made MD angry, and resources on unit

TheCommuter, BSN, RN · Mar 6, 2016

First of all, you did well for your patient overall. You noticed some clinical signs of deterioration and intervened before a code situation had the chance to occur. Therefore, I give you kudos for doing your job well.

If I cannot figure out whether the patient's hemorrhage is coming from the lady partsl region or the anorectal area, I'll put on a glove, lube my finger, and insert it into the anorectal area to perform gentle bowel stimulation.

If my gloved finger is bloody upon removal, I know it is a rectal bleed. If my gloved finger comes out clean or with only a smear of fecal matter, I know the blood is coming from the lady partsl area.

Advanced Practice Columnist / Guide · Mar 6, 2016

Taking the inaction of the charge nurse out of the equation, there are a few critical thinking aspects of this situation you could learn from. First, it's important to know the patient's history and why that patient is under your care. It sounds like you did that part by knowing that you have a patient who has post-menopausal bleeding and hydronephrosis S/P nephrostomy tube insertion with a history of HTN and diabetes now POD#3 from a D&C.

The second part of your critical thinking skill should focus on what body systems you think could possibly go wrong with this patient while she is under your care. Knowing the history and reason for admission, it would make sense that Renal and Genitourinary (GU) would be body systems you would worry about. When you saw blood from the perineal pad, your first worry would be GU bleeding because the patient had a D&C.

Because the patient already had a nephrostomy tube and the output isn't bloody, you can assume that this is not urinary in source and more likley lady partsl again because of the D&C. There is also no mention of history of GI complaints, hence, rectal bleeding is lower on your "nursing hunch" differential.

Third, you have to do the assessment. Take off all covers, clean the patient, and expose all orifices and see where the blood is coming out off. It can be simple as that. It is important to have accurate information when you are calling a physician about a change in status because that would make a difference on what course of action is coming next. I'm sorry your charge nurse wasn't supportive.

SnowShoeRN · Mar 6, 2016

We had a nurse educator on our unit, but she was seldom available during the night shift when I worked. Other resources included our charge nurse, nursing supervisor, and other floor nurses. I would have asked any, or all, of those.

I suppose what I would have done differently is to actually check if she was bleeding rectally or lady partslly. It may be embarrassing as a new nurse, but it's important. I would inform the patient that I was sorry, but I was going to have to have a look and verify that she was bleeding lady partslly as opposed to rectally. And then I would have looked. If there had been a ton of blood I would have wiped a bunch away and looked again. Perhaps I would have done an occult stool if I suspected a rectal bleed. As a PP said, using a gloved hand to check would be appropriate too.

With a sat in the 80's (low or high 80's? Was she moving around? Symptomatic? History of resp issues?) I probably would have thrown some oxygen on and called a rapid response. Was she sinus tachycardic? Any other abnormal rhythms? What was her BP? A HR in the 130's-140's could be pretty alarming depending on what else was going on, but if she was hypovolemic from blood loss it would make sense. Honestly I feel like I don't know enough about the patient or situation to gauge all of what I would have done differently, but is sounds like it could have been a pretty bad situation had she not ended up getting the blood she needed. A low O2 and increased HR, especially in this situation, would be consistent with hypovolemia.

KatieMI, BSN, MSN, RN · Mar 6, 2016

If you find something wrong, the question #1 (after you made sure that the wrong thing is truly so) is: does the wrong finding fits into whole picture, and if it does not, why so?

Your patient had low fever, which is OK after surgery but highly suspucious with nephrostomy tube. She (suddenly??) grew up hr of 140 (what was her bp, BTW?) and lost saturation. Neither of the latter two findings fits into "reaction on pain and temperature" unless one of them or both turned very suddenly to very much worse, especially SaO2. Providing yoyr vitals were correct, your differential would go between 1) sepsis/general inflammatory responce; and 2) something else (bleed, PE).

At this point, I throw up oxygen, 12-lead ECG, do quick full head-to-toe, monitor if not already on, vitals q15, good IV access. Possibly also ABG and bladder scan. AFTER I got that, I call doc with what I found (where I work, charge RN can order all this). If in 15 to 30 min I do not see 1) cause; 2) improvement; and/or 3) doc at bedside, I page rapid responce.

Reg. bleed, you should get two more female nurses or aids, light source, a few sterile gauze packs and some sterile saline and lubricant and tell the patient that you need to take a good look down there right now. Close the door, get her legs apart and look. If you do not see where the blood comes from, put your one gloved lubed finger in orifice. If it is rectal, you'll see blood. If not, clean the perineum with saline splash, wet your gauze with saline and gently press one against lady partsl opening and another one against uretra for like 30 sec. If there is active bleed, the blood will be on one of them. If still not clear, use three sterile pads (one at orifice, one at lady partsl opening and one at uretra) and check every 15 min.

Do not tell MDs anything definite till you are sure. If you are not, it is fine, just say so. "The lady is not doing good, I saw (this and this) but I am not sure where it is coming from, can you look, please?" is ok, as, in fact, medical diagnosis is his job.

brownbook · Mar 6, 2016

I can't help you with your unit resources. Your charge nurse is an idiot. Talk to her about what happened. Do so in a calm "therapeutic" way...."I" statements, active listening. Google how do discuss issues with a boss. If she remains an idiot tell her you aren't satisfied (or something like that) and are going to talk to her boss, go up the chain of command.

