Bleeding out

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Specializes in Transplant, homecare, hospice.

I'm trying to understand this. Maybe you can help me. I had a patient who had and OLT (orthostatic liver transplant) a day prior when I had him. He had abdominal ascities (common for ESLD pts). He had +1 to +2 generalized edema. No SOB, lung sounds clear but diminshed in the bases bilaterally. No complaints of pain, mild bizarre affect. A/Ox3, cooperative and pleasant. He was draining COPIOUS amounts of red bloody drainage from his chevron incision on the right outer aspect. And from also around his JP drain and in the bulb as well. This went on on day shift. My shift, into the next day shift and on and on it went. The MD's were aware. What is that supposed to mean? They were aware??? His Hgb was dropping fast! When I had him, it went from 11.0 to 9.6 in a 12 hour period. No brainer.

The 2nd night, I was reassigned to a fresh post op transplant patient but this OLT bleeder was next to my room. A float nurse who was not familiar with him or transplant protocol for him. I was always checking in on him and seeing how he was doing. The float nurse called me in to assess him to see what I thought. I immediately took his blood pressure and told her to call respiratory. His O2 sat was 96%, which was fine, but he was abdominal breathing and had increased RR. His abd was more distended, with less drainage. The feeling that I got was his body was holding onto the bloody drainage now and pushing into his diaphram and pushing on his lungs. This time when I listened to his lungs, they were absent on the right side and very diminished on the left side. The float nurse was nonchallant. I don't think she understood the severity of the situation.

What I don't understand is, the MDs were aware???? And when the PA was called when he was in respiratory distress, she was also nonchallant. The RRT was frustrated and kept coming to me to step in. I told her the patient wasn't mine, but kept stepping in to make sure the pt was okay and making sure that the float nurse was calling everyone and telling them it was a STAT situation. Why didn't the MDs pay closer attention to this? Why did they wait until this guy filled up with fluid? This isn't like our unit to be like this. The RRTs were asking me the same thing. I was frustrated and said, "I think we're doing too many transplants and they're loosing track of people." :o

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Specializes in Cath Lab, OR, CPHN/SN, ER.
What I don't understand is, the MDs were aware???? And when the PA was called when he was in respiratory distress, she was also nonchallant. The RRT was frustrated and kept coming to me to step in. I told her the patient wasn't mine, but kept stepping in to make sure the pt was okay and making sure that the float nurse was calling everyone and telling them it was a STAT situation. Why didn't the MDs pay closer attention to this? Why did they wait until this guy filled up with fluid? This isn't like our unit to be like this. The RRTs were asking me the same thing. I was frustrated and said, "I think we're doing too many transplants and they're loosing track of people." :o

I'm glad you were there for this patient!

I think you've already addressed the problem- the other nurse didn't understand the severity of it (because she's not familiar with that patient or the complications?). She probably failed to pass on the importance to the doctors. I'm sure if someone had gotten on the phone with a stern voice and said "You need to come see this patient NOW. Something is NOT right" (HELLO! No breath sounds on one side of COURSE is not right!) then the docs might have taken it a bit more seriously.

Charting your hiney off- if I put an MD is aware of something, I also put down why an action was not performed, and any follow up that may have been done (Ex- "Recalled Dr. Smith regarding _______, does not wish to give this med at this time due to hypotension" or something like that).

I had something similar happen with a nurse down in our ED once- I think it says a lot about you as a nurse that the RT was coming to YOU about the patient- they trusted you and saw that you knew the situation was urgent.

Good job- How did the patient turn out?

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Specializes in Transplant, homecare, hospice.

Good job- How did the patient turn out?

Thanks for the great advice! I'm not sure....last I saw him, he had just taken his clonidine. He was still the same when I had left. They had done a portable chest xray with pending results. I'll know on Saturday....I really felt like he needed a chest tube or for the liver team to go back in there and fix whatever was leaking....

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Specializes in Rehab, Med Surg, Home Care.

How low was his BP when you assessed him for the float nurse? Was there a doc available and did you talk to him/ her yourself? Did the "docs who were aware" put anything useful in their notes? (I know- who has time to read thru 2 days worth of notes let alone try to decipher the MD's handwriting if not computer entry...) If I have a pt like this I need to talk to an MD even if just the doc "du jour" and I'll tell them that even if they tell me I'm full of crap I'll be relieved 'cause I heard it with my own ears. I try to get a plan of action from them, especially heading into the nite shift; ie, actual physical/ VS parameters outside of which either there is some specific action I can take or I call them back. I've made several catches this way and actually saved time in the long run and especially, anxiety. I agree- scary patient. Please keep us updated!

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ignorance is bliss, with experience you loose it and become more aware as you know what can really happen

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Specializes in Transplant, homecare, hospice.
How low was his BP when you assessed him for the float nurse? Was there a doc available and did you talk to him/ her yourself? Did the "docs who were aware" put anything useful in their notes? (I know- who has time to read thru 2 days worth of notes let alone try to decipher the MD's handwriting if not computer entry...) If I have a pt like this I need to talk to an MD even if just the doc "du jour" and I'll tell them that even if they tell me I'm full of crap I'll be relieved 'cause I heard it with my own ears. I try to get a plan of action from them, especially heading into the nite shift; ie, actual physical/ VS parameters outside of which either there is some specific action I can take or I call them back. I've made several catches this way and actually saved time in the long run and especially, anxiety. I agree- scary patient. Please keep us updated!

I feel like I did the right thing. He was hypertensive. Not super high. It was 170/92. We are the call the MD/PA whoever is on call when it is higher than 160/90. She was going to give him a pain pill and call it a day. She said that we were causing his distress and making it worse. I told her that on our floor, we don't ignore respiratory distress, and HTN. And we don't freely hand out pain meds...especially in this case...but also because...they are LIVER transplant patients....Pain meds are PRN and he wasn't asking for anything for pain...he was saying over and over that he had SOB. Once the entire floor of nurses got involved, I backed off and went back to my own patient who was having UOP issues on POD 1 from an OLT.

I was not sure why the OLT bleeder was not being treated more invasively because it was obvious what was going on! I'll let you know what happened.

I like this float nurse. She's a really nice person, just not rational. Maybe like someone said, it's not her floor and she wasn't sure of what to do. Thanks for the input.

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Specializes in Med/Surg, Ortho.

Wow,, the entire floor of nurses got involved in this one case?,, Can you say anxiety attack?

Why wasnt the supervisor called to assist you and the float and the rest should have been told to stay back unless needed. I think i would have been short of breath and restless and upset if i had a dozen different nurses peering over me too.

Im not saying your evaluation was wrong,, just that that poor patient was getting red flags from all directions with that many different faces in and out of the room. Blood pressure may have been a bit lower had he not sensed from all the action that there was major trouble.

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