judgement error

[toopey]

I made a stupid error in judgment when working the night shift a few nights ago. I was caring for an 89 yr old man who was in poor condition with multiple health issues. His main issues involved diabetes, CHF, ARF and c.difficle. He had taken a turn for the worse several days prior with episodes of nausea and vomiting and decreasing urine output.

The pt's output had been only 100cc on the previous night. His blood pressure was around 96/55 and hR 65. On days he had an iv started of NS, he had been bolused 1000cc around 1400 and then the order was to run the IV at 100cc/hr for the next 12 hours. I started the night shift and was told by the rn going off that he wasn't doing well. He had only put out 75cc that shift. He was a DNR.

I was told we'd be working the shift short an rn. I was to be in charge (which always scares me because I have only been an rn for 1 year). That left me and 1 other rn on the floor. I began the shift caring for 8 pts and would pick up an extra 4 at 2300. When I did my assessment of this pt I found him much the same way he had been on days, vitals were similar and output was minimal. Per the dr`s orders I stoped the IV 12 hours after it had started. I assumed the reason for this was because the pt had chf. The pt had very little output still. I wasn`t sure what the next step was. It was the middle of the night. I DIDN`T CALL THE DOCTOR. I don`t know what I was thinking. when the day shift started the first thing the rn coming on said to me was why didn`t you call the doctor to address the low output.

I feel awful. I don`t think I am a good nurse. As much as I want to be good at this profession, maybe I am just not made of the right stuff!

[tewdles, RN]

OK...so you should have called the MD. The crucial thing for you is to understand why...so that you can improve your critical thinking skills and your confidence as a nurse. Don't beat yourself up over this...trust me...there are plenty of others who will beat you with this including your management team. The bottom line is this...the patient did not die...he was still in ARF...and the bolus did not destabilize his VS.

Let me go back to the "critical thinking" part. This is what you must have demonstrated to be asked to be in charge. It is a necessary part of being responsible for a floor/unit of patients. It requires that you can assess a situation and think beyond the "task". For instance, you completed the bolus as ordered and checked VS (ordered tasks). The oncoming RN said you should have phoned the MD...critical thinking...why? Apply your knowledge of physiology, pathophys, and treatment objectives to this patient. Identify the goals of treatment for this gentleman. Do you really think they were bolusing him for his CHF? What was the doc trying to accomplish? This is something that you will practice over and over again with different patients. You WILL get good at it. Please don't be afraid or embarrassed to ask your more experienced peers.

You have been put in a very difficult situation by your management. It is clear that you are not comfortable with being in a "charge" position. I am guessing that you don't feel that you have a choice about that matter. It certainly is flattering to feel that your superiors have that confidence in you. There is likely an hourly bonus for that added responsibility, right? Use the critical thought processes to organize your time and the division of care. It is about being aware of which people may crash and burn as much as it is being aware or who is time intensive and task heavy...they are often but not always the same patients. On the night shift it is imperative that you work as a team...support each other...communicate. Hopefully you have an experienced RN that roams the hospital overseeing the care and staff. Back in the day we called them "house supervisors". This person is your support and resource. Ask HER for her opinion and help. Good luck! I have a feeling you will be fine.

[ghillbert, MSN, NP]

You should not be in charge of a floor if you are so unsure of your skills. Refuse to be in charge - you are acting outside your abilities.

Having said that, beginners don't usually know what they don't know. At least you realize that you have things to learn. As stated by another poster, critical thinking means thinking a few steps ahead. If you stop IV fluids, you want to think about what they were trying to achieve by giving it, and whether it has indeed been achieved.

Obviously if the guy has CHF, and they were giving a fluid bolus, it sounds like they were prioritizing the lack of output pretty high. CHF - he already has low cardiac output, and low perfusion to the kidneys. Added to that, he has ARF, so impaired kidneys already. Adding in vomiting and diarrhea, you are further reducing the man's circulating blood volume and hence cardiac output. So his poor old kidneys are suffering. Throw in a low UO, and you have pretty strong evidence that the kidneys are in bad shape. They need output, and they need it now. A sick heart needs a higher filling volume to be able to eject sufficient blood. So you want to keep giving him IV volume.

It's too early to decide you're not cut out for nursing - we are all pretty clueless when we graduate. You learn by practice. Give yourself a break - there's a reason you're called a beginner.

PS: That guy could well have done with ICU and getting a CVC to guide his fluid resus. At 89yo, who knows if that would happen...

[ChristyRN2009]

I don't think I would assume that the fluids would've been continued. To my thinking, he has low output, already got a liter bolus and another 1200ml. I don't think continuing to bolus him would've worked with his kidneys in failure and the risk would grow exponentially of him going into fluid overload with resp. distress. What did his lungs sound like? What were his labs? I would not automatically assume that he was dry based on low UOP.

