In the pitocin thread, a suggestion was made about starting a thread about dangerous first year lessons learned. Personally, I shudder at the fact that there is no way I can know everything before I am on my own on the floor. I hate that some patients will be at my mercy as an inexperienced new nurse, and I am seeking all information possible in the interest of my patients' safety. So this is a very loud, desperate plea for all of you experienced OB nurses out there to contribute and share about scary situations that taught you valuable lessons.
Here are my two valuable lesson learned thus far:
1) NEVER TAKE SHORT-CUTS. Chances are, you will miss something, and it will be something big.
2) Suck it up and drink some coffee when you are tired and feeling lazy. These are the days that some crazy stuff happens, and your pts are depending on you.
To anyone and everyone: please contribute, no matter how small or insignificant you may think your words are!!!!!
Slamming a flush means pushing it too fast. Flush refers to saline that is pushed after the drug to "flush" the IV and get the last of the drug in that is sitting in the IV. So the flush may be only normal saline but it was pushing the meds in and if that goes too fast it can cause problems.
I'm a student too but I just learned to flush (always gently) last week.
I loved the "magtastic" I'm gonna have to use that.
What I have learned...
ALWAYS check tubing after new nurses. I had to take over on a pt who requested not to have the nurse who had been assigned to her. She was new and just was not getting it. I went in and was assessing the pt, checked her IV's and saw that she had main lined her pitocin and put an antibiotic through the pump, luckily she had forgotten to unclamp her iv so the bolus wasn't given adn we had an intact uterus.
pt's families can be horibly demanding and demeaning.
always eat something, even if its crackers in your pocket as you speed walk down the hall.
don't trust your toco-always palpate your belly.
always put on your gloves, you never know when you will deliver a precipitous baby, even when the doctor is at the desk.
I went in and was assessing the pt, checked her IV's and saw that she had main lined her pitocin and put an antibiotic through the pump, luckily she had forgotten to unclamp her iv so the bolus wasn't given and we had an intact uterus.
AAAAAAAH, that scares the bejeezus out of me. That sounds like the time one of our nurses bolused Mag. Very scary. I'm always very careful to check my lines.
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
so scary about the mainline pit. It can happen to ANY of us. I always label lines w/tape and the drug name and then apply the appropriate pump. The pumps can be labeled in their display as to what med/fluid is in each. I do use that feature too. Also, I plug in "piggy back" drugs closest to iv site, so I can see them quickly and clamp them off in an instant, if need be.
Particularly w/mag, you need a separate pump for each drip/fluid as you need to keep very tight I/O counts. If I use mag, I get a triple pump, for that purpose.
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
Also be aware of "name alerts". I gave the wrong ABX to the wrong "Smith" (not real name) once--- ----both on pitocin drips for post-dates gestations-----and BOTH had the same first name initial!!!!!
One was getting clindamycin due to PCN allergy---the other was getting AMP for her GBS. I hung the WRONG med and caught it JUST IN THE NICK OF TIME, when, I noticed the gal's allergy band. NEVER--- NEVER ---NEVER--- give a drug w/o checking the BANDS, no matter HOW time-pressed you are. (and I was so very time pressed, it was a record delivery day for us).
I did this in front of no less than 10 RN students. Talk about embarassing. But I did use it as a lesson for them------DO NOT DO WHAT I JUST DID.
I was very humiliated, but this showed them how when we are so very busy, a mistake can happen in a split-second. The 5 rights still apply, no matter HOW automated things are---no matter HOW experienced we are as nurses. I used that to drill it into their heads. Even an experienced nurse like me, makes mistakes when she is not paying proper attention.
The instructor thanked me for my candor. I in turn, thanked God for stopping me from making a very grievous error.
I ALWAYS check tubing after new nurses. I had to take over on a pt who requested not to have the nurse who had been assigned to her. She was new and just was not getting it. I went in and was assessing the pt, checked her IV's and saw that she had main lined her pitocin and put an antibiotic through the pump, luckily she had forgotten to unclamp her iv so the bolus wasn't given adn we had an intact uterus.
~Shea
I don't think this is an exclusive to new nurses issue. More than once I've taken over care of a pt (from experienced nurses) to find the pit line running onto the floor... (not been connected to the main line) So always assess your lines regularly. Also assess expiration dates... An ineffective labor pattern has been attributed to expired pitocin.
