I am a student nurse doing my OB rotation. My teacher assigned me a postpartum c/s patient to take care of. I was with her from the moment she woke up in recovery until the end of my shift. This young lady is 16 y/o, just had her first child, and the c/s was due to fetal distress. They had her on morphine, pitocin and mag. sulfate. Everything was going fine until around 12:30 pm. As I was assessing her fundus, I noticed that she had blood stains from her incision site. The blood had stained her gown and one of her sheets. I called the RN and asked her to look at it. She did. The blood was not bright red and it had made a small stain on her dressing. The RN instructed me to mark the dressing and assess the site in about an hour to see if the stain had gotten any bigger. In an hour, my teacher comes in to look at the site. The stain did not get bigger on top of the dressing, however there was blood coming from the bottom of the dressing. This was only happening in one spot. My teacher went to go and get some 4 x 4 to reinforce the dressing. When she came back with the 4x4 we went to go and put it on pt.however the pt. is now bleeding from 3 different spots from the incision and the blood is running like a steady stream. My teacher tells me to put pressure on the bleeding while she goes and gets the nurse. Both my teacher and the nurse walks in a couple of seconds later and the nurse assess the situation and says that we need to get a doctor to look at it. There happens to be a doctor (we will call her dr.1) already on the floor checking on another pt. so they have her come in to take a look. By that time, my patient has soaked through several 4 x 4. Dr. 1 looks at the site and continues to put pressure on the incision. At first she says that sometimes incisions bleed, but it is nothing to be concerned about. Then she states that she doesn't want to remove the dressing because is probably tamponading the blood. However, as the pt. continues to soak through the 4 x 4 she realizes that she is probably going to have to remove the dressing and look at the incision. Dr. 1 removes the dressing. The bleeding has stopped, and she inspects the staples and the incision. She decides that it is not necessary to reopen the pt. so she begins to put on another dressing. As she does this, my pt. starts to bleed again. Dr. 1 asks us to call Dr. 2. A few minutes later Dr. 2 arrives. Dr. 2 assess the situation, and at first she feels that everything is OK, but upon further investigation she states that they should probably remove the staples. The nurse asks Dr. 2 to please take the pt. to the OR and sew her up there and then take her to the ICU floor for further evaluation since ICU has a 1 to 1 nurse/pt. ratio and she is short staffed and does not have the personnel to watch the pt. around the clock. Dr. 2 does not agree to this. Instead, Dr. 2 makes out a laundry list of things for the nurse to get for her and states that she is going to remove the pt.'s staples and sew her back up in the room. Due to the fact that the postpartum floor is not setup for this type of procedure, it takes the nurses a long time to come back with the stuff. In the mean time, Dr.1 decides to inject Lidocain around the incision site to numb the area. She tries to break off the neck of the ampule bottle, but she breaks it in such a way there are little pieces of glass everywhere and jagged edges on the bottle. Then she inverts the bottle to withdraw the medicine with her needle and the medicine spills all over the place. Dr. 2 starts to remove the staples. As she is removing one of the staples, blood starts to squart out. She starts to apply pressure, and the blood stops. She continues on with the removal of the staples and once that task is complete she reaches into my pt. (with clean gloves, not sterile gloves) and starts removing blood clots. Now both doctors realize that this procedure has turned out to be more extensive than what they thought, and they call for Dr. 3. Dr. 3 comes in and takes over the procedure. She cleans the pt. out, irrigate her, and sew up the bleeder, then she packs my pt. with a saline soaked gauze and tells her that she will need to go to the OR tomorrow and be sewn up. She then puts on another dressing and leaves. My pt. is wondering why they would just leave this hole in her and not sew or staple her back up. Her mom is concerned about her daughter is catching an infection. The Dr. says that the pt. will be fine and they leave. I visited my pt. today and at 4 p.m. she still had not been sewn up. When the mom asked why, the nurse replied that the doctors were doing C-sections and they would see her daughter before the night was out. She also replied that they now have all the supplies the doctor would need to sew up her daughter on the floor so that the Dr. could perform the procedure in the room. When I checked my pt. she was still having drainage from the incision site, and it was soaking through her gown.
This is my question, is this normal? Should the doctors have ever perfomed a procedure such as that in an unsterile environment? Isn't my pt. at an increased risk for infection? If so, shouldn't somebody be administering some type of antibiotic? Also, how long can she be kept open like is? I know that she has a dressing on, but there is a reason why the doctors either stitch up or sew up your outer skin layer. Please explain this to me. I am really trying to understand because on the outside looking in, this seemed like unsafe health care.
If ever I am put in this situation in my career and I am sure it will happen unfortunately. Can I pull the doctor aside and tell him that this patient needs to go to the OR and demand something other than what they were doing? As an RN, I am the advocate for the patient. So, is this within my rights or would it be considered out of line? I mean, I understand they are suppose to know more than me, but if I don't feel right about something and something looks "wrong" to me, is it in my right to suggest or demand something else?
Because this one doctor said no, they were not going to the OR and you the nurse thinks that is a bad choice, can you go above their head on that?
Thanks:)
Yes! You go right over their heads. You call the 2nd call, chief resident, attending, charge nurse, nursing supervisor. Heck, if there's a rapid response team at your institution, this would be a great time to call them.
It is not only within your rights to insist on apropriate care for your patient, it is your legal, moral and ethical obligation to do so. Failure to properly advocate for your patient can land you in front of your BON as well as in a courtroom!
The first course of action is to speak to the doctor privately. If that doesn't yield satisfactory results, then you must call the nursing supervisor. Your next avenue is the attending (if you are dealing with a resident) or the chief of the medical specialty (in this case the chief of OB).
