Anxiety over Patient Care

[nursingcutie, RN]

Hello I am new grad nurse thats only been working for about 6 months. When this particular incident happened I had been off orientation for about 2 months. I had this post op GYN 60 y/o f who just had a hysterectomy and was DTV at about 12pm and then be discharged. Now if you ever cared for GYN patients its really important for them to void after surgery to ensure the bladder was not damaged. The patient voided only about 50ml at about 10 pm which was 2 hours after the surgery with nothing in her bladder when bladder scanned. GYN likes at least 200 ml of urine for their post op patients  and ordered a 500 ml bolus of LR on top of 75 ml/hr of LR for maintenance fluid. At about 11pm the patient only voided 100ml. GYN ordered another 500ml bolus and decided the patient needed to stay until morning to ensure she voided a good amount of urine. The patient kept voiding small amounts 50 or 100 ml. At about 12 pm she voided only 50 ml and when bladder scanned had about 200ml in the bladder. GYN ordered a foley insertion and the patient had a health output at first. Over the next few hours the patient only had about 50 ml of urine from the foley. GYN ordered another 500 ml bolus and said they would draw labs. I was a little skeptical about administering the bolus since this would be her third bolus and she has 75ml/hr maintenance fluid so I asked a senior nurse and she said to clarify with the doctor which I did. I even wrote a note identifying which doctor I spoke to before administering the bolus. The senior nurse told me it was okay as long as I clarified with the MD. To make a long story short the patients sodium level dropped to about 126 and she ended up having to stay another a night in the hospital for observation. She was fine and was discharged the next day  but I can never forget about because I feel as though I caused it and I am always scared that she can sue me for something or that it could've been much worse. I just want to know could I have done something differently and how do I get over this feeling of anxiety and impending doom?

[TriciaJ, RN]

Take a breath.  Your wall of text is a bit unclear.  Also was she to discharge at midnight or noon the next day?

What does DTV stand for?  I'm not familiar with it.  I assume she had a lap hyst since she didn't have a Foley when you received her.

I'm really unfamiliar with LR boluses for low urinary output postop.  I've administered a lot of NS 1000ml boluses.  If age is a factor, you could always put it on a pump and admin over 2-3 hours.

You clarified the order with the senior nurse and the MD and documented this.  I really don't know what more you could have done.  The doctor really has final accountability for what he/she ordered.

If anything comes of this, please ask sincerely what you should have done differently, for future reference.  It really comes down to, should you have refused to implement the order?  If so, what would be the specific rationale?

You said the patient was fine and discharged the next day.  She has no grounds to sue you for anything.  You will occasionally encounter patients with low UOP postop.  Ask your coworkers how that is typically addressed.  Maybe this particular surgeon just has his/her own way.

[Wandering-night, BSN]

Hello,

With the case of bladder scan at my hospital we have a standard procedure to straight cath the patient one time after bladder scanning the patient if they have about 500 cc or more in the bladder. If it was a persistent issue and patient still wasn’t producing any urine or not enough per hour based on weight and total I/O, I might have had a BMP draw if the output dropped to see if her bun/creatinine went up to suggest AKI or if there were initial electrolyte imbalances. Typically I see NS boluses given to help with output, hypovolemia, or drop in cardiac output and not much of LR. I’m not sure what his rationale for LR boluses were but he went to med school not me LOL! We can only do so much as nurses and it’s great you were advocating for your patient and contacted the doctor a lot! In the end it was the doctors decision to order those fluids.

[Hannahbanana, BSN, MSN]

If she was awake and alert, why not just push oral fluids of choice? 500cc is just a bit over two cups (480cc). Would you have been concerned if she was thirsty and drank that much? 
 

[nursingcutie, RN]

10 hours ago, TriciaJ said:

Take a breath.  Your wall of text is a bit unclear.  Also was she to discharge at midnight or noon the next day?

What does DTV stand for?  I'm not familiar with it.  I assume she had a lap hyst since she didn't have a Foley when you received her.

I'm really unfamiliar with LR boluses for low urinary output postop.  I've administered a lot of NS 1000ml boluses.  If age is a factor, you could always put it on a pump and admin over 2-3 hours.

You clarified the order with the senior nurse and the MD and documented this.  I really don't know what more you could have done.  The doctor really has final accountability for what he/she ordered.

If anything comes of this, please ask sincerely what you should have done differently, for future reference.  It really comes down to, should you have refused to implement the order?  If so, what would be the specific rationale?

