I keep thinking I did something wrong....

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Yikes. I am just finishing up my orientation on mother/baby. I had four couplets tonight, three were at least 24h or more past delivery, very straight-forward, no issues.

The fourth was a fresh section

Fundus was firm, output was great. Not worried about hemorrhage. LRS w/ 20u of Pit running at 150. OK.

So far so good. So I get in to get my first set of vitals and she has a temp of 38.4. everything else is as the L&D nurse said. Mom is awake, alert etc.

So I page the resident He says ok, he will be over. Give 650mg tylenol po along w/ her 1730 dose of toradol.

Ok. So I do that.

I give meds, recheck temp (in her ear) and no lie the temp is down to 37.7. Resident walks in, I tell him. OK.

About 20 min later, L&D doc calls me about pt. I get orders for 100mg gent now, then 8h later 80mg q8. Cleocin 900mg q 8h. OK

So I run the 100mg gent. While its about halfway gone, around 2230, resident is back again. Examines mom and comes out and tells me that her pain is uncontrolled. I told him that she's got 650mg tylenol and 30mg toradol on board already and not sure what else I can do. Orders presently for darvocette 2 tab po prn, ibuprofen after toradol is finished, tylenol for fever as ordered above, and the regular stuff--phenergan for nausea, benadryl, narcan, nubain etc.

So doc says at 2300, please give one darvocette and phenergan after the clinda goes in.

So the clinda gets started @ 2300 but for reasons unknown I and another nurse could not get it to go very fast. Was supposed to go at 100/hr but I think it went closer to 50. changed the tubing everything, no luck. Not sure why but it was 2315 and we were out of ideas. Hopefully next shift to figure out.

So then I go get the darvocette. I have never seen big pink pills (have not ever seen darvocette) so I looked it up in the medbook in the medroom. Its something that begins w/ a P and APAP. Ok, it has been 4h since the 650mg tylenol went in. Tylenol was ordered q4h. So I gave the darvocette. I told the oncoming nurse, so that she wouldn't give any more tylenol for at least four hours.

I go back to the chart and i can find no indication from the doctor's note that pt needs phenergan. No c/o nausea. I look in the orders and there is no order other than prn nausea. So I told the oncoming nurse. I wrote it on the kardex as the doc was speaking to me, and he was writing so I guess I just thought that he would be writing why in the chart. Well he didn't. So I told the oncoming nurse just that.

And then I went home.

DId I miss something? I am worreid mostly about the tylenol dose. I felt bad because I did not get into my other patients very much, being very consumed with having to clarify orders and the resident, doctors, and all the vs we have to do. So I don't know if I am just feeling like I let my other three patients down or maybe I just screwed up the med dose for this patient. Or maybe they are fine and I am just really tired.

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Specializes in Critical Care/ICU.

What did she say was her pain? You mention giving her tylenol but you don't mention assessing or documenting her pain?

I am not an OB nurse but any time the muscles in your gut are sliced through and through it's going to produce pain that will require more than just tylenol or toradol. More than likely the abx will make her nauseated.

Remember that a portion of the darvocet is tylenol, so when you give this you're klilling two birds with one stone - treating the pain and the fever. I would give darvocet around the clock to this patient (starting with 2 tabs) for at least the first 24 and not give any other tylenol. I would also give an antiemetic even before she becomes nauseated, because more than likely she WILL become nauseated. It's much easier to manage a patient proactively rather than trying to play catch-up with nausea and pain. I always recommend a "plan" to the patient and say look, as the anesthesia wears off you WILL have pain, and as you start drinking and eating you WILL be nauseated (along with the abx), let's do this, this this. They are usually more than happy to agree to such a plan and it makes it much easier on the nurse's planning of his/her shift.

What bothers me is if the patient said her pain was uncontrolled why didn't the doc order a little bit of morphine or fentanyl IV if he didn't want her to have the darvocet until AFTER the abx went in?? And why couldn't she have the darvocet before?? 650mg tylenol is next to NOTHING.