Some worst first year mistakes I've seen have been...
opening up the pit line to flush the air bubbles through....
For the pt with continuous variable decels... bolusing fluids for the whole labor thinking that would fix it... poor girl ended up getting like 10L
When we mixed our own pit.... mixing 2 bags at a time and not realizing one bag got all the pit added and the other got none
As for myself...
#1...I learned that sometimes we are the pts only voice. For the most part pts are ignorant about what is going on. We are not the Dr's handmaiden ... we are pt advocates and professional care givers.
#2...Just because the Dr has ordered it or the Dr is aware of it does not make it right or defensable. As first line care givers it is up to us to make sure pts are given safe care and that policy is followed.
I've been an RN since June of '04 and I've learned a few lessons...
-DO NOT talk on the cordless while getting a med ready, particularly an IV push. It makes for dangerous distraction. I was getting ready to give 25 mg of Demerol (yes our facility still uses it) IV push to an elderly open chole patient on a very busy night. We have the pre-filled cartridges that have a cc of air in them that needs to be pushed out. I was on the phone with another nurse and forgot to push out the air. I swabbed the port, connected it and then looked at it before I pushed any and about had a heart attack. Thank God I didn't push a whole cc of air into the line. I got off the phone ASAP and disconnected and pushed the air out, then gave the push REAL slow cuz I was shaking and my heart was beating like crazy.
-Don't give a bolus of LR through the same line that a patient is getting blood through. I had a bilateral total hip replacement patient that went into hypovolemic shock. The internal medicine doc was up on the floor shooting out verbal orders. We had already given the patient two 1-liter boluses of LR and he was getting the first of 2 units of blood. His blood pressure was still in the 70's over 30's, so the doc gave a verbal order to give him another liter of LR stat. So what did I do? I hung it wide open and ran it with the blood. Duh! What I should have done is gotten another line started for fluids. Live and learn. The patient wasn't harmed.
-Trust your instinct. Several months ago I was orientating a new RN (yes, my hospital has new grads orientating new grads ) and we had a patient who was 2 days post-op after a gastric bypass. She had gotten up to the bedside commode and back to bed and the PCA had forgotten to put her oxygen on her and she went back to sleep. When we checked on her in 45 minutes her pulse ox was 55% on room air. We immediately put on her oxygen, which had already been at 5 L to keep her in the 90's, and her sats went up to the high 90's again. I wanted to call the doc but another nurse on the floor, with 38 years experience, told me I should wait til morning since she went up to the 90's with the O2 on and she was denying dyspnea or chest pain. We did tell the surgeon in the morning when he made rounds at 6 am. He ordered ABG's, stat troponins, enzymes and it ending up being confirmed that she had had an MI. I still kick myself for not calling right when we found the low pulse ox.
Was working the postpartum unit... had a 28 weeker in for pylo. I checked on this girl at least 6 times on my 12hr shift. Only complaint was at 0300... pt c/o rt flank pain rated about a "4"... I associated this with the pylo...pt denied meds or other interventions... stated she had had it off and on for a few days... Well at 0600 pt c/o "bloody mucousy stuff when I wiped"... OH MY GOD... BLOODY SHOW... sure enough she was dilated 8cm and delivered about an hour later...
#2 There is no such thing as Braxton Hicks CTX in a pretermer. All ctx are to be considered the "real thing" until proven otherwise.
I thought of a good one with that last post - I learned this as a CNA on Antepartum High Risk:
NEVER put a pretermer on the commode because she says she has to have a BM. You experienced nurses are probably smacking your foreheads like, "No kidding!!!!" I had come on for my shift at 7 am and the nurses were in report. I was asked to help a pt off the toilet when she called out that she was finished. I heard the pt call out, so I made my way down the hall and she said "I just felt something go 'plop' and I am afraid to look." Sure enough, I lift up her gown and look between her legs, and there is a 24 weeker floating in the toilet. (Please remember that I am a nursing student still and a CNA at this point.) Despite the fact that I was certified in NRP, I freeze. Don't know what to do. Thank heavens about 4 nurses come flying in right behind me; one who had been pulled from L&D that day (and consequently is now my preceptor in L&D) picks the baby out of the toilet with a towel and starts stimulating it. The pt had come in in preterm labor the day before, but had been stabilized (so we thought) and transfered out to Antepartum. Now, any time ANY pt tells me she has to have a BM I stop and think about what is going on with her, and I either check her cervix if appropriate or I give her the bedpan!
always put on your gloves, you never know when you will deliver a precipitous baby, even when the doctor is at the desk.
