Ok I have to confess; I may be an experienced nurse but nearly missed something HUGE last night. It was a busier-than H@ll night last night; you know the kind. When you feel badly cause NONE of your patients gets your best cause you are too busy running around, putting out fires all over the place. It has been raining labor patients where I work this week. The floor looked like a tornado had blown through.... Anywhoooo...
I had a patient who had had a dense labor epidural (gosh I hate that). She had a foley cath which the OB insisted be pulled for the last stage of pushing (I understand why). Anyhow, I had turned off the epidural by this point and once the placenta was delivered, and I was sure she was firm and not bleeding, I turned down her IV rate to 75cc/hr, knowing her bladder would get full fairly soon. I was hoping the epidural would wear off and she could void at some point! In vain. I tried EVERYTHING to make this happen. Her peri swelled horribly and no amt of ice would bring this down. I continually assessed her bladder and uterine tones and bleeding to ensure she did not become distended. (I thought)....
Well, about 3 hours later, she began to have HORRIBLE pain. I KNEW this is not normal for a routine uncomplicated primip vag delivery, so I assessed for all the usual things, uterine tone, rule out infection, check bladder tone, etc. The bladder was non palpable, uterus altho 2 fingerbreadths above U, was midline. So, I got my charge nurse and asked her to 2nd my opinion before I called the doctor. I brought a foley incase cath was needed.
Well, she agreed with me, although the bladder was non- palpable and ute midline and firm, it might be a full bladder, so with MUCH effort, and two sets of hands, we cath'd her. Guess how much urine drained? 1900 cc! I have NEVER seen anything like it. I felt HORRIBLE. What kind of nurse am I to have missed something so basic? Duh. Well predictably, after suffering the discomfort of cathing her (which I truly had wanted to avoid), she reported immediate relief (duh). NEVER again will I overlook the obvious in looking for something more complicated. And never again will I make assumptions based on basic assessments; each patient is indeed unique. Fortunately, no damage was done. Her uterus was firm, we could massage no clots out and her bladder tone was ok. She was a happy camper after this. GRRRRRRRRRRRRRRRR.......Has ANYone else ever felt this badly? I feel terrible about this oversight! Lesson learned, fortunately with no harm to the patient.:imbar
I wish I'd had you as my post-partum nurse! I've needed to be catheterized post-partum on two out of my four births. My very first job as a graduate nurse was on the urology floor and we used to get called to do the difficult post-partum caths. I wonder what karmic debt was paid by my catheterizations?
The first time my nurse was like you and caught it after a couple hours. The second time I was in a small community hospital and had an old-school L&D nurse. I told her that I had experienced urinary retention after my last birth and asked her to help me void during the labor and after the birth. She completely blew me off although at one hour post-partum I hadn't voiced, my fundus wasn't firm and was still above midline, and I was passing small clots. She told me she couldn't cath me in the L&D room and that I'd have to wait until I got to post-partum.
It was another two hours before I got that catheter and by then I could palpate my bladder and see the fundus displaced. I was passing golf-ball sized clots. It was a scary, helpless feeling because I knew what was happening to me but I couldn't seem to get what I needed. Anyway, after catheterizing me and pulling off 1900 cc's of urine, I felt a lot better and the bleeding gradually stopped. My blood pressure was down to 84/40 by then so I ended up spending the night in the hospital instead of the same-day discharge I had hoped for.
Ah, well. It's water over the damn right now. This was way back when in '94 & '96 and I trust that the situation has improved since then. Painful as it was, there was no harm done. I had another baby at the same community hospital and had a graduate nurse with me - she had just passed her boards. I was impressed that she had taken the time to read my prior birth report - it must have been a slow night when I came in. Anyway, she was a real sweetie and a welcome change after the one in '96.
All we do is the best we can.....Can do any better and could certainly do much worse.....The patient was fortunate that you took the time and compassion to lessen her discomfort, whatever the etiology...THATS the difference....And, You are welcome.......
