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I went against another nurse... did I make the right call?

Posted

Specializes in PMHNP. Has 13 years experience.

Ok... I started a new job and I'm still orienting to this particular hospital. I have a patient I've been caring for this week who has BPH. He retains pretty badly and there's an order in place to straight cath for any PVR over 450cc. The order states to check pvr q 12 hours. Well, I checked him at 2:30 and he voided 100cc and retained about 400. I didn't cath him for multiple reasons, including that the order calls for 450. The urologist wants him to feel the urge to go which is why they won't put a foley in (which I have asked for). He has no distention, and no discomfort. I told the nurse coming on the situation and if he stated any discomfort, check him again. Well, the nurse training me (who I wasn't very impressed with) yelled at me as I was leaving and demanded that I go and cath him before I leave. I told her why I didn't feel comfortable doing that and she got all ****** off and said, "well then I'll go do it". I said, "that's your call... I am going to follow the orders as written."

Was I wrong???

classicdame, MSN, EdD

Specializes in Hospital Education Coordinator.

of course not. Your are the patient's advocate, then the MD's order-filler. She is WAY down the list of people you need to worry about.

guineachick, MSN, APRN, NP

Specializes in PMHNP. Has 13 years experience.

Nope as in, I was wrong or nope as in, I was right?

Virgo_RN, BSN, RN

Specializes in Cardiac Telemetry, ED.

If the order states to straight cath for a PVR of 450cc, and you scan 400cc, then no, you don't straight cath. I might have encouraged this pt. to attempt to void, though.

guineachick, MSN, APRN, NP

Specializes in PMHNP. Has 13 years experience.

I did and he got out 100cc. He states it's been like this for him for years. Not to mention that all the cathing has given him hematuria pretty bad. I didn't want to cause him more trauma if I didn't need to.

MedSurgeMess

Specializes in Med/Surg, ICU, educator.

I did and he got out 100cc. He states it's been like this for him for years. Not to mention that all the cathing has given him hematuria pretty bad. I didn't want to cause him more trauma if I didn't need to.

Good call. Just because someone is precepting, doesn't mean they know it all. I will say, though, that since you are on orientation, maybe having him void and scanning him again before leaving and making a decision based on that may not have been a bad idea. But if he has hematuria, he is probably having discomfort as well. As stated before, you are the patient advocate first and foremost.

guineachick, MSN, APRN, NP

Specializes in PMHNP. Has 13 years experience.

Thanks. I'm sure there are a million and one different things I could have done differently. I checked him at ten of three and my shift ended around 3:20. I was really trying to go by what the urologist said about trying to get him to feel the sensation of having to void. I cathed him 3 days ago and he had 650 in and didn't feel a thing. He's very used to having a lot of urine in his bladder so I didn't cath him. If he was at all uncomfortable, I would have cathed him, period. I think she was just getting a kick out of bossing me around. She was a really lousy nurse based on some of the other decisions she was making... I guess I have my first enemy at my new job!

lpnflorida

Specializes in psych. rehab nursing, float pool. Has 30 years experience.

What was the patient's bladder scan after voiding? You gave us what he bladder scanned at 2:30 before voiding but not after. If it had been me in your situation. I would have told my preceptor yes, I will scan him again and if he is 450cc I will cath as per doctors order. I do not believe in splitting hairs in a ******* contest.

guineachick, MSN, APRN, NP

Specializes in PMHNP. Has 13 years experience.

At 2:45 He urinated 100ccs. I then scanned him and found 400ccs left over. My shift ends at 3 so this was done at the end of my shift. I wasn't trying to split hairs, I was trying to avoid causing my patient more harm by straight cathing him. He has had multiple UTI's (And has one currently) because people are so quick to cath him. If I were the nurse coming on I would have taken my report and monitored him throughout my shift. If it seemed like he was in pain and unable to void, I would call the doc. I know this patient and that wouldn't have been the case. He would have continued to void small amounts and probably never exceed 450.

chenoaspirit, ASN, RN

Specializes in Med/Surg, Home Health.

I think you did the right thing. You followed orders and put your patient first.

guineachick, MSN, APRN, NP

Specializes in PMHNP. Has 13 years experience.

Thank you everyone for replying. I know in my mind I was trying to do right by the patient but I just wanted to hear from other nurses that I in fact did. Thinking of it now, (as I have been all night), I'm wondering if the nurse coming on complained because she might have to do it later herself. I assure you I wasn't being lazy, I've cathed him a million times and I don't mind doing it. In fact, I would rather do it than have someone else do it because I'm really gentle! I guess I could sit here and perseverate over it all night or let it go and see what happens when I go back on Monday. :jester:

ohmeowzer RN, RN

Specializes in ob/gyn med /surg.

well i would of cathed him at 400cc.. 50cc would not of made much a difference. if he hasn't voided at 400cc and only voided 100cc , then he is not emptying his his bladder ..in reality you need to do what you think is best.. you are the one in charge of your license.. if you feel good about it , then i feel good about it.. i wouldn't worry about it.. you did just fine...

You acted correctly. You followed orders. Personally, the only way I would have cathed him is if he was distended, uncomfortable, etc. Your preceptor was dead wrong for not following orders and for putting the patient through an unnecessary, uncomfortable procedure. One thing to think about is the potential for infection every time you cath someone.

RNsharkinaj

Specializes in medical-surgical. Has 2 years experience.

If he had 450 in before urination, and 350 after urination, you could document the situation and be covered, since technically you don't need to straight cath. Or you could recheck in an hour or so, ask him to void and then scan again. If it was the same or less, I would have the next nurse check it in 12 hours. If it was more than before or more than the volume in the doctor's order, I would carry out the order, and document doing such. Your preceptor is wrong, technically, if she cathed the patient, she would be carrying out the order incorrectly.

Order said cath at 450. It was not 450. You don't cath. Will he need cathed during the next shift... you betcha. But we don't cath to save the next shift work, we cath at 450....

webmansx, ASN, RN

Specializes in rehab.

Dear OP,

At the risk of sounding mean or being the bag guy, I will take the "side" of the precepting nurse, here is my reasoning

I work in acute rehab, all we do is bowel and bladder training (not all we do but sure feels like it sometimes ) ;)

You probably already know this but the reason why i an o caths above 450cc is done is that is the amount a "normal" or "avarage" bladder should hold before the urge to void is intense. Anything more the that 500 cc> causes the bladder to be stretched out and decrease the chances of returning to a normal bladder able to contract on its own, that is the stretching ruins the bladders ability to contract. with that said, and taking into concideration the guy had prostrate issues as well, which may further complicate things, I would have cathed the pt at 400cc, if the order was 450, why, because urine is continously produced by the kidneys. By the time you gave report , it may already be 425cc, whats 50 cc?! very little. If it would have been line 380cc then that would be a diffrent story. The nurse however should have communicated to you better that to yell at you and say "then I will do it". this is like parameters for blodd pressure. You get one of thoes that says "hold for sbp

Hope this helps. either way, you sound, (to me at least) like a good nures :)

I'm curious and this is not related to the topic, well sort of, but why is it that everyone is using "cc". I thought that had

been changed to "ml"?