I feel like a real DIRTBAG!

[SmilingBluEyes]

Ok I have to confess; I may be an experienced nurse but nearly missed something HUGE last night. It was a busier-than H@ll night last night; you know the kind. When you feel badly cause NONE of your patients gets your best cause you are too busy running around, putting out fires all over the place. It has been raining labor patients where I work this week. The floor looked like a tornado had blown through.... Anywhoooo...

I had a patient who had had a dense labor epidural (gosh I hate that). She had a foley cath which the OB insisted be pulled for the last stage of pushing (I understand why). Anyhow, I had turned off the epidural by this point and once the placenta was delivered, and I was sure she was firm and not bleeding, I turned down her IV rate to 75cc/hr, knowing her bladder would get full fairly soon. I was hoping the epidural would wear off and she could void at some point! In vain. I tried EVERYTHING to make this happen. Her peri swelled horribly and no amt of ice would bring this down. I continually assessed her bladder and uterine tones and bleeding to ensure she did not become distended. (I thought)....

Well, about 3 hours later, she began to have HORRIBLE pain. I KNEW this is not normal for a routine uncomplicated primip vag delivery, so I assessed for all the usual things, uterine tone, rule out infection, check bladder tone, etc. The bladder was non palpable, uterus altho 2 fingerbreadths above U, was midline. So, I got my charge nurse and asked her to 2nd my opinion before I called the doctor. I brought a foley incase cath was needed.

Well, she agreed with me, although the bladder was non- palpable and ute midline and firm, it might be a full bladder, so with MUCH effort, and two sets of hands, we cath'd her. Guess how much urine drained? 1900 cc! I have NEVER seen anything like it. I felt HORRIBLE. What kind of nurse am I to have missed something so basic? Duh. Well predictably, after suffering the discomfort of cathing her (which I truly had wanted to avoid), she reported immediate relief (duh). NEVER again will I overlook the obvious in looking for something more complicated. And never again will I make assumptions based on basic assessments; each patient is indeed unique. Fortunately, no damage was done. Her uterus was firm, we could massage no clots out and her bladder tone was ok. She was a happy camper after this. GRRRRRRRRRRRRRRRR.......Has ANYone else ever felt this badly? I feel terrible about this oversight! Lesson learned, fortunately with no harm to the patient.:imbar

[rn500]

I hadn't been doing L&D for *too* long, but long enough that THIS shouldn't have happened....

Multip, 9 cm for a loooong time (an hour or 2 I think), I was turning her this way and that trying to figure out why I couldn't get that last bit of cervix to disappear. I didn't THINK she had a full bladder, but I thought, what the hell.... straight cathed for 800cc... baby slid out on the bed before I had the cath out!

I like to tell that story to new L&D nurses!

[purplemania, BSN, RN]

From now on you should insist on taking only the patients with see-thru skin so you can "properly" assess them. You know, like saran wrap. If such patients aren't found, then I suggest you consider yourself a caring nurse who will add this episode to your list of experiences from which you have learned.

[SmilingBluEyes]

..................or get a bladder scanner like we have on our floor now. rofl. but nothing is perfect, so I still assume NOTHING.

[BETSRN]

The very full bladder can fool you. It can feel like a perfectly firm fundus. I had one myself the other night. I cathed her for 1400 cc's. Always go up and over to one side and you will probably find that fundus highly displaced. Always assume you have a full bladder. Don't feel bad that you missed that. It'sa common oversight.

[kmrmom42]

I do the same thing with the cath i give ones like that every opportunity to void before i cath them, because i just hate to do it and inflict any pain. but i know it has to be done.

When I first started in OB I used to do the same thing. I hated the thought of having to cath a postpartum Mom. So, I waited a lot and tried lots of other tricks before finally resorting to the catheter. Well, one day I waited too long....by the time I cathed the woman she had about 1500 cc's. I felt badly but not nearly as badly as when I returned the next day to find out that she had never been able to void on her own and had been discharged with a foley in! Wow. I was devastated. Now, at the least sign of inability to void after delivery I usually straight cath them. No more waiting for me. So far I have not regretted this change in my practice.

[SmilingBluEyes]

You guys all made me feel better. I do cath sooner rather than later now---having learned a valuable lesson indeed. That and having our bladder scanner is a WONDERFUL thing!

[tuppence]

Can I ask a dumb question? I noticed in a post earlier on this thread, someone mentioned that a patient couldn't get out of bed once her water broke. Is that standard, or are there certain circumstances that make that necessary? What is the reasoning behind it?

I'm a little curious because I know I was allowed to get oob, but then no one believed me that my water had broken, so they were all operating under the assumption that it hadn't, until it eventually became obvious that it had. (Opps!) Actually I have another question about that... (starting a new thread)

[SmilingBluEyes]

We allow our patients to ambulate freely and often, as long as the baby and mom are fine and there is no epidural going. Now, if pitocin is being used, they have to be monitored continuously. But I do allow them to move from bed to chair or stand if they choose, with the monitors on. I believe moving about is HEALTHY and BENEFICIAL in uncomplicated labors.

[TracyB,RN, RN]

We have a bladder scan on my unit (rehab)... It is AWESOME.... we have the only one in the hospital, so we occasionally get called to other floors to check a pt... It is a god-send.

[Mermaid4]

These things happen! And patients can fool you...You went through all the things that you should have while assessing her and then DID fix the problem..You are a great nurse and compassion is written all over your piece.....Take it easy on yourself.......Sounds like you took the time DESPITE the busy night, to take great care of your pt...