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
Well, I chalk it up to a lesson WELL-learned. And it was a reminder to me never to ignore pain that is not mitigated by the usual regimens. I am just glad I did not do permanent damage to her bladder or cause her to hemorrhage. THAT was indeed fortunate. "Someone" was teaching me a lesson and I learned well. Thanks for all your support and for being so non-judgemental. I truly appreciate it!
I had a similar experience not too long ago, and I beat myself up over it for a while (I'm better now).
Pt is a G2P2, uncomplicated vag delivery, strong epidural, foley pulled at delivery. She came out to me moderate bleeding, fundus firm in the midline, -1 from umbilicus, bladder non-palpable. IV of new liter LR /c pit was at a moderate drip (no pump available).
About an hour and a half after she came out to me, she had c/o abdominal pain, states it is kind of a crampy pain. Fundus firm, midline, -1, bleeding about the same rate as before, still can't palpate the bladder. Pt states she doesn't need to void and is starting to feel her legs again. Medicated for pain.
About an hour and a half after that, pt is c/o increasing abd. pain. Denies need to void, and can move legs well. Bleeding is same as it was, no clots. Still can't find the bladder. IV is dry..yikes! Foley inserted, 1400 cc out, immediate pain relief. Pt suffered no ill effects, went home the next day.
What's the deal? I kept assessing her abdomen, never could find the bladder, and I never felt the fundus off the midline. Perhaps I thought I was feeling the fundus and was actually palpating the bladder? Maybe all the pit in the bag (20U) kept her from bleeding like she should have if the bladder was so full?
Is there some trick that I've missed? I only graduated in May of last year, but I feel like I shouldn't still be having problems like this. Yeah, the pt was fine and went home as planned, but come on! I couldn't find a 1400 cc bladder?
Deb, I wish you had been my nurse the night I had my daughter, because you did eventually figure out the problem and rectify it. The nurse basically blew off my complaints for 5 hrs. without really attempting to figure out the cause of my pain. You should have seen the look on the day nurse's face in the morning when she felt my bladder and saw how many cc's came out. I can still remember the incredible sense of immediate relief.
You did the best that you could at the time, and took the time and effort to correct the problem. Obviously this was an old thread, but I am sure that the experience has only made you a better nurse. It is clear that any patient would be lucky to have you.
has anyone else ever felt this badly? i feel terrible about this oversight! lesson learned, fortunately with no harm to the patient.:imbar
thankyou for sharing your experience! it reminds me that even when i'm qualified as an rn ... i will need to be mindful of the little things as well as the big.
i'm just worried that i will forget the larger ones:o
Disclaimer: I've not yet started nursing school, I'm applying in the spring...so if it looks like I don't know what I'm talking about, it's because I really don't! :)
Something similar happened to me when I had my son last year. I had horrible pain and thought it was my uterus contracting. I really had no idea what was going on. LOL I was urinating a little, but my nurse told me I may need to be cathed.(sp?) Long story short, I layed in that hospital bed for hours until I just couldn't take it anymore and finally told her that I thought she would have to cath me. So she did and she got out around 800cc. I was so afraid of that catheter that I layed there in pain. My nurse wasn't too happy with me. She just kept saying "Why didn't you call for me?" I was cathed so many times over the next 2 1/2 days that I lost count plus I had to leave it in for 24 hours at one point, and I had to stay at the hospital another day.
Sorry for rambling, I'd never told that story though. LOL
SmilingBluEyes- I can tell what a caring nurse you seem to be just through your posts. And I'm sure I'll learn a thing or two just from reading them!
You did the right thing...don't beat yourself up over it :)
I never would have thought 1900cc in a bladder with a FF and up 1-2 at midline!
When I worked PP a new L&D nurse brought me a PT G2P2 SVD epidural no complications, I&0 cathed prior to del. She gave me report "The strangest thing happened....her fundus was firm at U, then it was up 2-3, then back down at U" She even had the resident evaluate her before transporting her. She had given her 5mg of Oxycodone because she was uncomfortable. I went in right after I got report to assess her and she was very uncomfortable, Sure enough there was something palpable at U! It was her bladder! Fundus was amazingly enough firm and palpable 2 FB below her right rib! 1700 cc in her bladder!
