new nurse advice. screwed up? - page 2

Patient: 40 something year old Jane-Doe. No medical history. Is post operative. Underwent general anesthesia. Had a ureter stent placement and stone removal. BP 80/50 HR 41 100% on 2L... Read More

  1. by   NurseBlaq
    Quote from introuble7
    Patient: 40 something year old Jane-Doe. No medical history.

    Is post operative. Underwent general anesthesia. Had a ureter stent placement and stone removal.

    BP 80/50 HR 41 100% on 2L cannula.

    subjective: Looks pale. She said she looks pale, also. Feels groggy. A bit swollen/edematous in the arms.

    States "was an athlete BACK IN THE DAYS. My blood pressure runs low, but not that low. I never had my heart rate measured." In the ER, base line was 100s/60s and her HR was 70s. Maybe because of pain?

    Should this warrant a "Hello Doctor! Explain above. That's it." Or should I have left it alone? I ask because the patient was OK when I left a couple days ago. My Charge Nurse said she'll be OK. Don't need the MD. But my director wants to talk to me about this. So I think something happened to the patient. I go back in tomorrow.

    Thanks. Should I have made the call?
    So what was the outcome? Update?
  2. by   Buckeye.nurse
    What are your notification parameters? For our patient population, most providers want to be notified for a SBP < 90, a DBP < 50, and/or a HR < 50.

    Those are minimal guidelines though. I'm more concerned about trends, deviations from normal (for each patient), and associated assessment findings. A low b/p and/or bradycardia in an asymptomatic patient who has had similar v/s for the past 24 hours is *much* different than a suddenly hypotensive or bradycardic patient who is also exhibiting worrisome symptoms.

    At the very least I would page the provider, get an EKG (we have standing orders for all our inpatients), ask the stat RN to come take a look at the patient, and get a repeat set of v/s in 15 minutes. You mentioned she was pale. Was her skin also cool/clammy to touch? I'd probably be calling an ERT to be honest.
  3. by   ThePsychWhisperer
    Quote from introuble7
    Patient: 40 something year old Jane-Doe. No medical history.

    Is post operative. Underwent general anesthesia. Had a ureter stent placement and stone removal.

    BP 80/50 HR 41 100% on 2L cannula.

    subjective: Looks pale. She said she looks pale, also. Feels groggy. A bit swollen/edematous in the arms.

    States "was an athlete BACK IN THE DAYS. My blood pressure runs low, but not that low. I never had my heart rate measured." In the ER, base line was 100s/60s and her HR was 70s. Maybe because of pain?

    Should this warrant a "Hello Doctor! Explain above. That's it." Or should I have left it alone? I ask because the patient was OK when I left a couple days ago. My Charge Nurse said she'll be OK. Don't need the MD. But my director wants to talk to me about this. So I think something happened to the patient. I go back in tomorrow.

    Thanks. Should I have made the call?
    I would much rather my nurses call me when they have suspicions of patient decline as opposed to not, even if it turns out to be nothing in the end. So what if you wake me up or interrupt my golf game? That's what I signed up for when I went into advanced practice.
    The patient's vital signs were pretty concerning, especially since there was such a decline from her baseline stats: she was experiencing bradycardia, was hypotensive without compensation, and was symptomatic. If you are ever in such a situation again, even if your CN says something similar, if your gut is still telling you that something is wrong, call the doc or the rapid response team.
    Remember, in the end, you are responsible for protecting your license, and don't think for one minute that your facility or your charge nurse will have qualm number one about throwing you under the bus.
  4. by   Kratoswife
    Any updates?

    Your charge nurse should have assessed with you!

    Even if the doctor dismissed you. We still have to advocate for the patient.




    That's why I left bedside. Too many ways to legally bind the nurse. Even if she/he is a new grad.


