is much appreciated.

    RiverNurse
  11. 7
    First, it wasn't so long ago that I was in your shoes, and I remember what it's like. Here's the nerd "5 cents on GI bleeds"

    --When they come from the ER with a note that they had melena or bloody vomit, I call the ER back and actually speak with the nurse that had the pt. How much blood? What color? When? Did you get a HGB before and what's the HGB after? Did the doc know? Yes, I know they're busy too, but that's need to know on the floor.

    --Crawl the pt's chart for any meds that could cause bleeding and see if you can get a APTT/PT/INR when they get there, if there's only one in the ER. If the person's been on lovenox at home, you may need to get an order for protamine, and if they've been on coumadin, you may need Vitamin K to get them back to a baseline. It'll help make the FFP or PRBCs work better at restoring semi-normal coag numbers. Especially, ESPECIALLY if the person is on dialysis, they may have a high rate of heparin on board and no kidney function to excrete it -- and dialysis doesn't take out heparin. And since protamine can crash a BP, don't wait until the BP's already in the toilet.

    --If you get an active bleed (bright red blood from anywhere, and more than a "dot"), say the magic phrase to your charge nurse -- "I need some help in here!" We're still new, and while we might be the most "book smart" folks in the world, you need experienced eyes when someone starts circling the drain. I had a person bleeding out, and thought I was being a "nervous nellie" about the amount of blood until I got my charge nurse in the room (15 yrs experience), she took one look at the blood and went "holy ####!" And yes, that person went to the unit.

    --Know your shock values. If a person looses more than 750ml, shock can begin (compensated/uncompensated, not the point here). And they had to have already lost something, else what brought them to the ER? Look at the total volume of fluid loss, and the time lost. I had a guy who lost 300ml of melena with clots over a period of 6 hours, compensating with blood, but nothing could compensate for when he dropped 800ml into the BSC and promptly had a seizure. Less than 300, no biggy was getting NS @ 100 in one vein and PRBCs x2 in the other, but he went into instant hypovolemic shock with the big gush. I woke up pretty much every doc/surgeon I could get my hands on, screaming for help, guy went to ICU and he still died. When I've got someone like that now, I have a "bleed table" posted in the room -- I keep track of bloody output, with orders to the CNAs to let me see it before they flush it.

    --From now on, when you get a GI bleed, you'll know to either look for a "call if systolic less than whatever" or if there's not such an order, call and get one. I work nights, and I try to "front load" my doctor calls...something like this:

    "Hey, Dr. X, this is Nerd over on East 3. I'm calling about Mr. R in 304, came in the GI bleed. ER said he had 1 tarry stool and 1 bright red emesis, approx 150 ml in the ER. I don't see an order for me to call you if the HGB falls below 8 or the SBP falls below 90 -- last lab the HGB's 8.3. The pt's been on coumadin for hx of afib, INR is 3.58, do we want to do a little vitamin K just to give him some help while we're waiting for the FFPs, or maybe some hespan since the lab's going to take 45 minutes and I can get 250 in before the FFP's ready?"

    Without sounding like "hey, doc, you forgetting something?" you're letting him/her make the decision on what he wants to be alerted on, and you're also letting him know what happened in the ER -- hopefully, you'll get orders on "call if HGB less than 8, or transfuse x if less than 8, or hespan if SBP less than 90," or whatever. The docs also see you as proactive, which helps with their comfort level.

    --with a GI bleed, assume this patient's sole goal in life is to bleed to death and die on your shift. Do everything you can go thwart that goal.

    Good luck, we need it out there...
    Hoozdo, blueheaven, 3rdcareerRN, and 4 others like this.
  12. 0
    Quote from RiverNurse
    .

    Now I am concerned - I had no idea that a "recommendation" to be written up in a chart was/is akin to filing an incident report in the chart. I take it this means that in the event of a lawsuit - I would be named - and held accountable?

    RiverNurse
    I would give a call to your Friendly Risk Manager and let your nurse manager know as well. They can advise what to do and help the situation and let the doctor know that that was waaaayyy inappropriate.

    Keep us updated and please don't be so hard on yourself. Live, learn and save the next patient's life knowing what you know now!


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