I feel like a terrible nurse, what should I have done?

Specialties Ob/Gyn

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I try as hard as I can to be a good nurse to my patient's and part of being a good nurse is being an advocate for the patient.

I had a couplet on Sunday and the baby had some things that were just not right about her. First off, she had very large fontanels. The anterior fontanel could be felt all the way to almost the top of her nose and laterally to almost her ears. It was not flat or bulging, just large. She had a very shrill cry. Sometimes her cry sounded typical, but sometimes it was very shrill. Her hands folded kind of towards her wrists, looked like a "V" shape. She also had reduced tone. She was pale and had sort of transulcent skin. Ped had seen her and just noted that she was breasfeeding well, had large fontanels and ordered a TSH and T4. TSH was mildly elevated. Baby wasn't breastfeeding real well and by day 3, she had lost 11% of her birthweight. Mom was pumping and had lots of milk, was supplementing with breastmilk after feeds and using a syringe. VS were all within normal limits, she had no problems maintaining her temps and she was small 5#13 at birth.

Anyway, my dilemma came in when she became my patient the 2nd night. I had seen and heard her the first night I worked, but then she was mine on my 2nd night. Mom is a nurse as well. I don't think that mom had even noticed that she was a little different and I really felt like I should tell her something. Who knows, maybe the baby is fine, but I felt like I should have told her something. Being new, I discussed it with 2 other nurses who said I shouldn't. It was the doctor's job to talk to her about anything like that. I felt like the doctor wasn't being aggressive enough to at least evaluate the head and make sure things were okay. All the nurses on both days and nights felt like something was not right with her, but nothing seemed to be being done except the blood tests. Of note, her first child had hypothyroidism, but was no longer considered hypothyroid. Which is why ped had told her he ordered TSH/T4. I know that hypothyroidism babies can have large fontanels, so I hope that is what it is if anything, since it can be treated.

I was frustrated all night. She was the sweetest little thing, but I can see how the nursery was frustrated because she would just cry and cry sometimes and it was very high pitched. Even being held. Then sometimes she would be fine and sleep peacefully. My frustration was that I couldn't tell if she was in pain or it was just the way she cried.

Also that I felt like I had bonded with her mother, yet I didn't have the courage to at least say to her "I am not sure if you have noticed, but XXX's fontanels are a bit large. You might want to ask her pediatrician about that and see what he thinks." I didn't want to alarm her, but I felt like no one had told her anything.

So, what would you have done?

*To my patient and her daughter~I hope that all turns out okay and I am sorry I wasn't a better advocate for you guys. You are in my thoughts and prayers. *

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I try as hard as I can to be a good nurse to my patient's and part of being a good nurse is being an advocate for the patient.

I had a couplet on Sunday and the baby had some things that were just not right about her. First off, she had very large fontanels. The anterior fontanel could be felt all the way to almost the top of her nose and laterally to almost her ears. It was not flat or bulging, just large. She had a very shrill cry. Sometimes her cry sounded typical, but sometimes it was very shrill. Her hands folded kind of towards her wrists, looked like a "V" shape. She also had reduced tone. She was pale and had sort of transulcent skin. Ped had seen her and just noted that she was breasfeeding well, had large fontanels and ordered a TSH and T4. TSH was mildly elevated. Baby wasn't breastfeeding real well and by day 3, she had lost 11% of her birthweight. Mom was pumping and had lots of milk, was supplementing with breastmilk after feeds and using a syringe. VS were all within normal limits, she had no problems maintaining her temps and she was small 5#13 at birth.

Anyway, my dilemma came in when she became my patient the 2nd night. I had seen and heard her the first night I worked, but then she was mine on my 2nd night. Mom is a nurse as well. I don't think that mom had even noticed that she was a little different and I really felt like I should tell her something. Who knows, maybe the baby is fine, but I felt like I should have told her something. Being new, I discussed it with 2 other nurses who said I shouldn't. It was the doctor's job to talk to her about anything like that. I felt like the doctor wasn't being aggressive enough to at least evaluate the head and make sure things were okay. All the nurses on both days and nights felt like something was not right with her, but nothing seemed to be being done except the blood tests. Of note, her first child had hypothyroidism, but was no longer considered hypothyroid. Which is why ped had told her he ordered TSH/T4. I know that hypothyroidism babies can have large fontanels, so I hope that is what it is if anything, since it can be treated.

I was frustrated all night. She was the sweetest little thing, but I can see how the nursery was frustrated because she would just cry and cry sometimes and it was very high pitched. Even being held. Then sometimes she would be fine and sleep peacefully. My frustration was that I couldn't tell if she was in pain or it was just the way she cried.

Also that I felt like I had bonded with her mother, yet I didn't have the courage to at least say to her "I am not sure if you have noticed, but XXX's fontanels are a bit large. You might want to ask her pediatrician about that and see what he thinks." I didn't want to alarm her, but I felt like no one had told her anything.

