Dangerous lessons learned in your first year of nursing

1 - First big boo-boo as a new RN - after a lady partsl delivery, CRNA said to go ahead and d/c the epidural catheter - I thought he was speaking to me, but he was actually telling that to my preceptor. What did I do? I went ahead and pulled out the epid cath. Saved it, like a good new nurse would, to show immediately to my preceptor. She just about had a cow on me! I didn't know that there was a training process in removing epid caths. Did I ever learn quickly, to always ASK if it's ok to do a new procedure when I was being precepted!

2 - Use your critical thinking skills, and not just "follow orders" of an MD/CNM. If it's something that you see will potentially harm your patient, then SPEAK UP.

Jen

L&D RN

d/c'd an IV on a girl that had not been up to pee yet. (had lots of IV fluid, but was a few hours out from delivery).....

she had eaten dinner, done fine.

DID NOT CHECK HER BLADDER FOR DISTENTION. (broke a very basic rule here)

She got up to pee, and briefly passed out. She was mottled and very nauseous. WELL NO WONDER; I had let her bladder fill up w/dang near a liter of urine, and her uterus was bogging up. She bled ......

a lot.

She also became shocky due to the concealed hemorrhaging/clotting in her ute, thanks to me.

Got 2 IVs in, open wide (bp was 70s over 40s, HR 130 or so and she was very shocky)

Massaged out two HUGE CLOTS (think liver here folks) and lots of blood.

Cath'd for nearly 1 liter of urine.(!)

SHAME ON ME. She "seemed" fine, 3 hours or so out from delivery.

Lessons learned:

* always check for bladder distention, even if you have cath, they can become clogged.

*always check fundus for firmness ,and often, in that first day.....

*NEVER EVER D/C a saline lock or IV til patient is stable on her own feet, voiding and taking PO nutrition well. NEVER.

She did fine thankfully, no thanks to me.

I have a few other stories, will let others share first. I learned many things the hard way, not having had a preceptor or residency to learn. I basically learned things by the "seat of my pants" and had God on my side when I screwed up.

We have this doc that is very aggressive with his labor pts. He will use high dose pit and if he thinks you are not going up fast enough he will increase it himself when you are out of the room. Well, when I was **NEW** to L& D (just out of orientation) he requested for me to give him 50 mcg of cytotec. He always used that dose. Also, I knew this pt personally just to make this whole thing worse. Anyhow, he inserts it and I run between 2 pts , this pt and one on pit. What did not occur to me at the time was that she was attempting a VBAC. It was ugly......decels, bleeding, a really LONG time (20 min)in the OR as doc allows anes resident to miss a couple spinals with FHR below 100 absent STV, pt begging to get a general, Charge nurse asking the doc to do a general, APGARS 1, 3, 7. Spent a week in SCN. She abrupted, but doc tells pt "It was such a small abruption" as if to say No big deal! When I see this woman I always ask about her daughter, and she is perfect and has no deficits at all. She is school age now. I am lucky I could follow up, because this one would really stick with me.

Lesson learned: Know ALL you drugs side effects and contraindications and question your doc if need be. Sounds basic, but when you are hurried and overwhelmed you can miss the big things. Even if it takes an extra 5 minutes and someone is breathing down you neck.

I know beyond a doubt that this doc would have found the cytotec himself and given it. I just felt so guilty for not questioning the high dose and the fact that ANY dose is contraindicated in VBACS.

d/c'd an IV on a girl that had not been up to pee yet. (had lots of IV fluid, but was a few hours out from delivery).....

she had eaten dinner, done fine.

DID NOT CHECK HER BLADDER FOR DISTENTION. (broke a very basic rule here)

She got up to pee, and briefly passed out. She was mottled and very nauseous. WELL NO WONDER; I had let her bladder fill up w/dang near a liter of urine, and her uterus was bogging up. She bled ......

a lot.

She also became shocky due to the concealed hemorrhaging/clotting in her ute, thanks to me.

Got 2 IVs in, open wide (bp was 70s over 40s, HR 130 or so and she was very shocky)

Massaged out two HUGE CLOTS (think liver here folks) and lots of blood.