In the meantime is there a co-worker you trust, fellow nurses, don't hesitate to ask your LVN's and even CNA's for help or ideas.. They have a lot of street smarts.

Also I'm not saying you did this, but I have been in "panicky" situations many a time. Do I push the code button?... ..what do I do?..is she bleeding "too much", where is the blood coming from...what do I do...type of panic. I am freaking out inside, but outside try to stay calm and think. (I find if I can use some black humor, make myself laugh inside, it helps release the pressure.) Your patient didn't seem to be in a situation where she was going do die. I would have sat myself down, try to calmly think through what was going on. What are the basics. As others said, what are, were her vitals. Think ABC's, were her airway and circulation stable? Is she in danger of dying, where, why, is she bleeding? You had the time to put her on her side, put a wad of gauze on her orifice, see if it got bloody, or just look at her orifice....was blood coming from it? Put a wad of gauze on her lady parts, was is getting bloody? Wherever it was coming from put a peri pad there. Check it every 15 to 30 minutes, was it saturated with blood or just 1/4 to 1/2 saturated. You could give the Dr. a specific report. Her vital signs are such and such, she saturated a peri pad in 1/2 hour and continues to bleed.

A rectal bleed and lady partsl bleeding can both be bright red.

The first thing you do in a code (or a dire situation) is take your own pulse.

keepingalive · Mar 7, 2016

The reason I knew she was bleeding lady partslly was a coworker told me how to check (as "TheCommuter" specifies). After the fact, I had already told the MD. My charge went ballistic, however. Because I was not 100% certain. I believe I emphasized that to her so she would go into the room with me, at least.

A week ago, we had another patient on the decline. This charge dialed up a different floor to get assistance from another charge. I am irritated that slipped her mind as I stood helplessly in clear need of assistance.

She DOES NOT receive patients. She was adjusting the schedule when I approached her. Seems her only duty on the floor is to read MD reports and pass-on information we might missed during change-of-shift report. Though I have no idea. This is +4 times I have asked for her set of experienced eyes and she has neglected me. She is always reading reports when I need her most.

I have a couple of experienced coworkers. 1/5 nurses are +3 years. We're all new graduates, with the exception of my charge nurse.

VANurse2010 · Mar 7, 2016

The reason I knew she was bleeding lady partslly was a coworker told me how to check (as "TheCommuter" specifies). After the fact, I had already told the MD. My charge went ballistic, however. Because I was not 100% certain. I believe I emphasized that to her so she would go into the room with me, at least.
A week ago, we had another patient on the decline. This charge dialed up a different floor to get assistance from another charge. I am irritated that slipped her mind as I stood helplessly in clear need of assistance.
She DOES NOT receive patients. She was adjusting the schedule when I approached her. Seems her only duty on the floor is to read MD reports and pass-on information we might missed during change-of-shift report. Though I have no idea. This is +4 times I have asked for her set of experienced eyes and she has neglected me. She is always reading reports when I need her most.
I have a couple of experienced coworkers. 1/5 nurses are +3 years. We're all new graduates, with the exception of my charge nurse.

I assure you her duties as charge are far more numerous than what you're thinking/describing here.

nutella, MSN, RN · Mar 7, 2016

One general thing I want to throw out that most hospitals (small and large) nowadays have a rapid response team.

Some hospitals have mandatory parameters that force the nurse into calling a rapid response, others wait for the nurse or doctor to initiate.

The rapid response would be helpful in any situation that warrants more intervention, resources, and a second pair of eyes. For sure desat into the 80s and bleeding would be a case for rapid response.

In a situation like that you want to reach out to the charge nurse - if not reacting get at least another coworker/nurse to help you with getting supplies needed, call a rapid response and such.

It is sad that the charge nurse is not guiding your more.

keepingalive · Mar 7, 2016

I assure you her duties as charge are far more numerous than what you're thinking/describing here.

No doubt. Preparing the schedule for next month was priority. I am not feeding anybody here BS. This was what she was doing. And yes, from what I have gathered, my practice and my charge nurses' role are parallel.

A week ago, we had another patient on the decline. This charge dialed up a different floor to get assistance from another charge. I am irritated that slipped her mind as I stood helplessly in clear need of assistance.

What's you're opinion on this^?

amzyRN · Mar 7, 2016

When I was a new nurse, other RNs and our charge nurse were usually good resources. You did fine. I probably would have put the pt on some O2 immediately (which you probably did) then called the doctor right afterward. Sometimes it's best to go straight to the doctor in a case like that. Any kind of destabilization like that usually merits letting the MD know. I don't understand why your charge would advise you in the way she did. It's good you listened to your gut. Never ignore it.

I don't see why it matters if it was rectal bleeding versus lady partsl. The patient is bleeding with abnormal vitals. The MD can come and do the exam. It's okay to tell the doctor you don't know if it's rectal bleeding or not.

neuron · Mar 7, 2016

Right when the nurse ignored you, and digressed the statement to about the pain pill and temperature, I would have immediately went in to the room to do my own assessment (as long as it was safe) and scoot her aside. Then FIND out where the bleeding is coming from. NEVER EVER trust another nurse to help you or rely on with giving 'care' (as far as your own practice goes). Many nurses/practitioners will take the back door. Unfortunately, when you 'called' the MD, maybe you should have been in the room checking? Maybe it's better to have more accuracy when you call.