You said the patient was fine and discharged the next day.  She has no grounds to sue you for anything.  You will occasionally encounter patients with low UOP postop.  Ask your coworkers how that is typically addressed.  Maybe this particular surgeon just has his/her own way.

DTV means due to void so after surgery they are supposed to void about 8 hrs later and a lot of the times with GYN patients once they void they can be discharged. But thanks for the kind words I just get really anxious that I didn’t do enough for the patient.

[nursingcutie, RN]

3 hours ago, Wandering-night said:

Hello,

With the case of bladder scan at my hospital we have a standard procedure to straight cath the patient one time after bladder scanning the patient if they have about 500 cc or more in the bladder. If it was a persistent issue and patient still wasn’t producing any urine or not enough per hour based on weight and total I/O, I might have had a BMP draw if the output dropped to see if her bun/creatinine went up to suggest AKI or if there were initial electrolyte imbalances. Typically I see NS boluses given to help with output, hypovolemia, or drop in cardiac output and not much of LR. I’m not sure what his rationale for LR boluses were but he went to med school not me LOL! We can only do so much as nurses and it’s great you were advocating for your patient and contacted the doctor a lot! In the end it was the doctors decision to order those fluids.

Thank you for input! Typically on our unit the MDs alternate between NS and LR for fluid boluses so that isn’t out of the ordinary for me. But again thanks for the input you really put me at ease.

[VaniCCRN, BSN, RN]

2 hours ago, Hannahbanana said:

If she was awake and alert, why not just push oral fluids of choice? 500cc is just a bit over two cups (480cc). Would you have been concerned if she was thirsty and drank that much? 
 

 

First off, the story is confusing because I believe the OP is mixing up AMs and PMs but it sounds like this was the course of care:

8am - post-op period begins. 
10am - patient makes 50 mL of UOP; MD orders 500 mL bolus LR and starts 75 mL/hr of LR
11am - Pt voids 100 mL; MD orders 500 mL bolus. 
12pm - 50 mL of UOP; bladder scan reveals 200 mL in bladder; foley is inserted and OP states that adequate UOP is made (however doesn't provide a number).

... next "few hours" acc to OP; pt only made 50 mL UOP. MD orders another 500mL of LR.

 

The patient probably received 1500 mL to 2000 mL of LR in total between boluses and maintenance. 

As far as the patient drinking water?

 

Perhaps it has to do with free water versus providing fluids that are more physiologically similar to plasma. Providing free water (I.e. drinking water/providing Dextrose 5% solutions) is more well suited for loss of free water. In the case presented by the OP, it sounds like it would be in the interest of the patient that the fluid stay in the vascular space so that it may be destined to enter renal circulation, and therefore end up in the bladder.

Long story short, OP this is NOT your fault. There are a lot of things that we don't know, like what happened intra-op? fluid loss? EBL? IVF received? What is her PMH? 

the SODIUM content in LR is I believe about 130 meEq/L and therefore, someone could potentially be made HYPOnatremic by over-treatment. 

0.9% NS has about 150 mEq of N+ per liter of normal saline. 

Maybe she should have been treated with NS 0.9%? 

 

 

 

[LovingLife123]

The LR didn’t drop her sodium.  Patients are often dry post op so that’s why the boluses were ordered.  I see nothing wrong with what occurred.  Were labs drawn preop to see that baseline sodium level?  Some people live with low sodium.  Especially if they are drinkers.  And in this case while NS would have been the better choice, nobody knew what the sodium level was at the time so LR was not a bad choice.  
 

Some patients just require more fluids than others post op.  You did nothing wrong.

[londonflo]

On 4/18/2021 at 11:33 PM, nursingcutie said:

Now if you ever cared for GYN patients its really important for them to void after surgery to ensure the bladder was not damaged.

 

Was this a lady partsl hyst?. It is important for every post op patient to void after surgery. Were you thinking of neurogenic bladder? The bladder is very close to the uterus and this is quite evident when a heavily pregnant women needs to void frequently.

According to you wrote you did nothing wrong...you kept a careful eye on her. I wonder though if you offered fluids frequently? What about post op teaching? Besides a watchful eye, we need to suggest interventions. (BTW I am an old nurse and our hysterectomies stayed atleast 5 days....) Did you check her HGB post op, maintain DVT prophylaxis, work with her bowel function returning? Get her up to walk?I do not see a lot of independent nursing interventions in your post...just following MD orders for the most part. I wonder if this is what worries you??