Cath'd for nearly 1 liter of urine.(!)

SHAME ON ME. She "seemed" fine, 3 hours or so out from delivery.

Lessons learned:

* always check for bladder distention, even if you have cath, they can become clogged.

*always check fundus for firmness ,and often, in that first day.....

*NEVER EVER D/C a saline lock or IV til patient is stable on her own feet, voiding and taking PO nutrition well. NEVER.

She did fine thankfully, no thanks to me.

I have a few other stories, will let others share first. I learned many things the hard way, not having had a preceptor or residency to learn. I basically learned things by the "seat of my pants" and had God on my side when I screwed up.

Off topic, but you just described what happened to me right after I delivered my last child. IV infiltrated during delivery, so they just pulled it. I couldn't pee post delivery, but I had been up to the bathroom with the nurse earlier so I thought I'd try to go on my own. It had been several hours (as in I was admitted at midnight, peed then for a sample, and this was at 10 am and hadn't gone since then) since I had urinated and I knew that I had to go soon or I'd be cathed. I stood up to walk to the bathroom and on my way there there was a big (and I mean big) gush of blood all over myself and the floor. I hobbled to the toilet, and my last coherent thought was, "I'd better pull the emergency call bell." All of a sudden, there's yelling going on around me, and me, being nurse minded, yell back..."I'm all right, I didn't fall or anything!" (just thinking of all the paperwork involved for them). They are pulling huge clots out of me, I start leaning (falling) over, they yell "Put your head down", I'm thinking, "Have you seen my stomach recently??" and then I get a dose of that ever so pleasant ammonia thingy. To shorten this story a bit, I wind up in bed and straight cathed for some crazy amount (I was still out of it), but then felt much better.

I guess what you can get out of this story (besides a headache) is patient education....if I'd known that there was a risk of heavy bleeding, low BP and the side effects that go with it because of the fact that I hadn't urinated in a while, I would have called for the nurse before I tried to ambulate to the bathroom independently. Luckily, when those nurses saw the emergency bell there were at least 3 nurses in there almost instantly. But, if they were all busy, I would've passed out on the toilet. So, err on the side of caution.....I seemed fine to my nurse, but I quickly went downhill. Educate, and tell them to always ask for help.

As a new grad, I oriented first to postpartum/mother-baby care, for about 3 months, and then to labor for another 3 months. About a month after I finished labor orientation I took a postpartum eclamptic pt on mag- she had seized at home about a week out from delivery. She was 1:1, so I had no other pts, but the floor was really busy. I did have a more experienced nurse available as my resource though. I kept our policy in hand, and thought I was doing a good job. She had been feeling really "magtastic" (as I call it)- flushed, weak, miserable- since the mag was started. About 2 or 3am I was no longer able to elicit patellar DTRs. I know now that I should have called the doc right then, but her urine output was still adequate/unchanged, her respiratory rate was unchanged, so I continued to monitor her. And did not bring this change in her status to the attention of my resource. I showed her my flowsheet but it was for a question about how often to have the pt pump, since she was really tired (clue #2 that she was getting mag toxic, she was really lethargic). I thought since her UO & RR were good, it was OK. 7am rolls around, my relief is a no-call-no-show so I offer to stay until 8:30 when someone else could take her over. Doc calls for report, orders a mag level immediately. My relief takes over before the results come up. Therapeutic value for our lab is under 8, her mag level was at least 10!

I learned this a couple days later, when I was called in for a "meeting" with my clinical coordinators and manager. The meeting started with my manager asking if I still felt that labor & delivery was where I wanted to be, and ended with me in tears but back on orientation for 3 months as a sort of probabtion.

I learned a good lesson though. Luckily the pt did not suffer any lasting harm, the mag was shut off as soon as the mag level came back and she was fine. Everyone was actually puzzled as to why she got mag toxic so quickly on a standard dose (2gr/hr) . The next time I had a pt on mag, as soon as she had the slightest change in reflexes (I think she was 2+ to start and they diminished slightly in the middle of the night) I called the provider and got an order for a stat mag level. Of course in the AM when the doc covering that midwife called for an update and I told him the mag level, he bit my head off- "who ordered a mag level? I didn't order that" but bit his tongue when I explained (he's a complete jerk anyway). And even this past week, when I had a pp pt on mag, I dragged the midwife out of bed to come do an assessment on our pt when things changed. I've learned my lesson, and I never hesitate to tell my story to a newer nurse if I think it will help them. I nearly lost my job over it, but more importantly, I risked my patient's safety. And I never want to feel like that again.

