CT output & notifying MD

allnurses Guide · Dec 5, 2008

I would clarify with the surgeon when they give the order. Ours usually specify for notification if drainage > x mls/hr for 2 consecutive hours - helpful because a one-off dump wouldn't affect it. If you thought it was an isolated incident which didn't continue, I would not call about it.

PS: You ambulate patients at 4:30am? Wow - that's an early morning walk!

highlandlass1592, BSN, RN · Dec 5, 2008

Missing some information here. You said the pt dumped 180 cc and you said it was due to normal physiological changes, ie pocket drainage. But you didn't list some assessment clues: was the drainage more serous or more bloody? Did you go ahead and send any labs? If you didn't call the MD, what were your o/p's for the following hours?

I think you can definitely call the physician if you're concerned but if the drainage was more serous, I would have sat on it a bit then maybe called in an fyi if something felt fishy. If it was a one-time dump and the fluid wasn't bloody, I probably wouldn't have called them either.

Now as for the other part of your post about following orders. I'd disagree with your charge RN that you only need to follow orders if something happens. I'm guessing you don't have residents to back you up...maybe a private hospital? Who do you notify in an emergency, the attending surgeon? That can complicate matters. You need to know what your chain of command is in an emergent situation and follow it accordingly. If you work off standing orders, do you have a contingency for such a situation? (Does the order say anything other than to notify for CT o/p >150/hr? some places I've worked at do have further orders than that. If not, that may be something they want to get addressed) I think an important point is to know what your docs really want you to do. As you develop relationships with them, you should grow in your understanding of what they want you to do in situations.

That all being said I think the gist of your post is the fear of being hung out to dry regarding MD's. I can understand your concern. But your best defense against being hung out to dry is using appropriate nursing interventions and document, document, document. Say you had called this physician, notified him of the situation and he didn't give you any orders. This doesn't release you from liability if something does happen and you didn't follow the standard of care for critical care nurses, legally you could still run into trouble. You need to cover yourself by charting an assessment of the situation, what you found, and what you did about it...just calling the doc isn't enough. And if you don't get orders, you can still institute appropriate interventions: frequent monitoring, assessments, if allowed by your standard of care lab draws, etc. It's hard when you're a newer nurse to develop the confidence in these situations.

Yes, I've seen other MD's try to get nurses in trouble. I've been the object of such a situation; the doc was a total idiot and wanted me to pay the price for his substandard tx of a pt. That all being said, my charting really saved me. Everything was documented in a timely manner and no fault could be brought to my door. If you are really worried that your license is in jeopardy, call the doc. Worst that can happen is you're gonna get yelled at....won't be the first time, won't be the last. You learn to deal with it. But I think as you gain more confidence and experience, this type of dilemna will become easier for you to handle. My post was long winded, sorry about that...it's a tough topic to deal with. It's hard when you're young and there seem to be so many grey areas. Just keep plugging away. :twocents:

WalkieTalkie, RN · Dec 17, 2008

Quick Question -
On my facility's post-acb orders, it states 'Notify MD if CT output greater than 150 ml/hr."
I have been a CVICU RN for 1 1/2 years but still feel like I never know when it is appropriate to notify MD's, etc.
My patient was bathed and ambulated at 4:30 am. The past 6-10 hrs the CT output had been 10 - 30 ml/hr. When I checked my CT output at 5 am, my CT output was 180 ml.
There was no changes hemodynamically. No change in BP, HR, RR, O2 sat, patient complaints, etc. It was pretty obvious that it was pocketed fluid that drained after ambulating.
I went to my charge RN, and informed her of the dump and asked if I should notify the MD. She asked about the patient and she asked me what I thought. I explained that it was just a normal physiological change after ambulating. I told her about the order and I felt like I had to protect my self, follow the order, so that if something happened to the patient in an hour and I hadn't called the MD, if could come back and reflect poorly on me.
She said that I have to be able to not be a 'robot' and you only have to follow the orders if warranted by a change or something needs to be done.
When I passed report on to the next nurse, the said they would not have called the MD either.
Am I wrong in thinking that I should follow the orders exactly to avoid a legal issue? I have just seen some MD's go after nurses and their licenses due to unforeseeable events ... say my patient above coded 30 minutes later, the MD comes in and sees that and starts to question why they weren't notified, not that they should have been, but to point finders...
Thanks.

Quite honestly, I probably wouldn't call for this. Was it bright red blood? Was there more after it came out? I usually dangle my patients a couple of hours after extubation and this almost always happens. The same thing happens when we get them up to the chair in the morning (usually somewhere between 50-150 ml) from turning and bathing, etc.

If the blood was bright red and had previously been serosanguinous, I would be concerned and call.