~Shea
That was probably my biggest lesson thus far. WEAR GLOVES! I often didn't wear gloves at delivery so that I could finish up charting or write on my strip. We always have a nursery nurse, MD, and charge nurse in there. Sometimes, you have the time to actually catch up while the pt is pushing. Anyway, I was holding a foot and no gloves on. SHOULDER DYSTOCIA!! We had tried everything and it had been 5 min. MD tells me to apply suprapubic pressure. Still no time to get gloves. I apply pressure for >3 minutes. It was horribly messy. We do get baby out at the 9 min mark. (bad situation, baby survived but seized for days, i wish i knew long term). I was covered to my elbows.
NOW, I always keep a box of gloves at the bedside, within my reach. I always keep a pair or 2 in my pocket. They do get on, not always correctly, but they are always on!
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
I don't think this is an exclusive to new nurses issue. More than once I've taken over care of a pt (from experienced nurses) to find the pit line running onto the floor... (not been connected to the main line) So always assess your lines regularly. Also assess expiration dates... An ineffective labor pattern has been attributed to expired pitocin.
Some worst first year mistakes I've seen have been...
opening up the pit line to flush the air bubbles through....
For the pt with continuous variable decels... bolusing fluids for the whole labor thinking that would fix it... poor girl ended up getting like 10L
When we mixed our own pit.... mixing 2 bags at a time and not realizing one bag got all the pit added and the other got none
As for myself...
#1...I learned that sometimes we are the pts only voice. For the most part pts are ignorant about what is going on. We are not the Dr's handmaiden ... we are pt advocates and professional care givers.
#2...Just because the Dr has ordered it or the Dr is aware of it does not make it right or defensable. As first line care givers it is up to us to make sure pts are given safe care and that policy is followed.
Great post....and you are right, IT IS NOT a "new nurse" issue. I have seen some "old" nurses make huge mistakes too. It does pay to assess and re-check things frequently, even after yourself. We are all human. Most new nurses I know, actually make few mistakes cause they are so much on their toes----often they are the ones who find errors cause they are so alert, being new.
And yes, we are our patients' advocates. Very good points.
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
I hate the term, "Braxton Hicks contractions". It seems to imply "fake contractions" or false labor. There ARE no false contractions; ALL are "real". Even if patient is full-term, never, ever say "you are in false labor" to a patient. This would imply you think what is going on w/her is "all in her head", or somehow not real.
And, in a pretermer, this is indeed MUCH more troubling. I recognize all contractions as "real" contractions, and treat them as such. If a woman presents who is preterm, teach her to count her contractions and report them if they are more than 4-6 an hour and don't go away.
If the woman is full-term---- please, DO NOT use the terminology "false labor" with her. It's not "false" in her mind, not are contractions ever false. Treat it appropriately. If she is not yet in active labor, ask the dr. for pain meds or a sleeper before you send her home. Take her discomforts seriously and never use the term "Braxton Hicks" with pregnant women either. The implications are just wrong.
) and we had a patient who was 2 days post-op after a gastric bypass. She had gotten up to the bedside commode and back to bed and the PCA had forgotten to put her oxygen on her and she went back to sleep. When we checked on her in 45 minutes her pulse ox was 55% on room air. We immediately put on her oxygen, which had already been at 5 L to keep her in the 90's, and her sats went up to the high 90's again. I wanted to call the doc but another nurse on the floor, with 38 years experience, told me I should wait til morning since she went up to the 90's with the O2 on and she was denying dyspnea or chest pain. We did tell the surgeon in the morning when he made rounds at 6 am. He ordered ABG's, stat troponins, enzymes and it ending up being confirmed that she had had an MI. I still kick myself for not calling right when we found the low pulse ox.
Lizstill
10 Posts
Slamming a flush means pushing it too fast. Flush refers to saline that is pushed after the drug to "flush" the IV and get the last of the drug in that is sitting in the IV. So the flush may be only normal saline but it was pushing the meds in and if that goes too fast it can cause problems.
I'm a student too but I just learned to flush (always gently) last week.