"magtastic"

what a cool term Sara!

GREAT info, everyone. Keep up the good advice.

Sarah,

I was just wondering .. do you guys not do routine mag levels? Our Mag protocol includes a Mag level Q 6 hours. I hate it for these pts that they have to be stuck so often, but then again it does keep a suprise from sneaking up on you like you had. It also helps to ensure that the pt is within a theraputic range.

We don't do routine mag level checks. We monitor the patient. Sticking a patient q6h seems a bit over the top (in my opinion). Diligent assessments will also catch a problem.

what a cool term Sara!

Thanks Deb :) It fits, don't you think?

Sarah,

I was just wondering .. do you guys not do routine mag levels? Our Mag protocol includes a Mag level Q 6 hours.

No, it's not part of our protocol to do routine mag levels. I think it would be better if it was, since they're getting fairly liberal with mag lately (ordering it a lot more often, even since I started 2 years ago) One practice seems to be somewhat routinely ordering a mag level after some number of hours to ensure it's in therapeutic range, the other practice, not so much.

Most places I know of do not do routine magnesium levels. They seem to "lag" and not always stand accurate to patient responses. I learned a valuable lesson: YOU CANNOT RELY ON MAG LEVELS TO DIAGNOSE TOXICITY IN YOUR PATIENT. If you do, you are in trouble. (maybe). You need to assess-assess-assess. Another story:

Had a girl who had been on mag for a week---- pretermer who was 33 weeks' or so with definate threatened preterm labor going on. She had tolerated it very well and never had a single problem w/the mag drip the whole week. She was also fine when I did my a.m. assessment on her at 0700. Well around 0830 or 0900, the social worker came from her room to talk to me and said (*I WILL NEVER FORGET THIS*): "your patient is talking very strangely; she is slurring her words, does she have a speech impediment or something?" (the social worker had never seen her before---thank goodness for that lady)

UMMM no!!!!!! No speech problems I know of!

I went in there and the patient managed to tell me, (and yes, she was very slurred) she felt very "heavy" in her chest, like an elephant sitting on it. She had zero reflexes and her face WAS INDEED slanted very strangely to one side. She did NOT look like that when I assessed her as I came on my shift (about 1-2 hours' prior).

Well of COURSE I turned off the mag, got O2 sat on, put O2 on via mask and called the dr, who ordered a stat mag level. It was 5. something----(this was years ago, do not remember the level but NOT NEARLY TOXIC). WHAAAAAAAAAAT?????

Anyhow, I got the calcium gluconate drawn up, and asked dr if I could push it (I was talking to dr in patient's room). She said "no just wait and see what happens".

I am not lying, within 15-20 min of turning off the mag drip, the patient began to return to normal. No more facial or speech symptoms and she was able to tell me, her chest felt MUCH BETTER. Thankfully, she never dropped her sats below 99%.

So I caution you, never, ever rely on mag levels to do the job. I think that is why many places have moved away from doing this. Assessment is the only way to truly diagnose a toxic or allergic reaction to magnesium.

Lesson one: do not rely on mag levels to help you here.

And the lesson I also learned? DO YOUR ASSESSMENTS HOURLY as long as the person is on mag and for a few hours after ward!!!!! Some become "toxic" at much lower levels than others. (this really is Nursing 101---assessment has never been more important than it is when your patient is on a medication like mag sulfate (or any tocolytic).

See I how I learned things the hard way??? I really nearly quit OB that first year.

Magtastic .... I love it! I was cracking up! We call the patients "magnetized" at my hospital......

Vital signs being done - "vitalized"

And of course.... pitocin is "vitamin P"

Jen

L&D RN

We always just say someone is "magged out". And yes, SBE I know that lab work or any diagnostic testing of any kind is not a replacement for pt assessment.