OP, you probably should've called the MD. You will almost never be wrong in calling the MD if only to CYA. But it sounds to me like this patient probably wouldn't have had a different outcome or even a different course of treatment necessarily given his clinical picture presented here. If he is still there when you get back to work, look at his chart and see if the MDs changed the orders, look at his lab and lab trends, his IO for the days leading up to and after the day you had him. I did this when I was a new nurse and it helped me to look at what happened after I took care of my patients-it made me think about my interventions and what I did vs what I could've done, etc. Hope this helps, but please don't beat yourself up, you are not a machine and you are not perfect. Charging with 12 patients of your own? Sometimes you just have to maintain life on your shift and like a pp said at least you are questioning your judgement vs. not even caring. This is how you learn. I think you are a good nurse, just need experience that only comes with time. Keep it up.

[NickiLaughs, ADN, BSN, RN]

We learn more from the mistakes we make than the things we do right. We all make mistakes, just take it as a learning experience. As far as his condition, it sounds like there's not much they could have done, other than throw some Lasix at him. But it would definitely be a CYA to call the MD. If the MD doesn't order anything, than it's on HIM.

[Kylea]

Like the previous post stated, we learn more from our mistakes than the things we do right. I can tell you right now, after three years of nursing, there are tons of things that I don't remember. That's just nursing; you use it or you lose it. But I do remember everything that ever had to do with a mistake that I made. Use this as a learning experience. It will never hurt to call the doctor, just so you are covering yourself. Don't say that you aren't a good nurse. A bad nurse would insist right now that they are a good nurse, and that he/she did not do anything wrong.

[LaurenBoog]

You say that you made a judgement error, but I don't see it!

Just because another nurse questioned you during report does not mean that you made a judgement error. Did the other nurse know the patient's lab value trends, the "turn for the worse", the patient's decreasing urine output over the past several days, and the patient's medical history? The other nurse sounds like he/she was only thinking about the decreased urine output for one shift, without looking at the whole picture.

Just going off of the information you gave, the patient seemed to be very sick, and getting worse, but it doesn't sound like anything dramatic happened on your shift that was out of the norm for the patient. It's not as if the patient put out 300 cc's on day shift, and then nothing on your shift. As you said, the patient had a large fluid bolus on day shift, and still only had 75 cc's UOP. How much more fluid would the MD want to give before he/she decided that the patient's kidneys weren't responding?

If I were the day shift nurse, I would speak to the MD during morning rounds (or call if I thought that the MD would not be by for several hours), mention the lack of UOP, and try to discuss the plan of care. If the MD/family/patient wanted aggressive treatment, then dialysis and ICU transfer may be in order. However, it does not sound as if they were treating this patient very aggressively. IMO, calling the MD in the middle of the night, when the MD is already aware of the very low UOP, is unnecessary.

Others, please feel free to correct/educate me. I also am a fairly new nurse, and welcome the input if I am totally off-base in my reasoning.

[leslie :-D]

yep laurenboog, i'm with you.

i am an experienced nurse and i'm pretty sure i wouldn't have called the doc, for new orders in the middle of the noc.

the pt had not deteriorated and was holding his own.

i would have had the day shift call w/an update and to see if there are further orders.

of course, i would have written a thorough nsg note as well.

so op, i'm not convinced you made a judgment error.

what i suggest you do, is review this pt's patho...

because you need to understand the rationales behind the bolus and ivf...

as well as understanding what is priority.

it's not easy and i wouldn't expect you to readily understand it.

but just for your own nsg growth, it wouldn't hurt to review.

wishing you the best of everything.

leslie

[ohmeowzer RN, RN]

i read your post , and you are only human and yes you should of called the doc .. i do think you should of review your skills.. but please remember you are a human and still learning .. being a RN for a year you are just getting your feet wet in this business.. it take a year just to get use to it... this as a learning expirence and please don't beat yourself up over this.... your manager must of saw that you are good nurse , she made you charge,,,, as my gammy use to say ' don't cry over spilled milk , it could of been whiskey"

[Virgo_RN, BSN, RN]

If anything, the nurse who reported off to you should have called the doc, since she was the one who gave the bolus and the patient only had 75cc out on her shift.

I agree with the others that since this was not a change in condition, the MD was aware of his low UOP and had given orders, you did not need to call. Only if the patient's condition changed, i.e. respiratory distress r/t fluid volume overload, zero UOP, change in LOC, etc. So long as his condition had not changed, and the MD had already been alerted to his condition and had given no instructions to call for further orders, you did nothing wrong.

[kanzi monkey]

I once bolused a patient in ARF till the cows came home (per the doc's order, mind you). That day I learned what flash pulmonary edema looked like.

Low U/O does not necessarily = decreased fluid volume. The patho involved with ARF and CHF is very complex, and in the moment it is sometimes difficult to assess which is the "chicken" and which is the "egg"--doctors have a tough time deciding how to treat it, much less nurses. IMO you were treating a patient who did not seem to respond favorably OR poorly to an intervention (IVF bolus). The patient was stable, didn't show signs of decompensating while you cared for him. You did the right thing--pass it on. Sometimes it's not possible to successfully diagnose and treat during the course of one shift--do not own that responsibility (I think both me and the doc in my example felt the onus was on us to fix that patient. we were both new. i'm sure neither of us will make that particular mistake again. the patient lived, btw. and peed plenty the next day)

[MedSurgeMess]

I think you did okay. The patient was a DNR, apparently no aggressive treatment. Low UOP that had been going on as well as other issues that were the norm at this time does not = middle of the night call