You sound like you will be an excellent patient advocate. You can be my nurse any time!
I am a student also, so this is my guess. We do wound care as clean, not sterile, so maybe they looked at it as a wound, although it seems a little more involved than that..........................
:)
Quick point, you are correct - this is more involved because this isn't simply wound care it is a surgical wound/incision which is different.
Wow! This sounded like a real mess! :smackingf
I certainly hope this isn't the norm at this facility. Smilingblueeyes made some very good points, as always!
We have a code word on our unit when something is going on in a patients room and someone is uncomfortable with it that person tells the other person "I think we need some consensus here" We then take our discussion out of the patients room if able, or the other person knows that if they don't stop what they are doing the other person will start the chain of command.
It stops arguing in front of the patients and also lets the doc know that you are concerned enough that you are going to start getting help.
We had a case where an MD had put a vacuum on three times and was going to put it on a fourth after it popped off. The nurse asked for consenus, the patient ended up with a c-section for an 11 pound baby.
The MD said afterward, he really needed someone to make him pause and think about what he was doing. He actually thanked us!
Specializes in MedSurg-1yr, MotherBaby-6yrs NICU 4/07.
We, on occasion, do open incisions in the room, BUT NOT IMMEDIATELY POST-OP!!! This pt. would have gone back to OR. We are a high risk hospital, so we do have the equipment and manpower to do this. When we open incisions in the room, it is a day or two later on a "leaky" incision to reduce the amount of drainage and to prevent dehiscence of the wound. An opened wound is cleaner than one that pops open. Also, by letting the wound drain and be packed decreases the chance of infection. All of the fluid being behind the incision is breeding grounds for bacteria. That being said, your situation was very different. It was an actively bleeding wound, probably a bleeder not cauterized, and she needed OR exploration and repair. I am so sorry you experienced this, and then again I am glad. You learned that day, and through all of these posts many valuable lessons.
This is a mess ----they got in WAY OVER THEIR HEADS.I agree with Karen. What should have happened, is OR prepped/Team readied and patient whisked there for evaluation and PROPER treatment. There are so many things wrong with this scenario, I can't even enumerate them. It's obvious the people involved had no real clue what to do next.....
Figuring out WHERE the bleeding was coming from,yes, a priority.
I am also curious.....
What were her vital signs? You state she "squirted" blood, (not just oozed)----and someone reached in with (NONSTERILE!) gloves and "removed clots".....
this screams "trouble" right there!!!! Did her vital signs ever change? Did develop a fever?
And yes, you are right; infection is a huge risk here. I wonder if they ever did tx with antibiotics, given this situation, or at least order CBC and blood cultures?
I have to say the way it would have worked on my unit, is the primary doctor (the one who did the csection----or the physician on-call if after hours) would be up, surveying the situation, and correcting things in our OR prior to leaving the patient this way..... I can't speak for this institution, but it just appears to me there too many "cooks spoiling the brew" here---meaning too many doctors who did not know what they were doing messing around in there. While SOME wounds are re-opened and packed with sterile curlex, and left without re-stitching or stapling, this is usually later in the game, when wound healing is in jeopardy and they have signs of infection or dehiscence going on. This situation clearly is different.
I have to say, at best, it appears you witnessed some very disorganized care---at worst, serious neglect.
Finally, did you have a post-clinical conference to discuss the situation with your instructors? I wonder what they had to say, what their impressions were, since they actually witnessed this.....I was not there; you and your instructors were. This should really be discussed among you. Very serious situation going on there.
Situation is horrible, all around. So sorry. If you have more questions, or specifics to add, please let us know. Will keep checking.
Thanks everyone for replying to this message. l have had 2 test and 3 papers in the last week so I haven't been on-line, but I did want to give you an update on my patient. When I visited my patient last Wed. the doctors hadn't sewed her up yet. Before I left (around 4p.m.) I suggested to her mom that she should start to make some noise (because we know that the squeaky wheel get oil first). I came back to visit my patient on Thursday afternoon and she looked much better. She was sitting up in a chair, holding her baby, and had just finished her 3 round of antibiotics. She told me that they came and sewed her up around 6 pm Wednesday evening.
In response to your question, Smiling Blue Eyes, my teacher had me take my patient's bp every 5 minutes while the doctors were deciding what to do. Her pressure kept going up 150-160 systolic but she had PIH (which was why she was on Mag) and the doctors didn't feel that the BP was much of a concern. I didn't take her temp so I do not know if she spiked a fever. In post conference with my teacher, all she could do was diplomatically tell me that she did not know why the situation was handled the way it was.
I have learned so much from your replies. I am student nurse and so I have to walk a very fine line. However, I have been wondering if I was the RN, what should I have done? I really felt that the doctors were not providing safe care, and what bothered me was that nobody stood up for this young woman. I'm glad to know that there is a chain of command that a nurse can take when she sees a problem instead of just standing by watching a bad situation get worse.
i am not even a nurse but just reading about this made me wonder why didn't they call a surgen down to access the wound to see if the pacient needs to go back to the OR? but very good obersvation on your part debrasdd99
If I had been the nurse I would have initiated chain of command. This situation should have been handled in surgery. Your story makes my skin crawl. I guess the one good thing is you learned a lot from the experience (which I hope the patient survives!)
CarVsTree
1,078 Posts
Yes! You go right over their heads. You call the 2nd call, chief resident, attending, charge nurse, nursing supervisor. Heck, if there's a rapid response team at your institution, this would be a great time to call them.