    Please update us!
  5. by   Have Nurse
    You mentioned her surgery but with those vitals I wondered what her blood loss was....? Definitely would have called. It's ok to do that, even if a nurse tells you not to, especially if that's your patient. If her post op vitals have not reached her pre op norm, within an hour or two after she leaves Recovery, it needs to be addressed pronto.
  6. by   NuGuyNurse2b
    I'm not going to repeat the same thing cause as you can see the consensus is that you should've called the MD. But this is a teachable moment and I can tell you as a new grad nurse 2 years ago I was in the same shoes, but something in me told me to call anyway. I had the same reservations as you because it was late in the evening, the patient wasn't doing too bad, she was alert/oriented, vitals aside from the BP were normal. I was on the fence but thank God my fellow workers were some of the most experienced nurses in the whole hospital. The MD dismissed my concerns, my fellow experienced nurses urged me to chart everything. I come in the next day, found out the patient was transferred to ICU during the night shift. Sepsis. Her BP tanked during the night, she had a fever, she became diaphoretic. I did get a side talk with the director and the only reason I wasn't written up was because I documented that I called the MD and they didn't do anything about it. I should've monitored her more closely, taken repeat vitals, called the house coverage just to say hey come look at this patient cause I called Dr Joe Schmoe and he's not bothered by it. But it was a lesson I learned and you only need one of those to never repeat it again.
  7. by   GeminiNurse29
    If you ever have any hesitation to call the Md, just remind yourself that they are getting paid a lot of $$$ to pick up and make the decisions. And as others have pointed out, it's your license on the line.
  8. by   RotorRunner
    You're describing a patient with poor perfusion. Even if her BP "runs low", in this case, she is clearly symptomatic with poor perfusion. This would be a definite case where you need the physician to evaluate. I don't want to sound dramatic, but the signs and symptoms you are describing are ominous.
  9. by   osceteacher
    Your lead has put you right in the firing line i'm afraid, with those vitals you absolutely should have called it in. I would be mad as heel at the charge nurse who lead me wrong.
    Last edit by osceteacher on Jun 14 : Reason: typo
  10. by   jive turkey
    Quote from introuble7
    Patient: 40 something year old Jane-Doe. No medical history.

    Is post operative. Underwent general anesthesia. Had a ureter stent placement and stone removal.

    BP 80/50 HR 41 100% on 2L cannula.

    subjective: Looks pale. She said she looks pale, also. Feels groggy. A bit swollen/edematous in the arms.

    States "was an athlete BACK IN THE DAYS. My blood pressure runs low, but not that low. I never had my heart rate measured." In the ER, base line was 100s/60s and her HR was 70s. Maybe because of pain?

    Should this warrant a "Hello Doctor! Explain above. That's it." Or should I have left it alone? I ask because the patient was OK when I left a couple days ago. My Charge Nurse said she'll be OK. Don't need the MD. But my director wants to talk to me about this. So I think something happened to the patient. I go back in tomorrow.

    Thanks. Should I have made the call?
    If the patient was ok after your shift I'm betting the director wants to talk to you because whomever you gave report to saw the patient's vitals, condition, the fact the doctor was never consulted, then complained.

    Here is an ace you can always have up your sleeve:
    Abnormal vitals + symptoms (even slight ones)=call Dr. He/she can get mad all they want. Too bad. Kiss my glutes if you mad.
    That same doctor that will get mad you called is the same doctor that will say you should have called if that patient crashes.
  11. by   CodeQueenRN22
    First question is how long had she been Post Op, what were her vitals in PACU, next questions would have been towards her labs, what were wbc, lactate, and bilirubin looking like, has she gotten any fluids post op, and what were her vitals afterwards if she did get the fluids. Def would have called the doctor just to cover myself despite what the charge said you have to cover your license.
  12. by   broughden
    Quote from introuble7
    Patient: 40 something year old Jane-Doe. No medical history.

    Is post operative. Underwent general anesthesia. Had a ureter stent placement and stone removal.

    BP 80/50 HR 41 100% on 2L cannula.

    subjective: Looks pale. She said she looks pale, also. Feels groggy. A bit swollen/edematous in the arms.
    Yes, you should have called.
  13. by   5150nurse30
    It is a learning moment always follow that little voice in your head, I had a very large stone jammed in my ureter and had a stent placed, had blood FILLED urine for 2 weeks did become anemic so these surgeries while common can go south quick. I hope it was nothing serious good luck to you.

close