Common Bedside Emergencies

I'm pleased to see this thread start up. I think there is too little focus on what to do when things go wrong in school, so I'm always glad to discuss this.

: What if my patient stops making urine? - what is going on with the patient? Did they come to the hospital already in kidney failure? Did they stop making urine or is it that they stopped emptying their urine? Or are they going just a little bit at a time? Do they have BPH or other prostate problems? Are they on dialysis? Are they in pain? When was the last time they went? Be sure to keep track of I&O. Has the patient recently had a foley removed? (If so, they have 8 hours to pee or they need to be straight cathed. Be prepared to insert a foley. If there is already a foley in, make sure it is not kinked. Assess intake. Do they have an IV going? Someone who hasn't peed in the last 10 hours who is asleep without an IV is different than someone who's on an iv of 150/hr who hasn't peed in 10 hours.

: Makes too much urine? - are they getting lasix? What makes you think they are peeing too much? I'm hard pressed to think of how this is a problem. Usually if they are peeing a TON, it is because they are getting a diuretic and are excreting a huge backlog of fluid in their legs/feet/lungs that has been making them edematous and coorifice, or it is because they are one of those patients with a half gallon jug of water on their table who also has a 175ml/hr IV going.

:Pulls his foley out? - assess the situation for safety first. Was this an accident or is the patient in need of restraints? Get help (the tech, the charge, another nurse) Get the situation safe first, take a set of vitals, approximate how much blood was lost, call the doc and anticipate the order of another foley being carefully inserted. They will probably ooze some blood for a while after. Medicate for pain. Do whatever possible to stop this from happening again. Put the call light nearby, strap the foley to the leg more securely, increase rounding on him, whatever.

: Twice? - think this guy needs restraints/sitter or haldol or something!

: Develops hematuria? - assess the amount of blood, how dark is the urine. Was there trauma? Anticipate potential CBI if there are clots. If no clots, no CBI, but possibly some gentle flushing of the foley.

: With clots? - call for a CBI order. Clots mean CBI.

: Without clots? - depends on the patient, its either a wait and see thing or they may do a couple times of gentle manual flushing to check for clots. You can do this by disconnecting the yellow portion of the foley from the clear portion, and using a syringe from an irrigation tray to gently flush. Get a fresh set of vitals, ensure the patient is not in distress and let the doc know to come up and evaluate him. I know blood in the urine looks scary but don't forget that blood can really discolor urine to make it look like the whole bag is bloody when its not always that bad.

: What if his BUN and creatinine are doubling every day? - again, depends on the patient. What meds is this guy on, what is he here for, does he have acute renal failure? Is he being well perfused? Ensure the doc sees these labs.

Hope this helps some!

This may not be quite what you need, but these are the things that were very scarey for me.

• Pt has vaso vagal episode and faints, which sometimes happens during evaluation of postural hypotension
  

• Pt falls when getting out of bed
  

• Pt has pulled out his IV, twice
  

• Pt falls down in bathroom
  

• You find the keep open IV empty after getting an IV count of 900 cc at shift report.
  

That is enough to think about for now.

THANK YOU SOO much Avah! i'm saving your response on one of my notes so i'll have it handy when i need it :)

thanks also centex. so what have you done when this happend? please enlighten us new grads :)

I agree that this type of Q & A is useful. I think newbies could probably use a bit more "what info would the MD likely want" and "what might the MD likely do/order" in regard to various situations/findings.

ok, the answers to your questions lie below.

you find the keep open iv empty after getting an iv count of 900 cc at shift report.

first, assess your patient. (your instinct is to run for help.) all physicians want accurate vs that are recent. pts are to be assessed for fluid overload, adequate urine output. assess the iv site for patency and put up a new bag of fluid infusing at the proper rate. (remember the 5 rights.) report to the charge nurse and quickly provide vs, assessment findings and intervention. if you notify the physician, he will most likely say to continue to monitor the patient.

pt has vaso vagal episode and faints, which sometimes happens during evaluation of postural hypotension

this is a preventive strategy. if the pt is in bed, assess your pt in lying position. have the pt sit forward for lung auscultation and initial bp, pulse. if that is wnl for that person, let them dangle at the bedside to allow their bodies to gradually acclimate to the change. most of these patients are hypovolemic, anemic or having a response to medication. dangling is not really sitting. it is like pre-sitting. re check bp, pulse, respirations. sitting is when they are stable on the side of the bed, and more likely to hit the dirt. if they have an ambulatory aide, such as a walker, get it and let the pt use it. but not before checking their bp again. when they are no longer dizzy, assist them to standing. if the pt becomes dizzy at any point, safety is first. this is where the art of nursing comes in. once the patient is back in bed and safe, call another nurse using the call light. or, if the person recovers quickly, offer clear liquids per unit procedure and evaluate meds that are ordered for that pt. based on your assessment and information from the physician and charge nurse, you can plan your care for the patient, which includes checking out meds for effects, side effects that might make your patient worse. review all antihypertensive, diuretic and cardiotonic drugs, previous vs, intake and output before notifying the physician. expect medication changes. if the pt has low bp you might ask if the physician would like to hold any meds; clarify this order by reading it back to him/her verbatim. no excuses. you know how to do the rest.