So, what would you have done?

*To my patient and her daughter~I hope that all turns out okay and I am sorry I wasn't a better advocate for you guys. You are in my thoughts and prayers. *

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

Been there. I think you are wonderful nurse. As time goes by, you will gain confidence enough to know when to say something like this to a parent, and do it. You probably felt it "was not your place" or you might upset the mom if you did say something. I would have said what you were thinking, "you know, I noticed the baby's fontanels are larger than usual. This could mean nothing, or could warrant further investigation by your baby's pediatrician; make sure you ask about this at your first well-baby check up. Until then, please make sure you see your baby's pediatrician immediately if she feeds poorly, continues to cry shrilly and out of control, or stops wetting 6-8 diapers a day, or develops a fever."

I think you did very well. Your observation skills are VERY good, and sound. Do not diss yourself too much. Learn from what happened here as much as possible and never be afraid to make your observations known when needed. You are an excellent nurse!

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

Been there. I think you are wonderful nurse. As time goes by, you will gain confidence enough to know when to say something like this to a parent, and do it. You probably felt it "was not your place" or you might upset the mom if you did say something. I would have said what you were thinking, "you know, I noticed the baby's fontanels are larger than usual. This could mean nothing, or could warrant further investigation by your baby's pediatrician; make sure you ask about this at your first well-baby check up. Until then, please make sure you see your baby's pediatrician immediately if she feeds poorly, continues to cry shrilly and out of control, or stops wetting 6-8 diapers a day, or develops a fever."

I think you did very well. Your observation skills are VERY good, and sound. Do not diss yourself too much. Learn from what happened here as much as possible and never be afraid to make your observations known when needed. You are an excellent nurse!

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Thanks for your reply, SBE!! I always enjoy what you have to say and you inspire me to be the best nurse I can be. I know I have learned from this experience and hope to handle things like this better in the future. Thanks!!

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

we all make mistakes. we all see in hindsight how we can do better. i can't say how many times i have kicked myself when i screwed up (or thought i could have done better). it's all part of the package. you seems LIGHTYEARS ahead of me at the same point, really. i really had to learn a lot the first 2 years, and i look back and shake my head at times how much i did not know......

you did well. and you continue to be a wonderful patient advocate. i think you are on a great path. you CARE. i respect you 100%!

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You did well. Did anyone document frontal-occipital circumference? I was caring for a 6 mo old with unrelated illness once and MD did not agree he "looked funny". Mom stated he was fussy a lot, but she thought it was his temperament. I measured head at beginning and end of shift and convinced next nurse to do the same. Within 12 hrs there was a notable difference. The kid ended up having a shunt placed. Mom sent us a card saying "he was a different baby now". Heck, he had a headache for 6 months!

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thanks guys! i am learning more and more to trust my gut. whenever i don't, i feel bad about it later. it is usually after talking to some of the other nurses and then i get talked out of whatever i wanted to do, figuring they are more experienced. no more! not that i won't ask for help and opinions when i need them, but i will ultimately follow my instincts.

purplemania, we didn't do that. i have a feeling that the day nurse i gave report to was going to talk to the pediatrician. she was asking all kinds of good questions and she is a good nurse, so i am sure she got something done. hope when i go in next time i can find out what happened to her.

thanks again!

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I admire your caring and work ethic and as a new nurse myself (graduated in Dec2004), I am also struggling with this area of nursing. I have confidence issues and am gradually increasing my skill in discussing pt concerns with the docs. I know it sounds stupid, being so nervous just to communicate with another human being, but I just get so nervous. Well thanks for setting just a great example for me and for sharing your wonderful experience with us. Keep on doing a great job! You sound like an awesome nurse! :)

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You are a patient advocate and the best sort...One who speaks for those who can't speak for themselves....Kudos to you!

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Specializes in Critical Care, ER.

I think I would strongly encourage her to followup with her pediatrician with tact but saying the part about XXX is really beyond your scope of practice. In essence you are suggesting a diagnosis which can potentially upset mom. If you want to advocate, why not be more assertive with the peds attendings on the floor? You could use your instinct and evidence ( as well as that of all the other nurses) to really encourage the attending to investigate further.

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Nurs546-Thanks! It is hard for me to talk to the docs, too and I was an MA for 8 years and worked with docs all the time! I think not knowing them well has a lot to do with it. I rarely see them since I work nights and don't have a real feel for them. Good luck to you on your journey to becoming a great nurse! I know I have a long road ahead of me!!

Mermaid-Wish I had been a better patient advocate. But, I have learned and will next time!

Bluesky-I was using XXX as a name, instead of putting a name there. I wasn't talking about Trisomy X. I would never tell a patient/patient's parent they had a specific illness because that is the doctor's job, especially with no proof. I merely wish that I had told her that her daughter's fontanels were a bit large and that she might want to follow up with her pediatrician.

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