So I would never think 1900 in your situation, kwim? It's just amazing how quickly some women can fill their bladders after delivery!
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
Wow thanks for the support in revisiting this thread. Do you know I use this lesson to new nurses? Yes, I am one who readily admits to mistakes and lessons learned. If I can spare another patient the discomfort of that night, thru simple interventions like making sure her bladder is empty, I will tell EVERYone what I did. I really feel it's a clear illustration why we can never assume anything and to take pain seriously in our patients. I am just glad I can admit the error and move on.
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
Wishful, I wish they had used a foley for you. If I feel a patient needs cathing that badly, esp w/swollen perineum (big clue) I just place a foley and let them rest 6-12 hours. Eventually, things get better, swelling goes down, innervation returns to normal to the pelvis/bladder and we can then take out the foley. I do NOT like multiple catheterizations....too much discomfort for the patient and too much risk of infection.
OK, Since we're sharing...I can top your story. When I was in nursing school, I was doing a clinical rotation at a nursing home and I was the treatment nurse for the week. I went thru the "treatments due" book and found that a LOL needed a foley change. She was definately nearing her last days so I asked the charge nurse if it had to be done or could we spare her the procedure. She told me to do it. Soooo...I grabbed another student as I knew with all this lady's contractures it was going to be tough to get her legs apart. So there we were, me with my sterile gloves and field ready to go and my partner holding this lady...wouldn't you know it, I had no idea what I was looking at. So I tried to cath what I thought was the spot. Hmmmmm, nothing. Got another kit, started over, tried again....Hmmmm, nothing. Now mind you, everytime I tried, she let out a groan, I felt horrible. So I page my instructor, we get another kit and the 4, yes 4 (another one of our instructors who was on maternity leave happened to be visiting) of us proceeded to try again. When I'm ready to insert my inst. asks me where I've been trying and I point and her and the other start laughing. She said "as we age, sometimes the meatus falls into the lady parts" so she pulls up all that skin and Bam! there it was, in the lady parts. So I finally get it in and...I swear to God...the lady dies right then and there. I swore I'd never touch another pt. and quit school at that moment. I was so distraught! (Obviously the instructors eventually asurred me that it wasn't my fault and I stayed in school) My instructor said..."well, at least she went out happy and with a tickle"......I HAD BEEN TRYING TO CATH HER privy parts!!!!!!!
Danielle
PS- S Blue Eyes...I PM'd you about the LPN in L&D post.
thankyou for sharing your experience! it reminds me that even when i'm qualified as an rn ... i will need to be mindful of the little things as well as the big.
KnitRN
10 Posts
I wish I'd had you as my post-partum nurse! I've needed to be catheterized post-partum on two out of my four births. My very first job as a graduate nurse was on the urology floor and we used to get called to do the difficult post-partum caths. I wonder what karmic debt was paid by my catheterizations?
The first time my nurse was like you and caught it after a couple hours. The second time I was in a small community hospital and had an old-school L&D nurse. I told her that I had experienced urinary retention after my last birth and asked her to help me void during the labor and after the birth. She completely blew me off although at one hour post-partum I hadn't voiced, my fundus wasn't firm and was still above midline, and I was passing small clots. She told me she couldn't cath me in the L&D room and that I'd have to wait until I got to post-partum.
It was another two hours before I got that catheter and by then I could palpate my bladder and see the fundus displaced. I was passing golf-ball sized clots. It was a scary, helpless feeling because I knew what was happening to me but I couldn't seem to get what I needed. Anyway, after catheterizing me and pulling off 1900 cc's of urine, I felt a lot better and the bleeding gradually stopped. My blood pressure was down to 84/40 by then so I ended up spending the night in the hospital instead of the same-day discharge I had hoped for.
Ah, well. It's water over the damn right now. This was way back when in '94 & '96 and I trust that the situation has improved since then. Painful as it was, there was no harm done. I had another baby at the same community hospital and had a graduate nurse with me - she had just passed her boards. I was impressed that she had taken the time to read my prior birth report - it must have been a slow night when I came in. Anyway, she was a real sweetie and a welcome change after the one in '96.