note to self: don’t forget that diabetics' blood glucose levels can fluctuate wildly when they are ill. adjust your plan of care accordingly.

pt falls when getting out of bed

pt has pulled out his iv, twice

pt falls down in bathroom

all of the above heart stopping events are really the same thing. bad. again, take a deep breath and focus on the patient. do not flee the scene. you are the best bet right now. evaluate for injuries. apply pressure to any bleeding. check the foley, if applicable. pull the emergency cord and stay with the patient. do not move her/him until help arrives. check the pt's pulse, respirations and bp if possible. (check your own pulse.) turn the head to avoid aspiration, if applicable. pray. for kindness, for wisdom, for the patient. then help will come and another nurse can help you make the next decision. write down all the vs that you took so that your charting will accurately reflect the event. that is why nurses wear such big watches. check the time. usually this sequence of events will result in a visit by a physician. expect to do vs every 15 minutes and receive new orders, including, but not limited to transfer to a higher level of care, draw blood, check blood sugar. make sure they aren’t septic. so if they have a catheter, iv site, surgical incision, any disruption of their integumentary system, assess it immediately for signs of infection.

i get tired, just writing about it, but it is so nice of you to ask me for follow up. please remember that these are skills honed over several decades and two separate centuries. we all have our own style, and this is how mine has turned out.

thank you for asking me to expound.

Great questions and answers. Just what I need.

These are the sorts of things we are not taught in school but are expected to know on the floor.

Thank you Thank you.

once again thank you centex! this helps a lot :) i'm just really nervous that some of these might happen while i'm on the floor... and i'm brand new!

to everyone, please feel free to post more bedside emergencies :) i know our experienced nurses have a lot of things in their hands, but if two has responded, maybe others will to :) .. KEEP THEM COMING! =]

: Develops hematuria? - assess the amount of blood, how dark is the urine. Was there trauma? Anticipate potential CBI if there are clots. If no clots, no CBI, but possibly some gentle flushing of the foley.

: With clots? - call for a CBI order. Clots mean CBI.

: Without clots? - depends on the patient, its either a wait and see thing or they may do a couple times of gentle manual flushing to check for clots. You can do this by disconnecting the yellow portion of the foley from the clear portion, and using a syringe from an irrigation tray to gently flush. Get a fresh set of vitals, ensure the patient is not in distress and let the doc know to come up and evaluate him. I know blood in the urine looks scary but don't forget that blood can really discolor urine to make it look like the whole bag is bloody when its not always that bad.

Also, if you're giving blood, new pinky-red urine can be a sign of an acute hemolytic reaction. Stop the blood, call the blood bank and the MD.

awsome thread,thanks!!

bedside emergencies from icufaqs.org = godsend

http://www.icufaqs.org/BedsideEmergencies.doc

I'm pleased to see this thread start up. I think there is too little focus on what to do when things go wrong in school, so I'm always glad to discuss this.

: Makes too much urine? - are they getting lasix? What makes you think they are peeing too much? I'm hard pressed to think of how this is a problem. Usually if they are peeing a TON, it is because they are getting a diuretic and are excreting a huge backlog of fluid in their legs/feet/lungs that has been making them edematous and coorifice, or it is because they are one of those patients with a half gallon jug of water on their table who also has a 175ml/hr IV going.

/quote]

Re: Making too much urine. I took care of a quadraplegic who drank so much she depleted her sodium...I'm talking the woman would put out in excess of 1500ml urine in a 8 hour shift. She eventually required a fluid restriction b/c of this problem. So too much urine, I'd check for hyponatremia or something like diabetes insipidus/siadh.

Re: Making too much urine. I took care of a quadraplegic who drank so much she depleted her sodium...I'm talking the woman would put out in excess of 1500ml urine in a 8 hour shift. She eventually required a fluid restriction b/c of this problem. So too much urine, I'd check for hyponatremia or something like diabetes insipidus/siadh.

I'm curious, how much was that woman drinking per day? And how low did her sodium go?