As far as finding a note from the doc regarding why the phenergan was given...good luck. If you are more comfortable with having something more concrete and you can take verbal orders, just write a verbal: "please give 12.5 mg phenergan IV (or po) x 1 now."

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Specializes in Critical Care/ICU.

Also, it is your job to write in the chart why the phenergan was given - not the docs. You could make a note stating something to the effect that MD at bedside, recommended giving dose of prn phenergan now. Med given, see MAR.

You are tired. :)

A lot of this stuff will come to you with experience. It is mostly using your nursing judgement. One thing though, please please please thoroughly assess and treat pain. It's just as important as those vital signs.

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Specializes in med-surg.

Anesthesia usually causes nausea. ... I agree with the above post "uncontrolled pain" and all you have is DCN??? You can always give Phenergan as an agonist to pain meds to give it a little extra "kick". As far as the IV not running well, probably close to being infiltrated or positional... OB is NOT my field of choice;I avoid it all costs. I don't do well with hysterical hateful pregnant women or their families...But C-sections are a pain and much harder to recover from than lady partsl deliveries.. Our section's always came out on PCA demerol, made life much easier......

Get some rest; you'll learn to prioritize with experience.. you can't be all places at all times Good Luck

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I was tired last night!

I documented her pain which she rated a 4-5/10. She received the toradol for her pain and the tylenol I obtained as a verbal order for her fever. I ended up giving them pretty much together.

When the doc came out and told me her pain was uncontrolled, it was the first I"d heard of it. Last time I'd gone in to check her respirs she had been sleeping so I thought it was going well.

Usually we give percocet Either way, she had darvocet ordered and he said to give her just one ( I had order for one and an order for 2, both on a q4h prn basis).

I had an order for prn phenergan, and you are right, I'd forgotten that phenergan potentiates the pain meds. But it was just weird last night when he said to give the phenergan just as he stood there charting but I found no indication of why in his note nor a specific order other than prn nausea. If I hadn't been so distracted trying to straighten out the med orders (pharmacy changed her gent from 75 to 80 and I was trying to understand why and what to do)I would have probably asked him for a verbal order and had him sign it.

My biggest worry--I realize now after sleeping on it--was that I gave her either the wrong med (I'd never seen darvocette before and the pixys just gave the name darvocette, not the generic name that was on the pill. I looked it up of course but I was hoping to see a picture of it somewhere or another nurse just to confirm it. ) or that I had given her too much acetominophen in general (the 650 I'd given her and then 4h later the 650 in the darvocette) I woke up this morning and realized that what was bothering me was the amount of acetomenophin she received.

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daily max dose for tylenol is 4 grams. where i work generally we give 1 gram at a time. so the 650 mg tylenol you gave plus one darvocet (which is a large pink pill) would not have toppled her over the daily max dose.

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thank you AM-RN. I am glad to hear that the large pink pill was right. I knew it was the right medicine on an intellectual level--I did look it up but without a visual I just felt uncomfortable.

last night was stressful for me.

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Specializes in med-surg.

I have a pocket reference guide titled "GENERIC-BRAND comparison handbook. I can post the address to order one if you would like. (I hope this isn't misconstrued as advertising) Unsure....

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Specializes in med-surg.

Gent comes in 80mg/2ml? or 80/ml, can't remember off the top of my head. More than likely, the MD didn't write for the correct doseage (they have a lot to try to keep up with as far as meds go) and the Rx just quietly corrected them:smokin: I found the book: this was published in the early 90's, but I know they still make them;;; Print: Quantity of Books requested, your name and address and mail to UDL laboratories, INC, PO Box 10319, Rockford, ILL 61131-3019. Cost $2.00 if you are a med nurse, then this is a must have.

If you like OB, then hang in there. The way things are going, soon it will be a highly sought field...I shied away from it due to the awesome responsibilty (two lives vs one), the statute of limitations (age of majority + two yrs after date of discovery; I think it's something along those lines), and it made me so angry to see the "Breeders" in for yet another delivery. It got to the point that I would say to those babies " i hope the world is kind to you and I'm sorry your mother is an idiot" I'll take a code in the middle of shift change any day of the week.

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