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made MD angry, and resources on unit

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by keepingalive keepingalive (New) New

I have been caring for a patient who was admitted for post menopausal bleeding and hydroneprosis. History of hypertension and diabetic. Patient is 3 day post d & c, and has a nephrostomy tube/bag.

On my shift, she starts to complain of headache and her temperature is 100.2. My charge nurse gave Norco because it will help with the elevated temperature and pain. Not 5 minutes goes by. Coincidentally, right after she swallows the pills, I ran her vitals (again) and her respirations are increased, and her o2 saturation dips into the 80s with hr at around 130-140ish.

I tell my charge nurse and she told me the abnormal vitals were because of pain and temperature.

I returned to check the peri-pad and the patient is actively now bleeding. I thought it was rectal because I have no idea how to distinguish between vaginal and rectal bleeding. So I tell my charge nurse. "The patient is rectally bleeding."

She asks "Are you sure."

I replied "I'm not sure. I do not know how to check. Can you assist me?" And then she ignores me. And reiterates the abnormal vitals were because of pain and temperature.

At this point, I realize she is not going to check with me. I get on the phone and dial the MD. I told him about the rectal bleed, the vitals, etc...

Turns outs, the patient was bleeding vaginally and needed a couple of units of blood. MD was angry I told him "rectal bleed." Oh well.

Anyway, when you (YOU) were a new nurse, who were/was your resource on your shift? What would you have done differently?

Edited by keepingalive

TheCommuter, BSN, RN

Specializes in Case mgmt., rehab, (CRRN), LTC & psych. Has 15 years experience.

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 vaginal 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 vaginal area.

juan de la cruz, MSN, RN, NP

Specializes in APRN, Adult Critical Care, General Cardiology. Has 27 years experience.

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 vaginal 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.

Edited by juan de la cruz

SnowShoeRN

Specializes in Family Medicine, Tele/Cardiac, Camp. Has 10 years experience.

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 vaginally. 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 vaginally 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

Specializes in ICU, LTACH, Internal Medicine. Has 8 years experience.

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 anus. 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 vaginal 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 anus, one at vaginal 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

Has 36 years experience.

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 anus, see if it got bloody, or just look at her anus....was blood coming from it? Put a wad of gauze on her vagina, 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 vaginal bleeding can both be bright red.

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

The reason I knew she was bleeding vaginally 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

Has 6 years experience.

The reason I knew she was bleeding vaginally 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.

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.

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^?

Edited by keepingalive

amzyRN

Specializes in ED, Cardiac-step down, tele, med surg.

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 vaginal. 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.

Edited by amzyRN

fibroblast

Has 5 years experience.

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.

After a d&c there is usually not a ton a bleeding. So I can see how you could perhaps think that the bleeding could be coming from somewhere else. That coupled with the other signs/symptoms of impending distress, and yes, a call to the MD to assess would be warranted. As in some instances a rapid response.

Charge should have taken this more seriously, and curious as to what the response was after the MD was called and blood was ordered. Take away the "where the blood was coming from" thing for a moment--literally, what happened when MD was "2 units of PRBC's" and the charge realized that you made a good catch?

Hopefully, this patient was sent to a higher level of care, as if there was still bleeding, giving blood would be like my gramma who was a nurse would say "spitting in the breeze".

As a newer nurse you are still learning. But good on you to realize something was amiss, and to react accordingly. If there's a meeting regarding this, make sure that you really stress that you were taught it good practice to update the charge nurse not only every couple of hours, but on a PRN basis. And that if the policy is different, you need to know the proper procedure.

And in communication, make sure that you are to the point "room 233 is s/p D&C and is actively bleeding with bright red blood. Also she is c/o 7/10 pain. I medicated per order with____________. Her vitals are increasingly unstable, and I am concerned about the amount of blood I am seeing that is bright red. I would like to call the MD for further assistance."

If you are still being ignored this is a patient safety issue, and needs to be brought up the chain of command. For no other reason other than it is a patient safety risk.

Let us know how it goes

To determine the source of blood, couldn't you ask the patient? If there was a rectal bleed, surely she would feel a gush of what would probably feel like uncontrollable watery diarrhea. For some who is AOx3 and continent, this is something out of the ordinary.

SnowShoeRN

Specializes in Family Medicine, Tele/Cardiac, Camp. Has 10 years experience.

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.

If you're that concerned about the safety situation, why not go to your nursing supervisor or manager and have a talk with them? You don't have to be all like "so-and-so is terrible and super unapproachable and super unsafe," but you could say something along the lines of "May I speak to you confidentially? As a new grad, I don't always feel like I'm getting the support I need from my charge nurse. This concerns me because xy and z. For example, the other day when I had a patient who was bleeding vaginally..."

Your manager may clarify charge nurse roles you haven't noticed before or point you in the direction of other resources you weren't aware of. Or they could do nothing and that may signify that you need to consider leaving your work environment.

In any event, nothing will change about the situation until you do what you can on your end. Best of luck with things.

imintrouble, BSN, RN

Specializes in LTC Rehab Med/Surg. Has 16 years experience.

As everyone else has already said, the OP did fine for her patient.

If I'd called an MD and said "I don't know" about the bleeding, I would have been slaughtered. All places are different.

If I'd called and said "I did this, and this, and this, and I don't know, he/she wouldn't have liked it, but my butt would be intact.

"I don't know" is possible, but you have to qualify it with everything you did to try and find out.

All responders have been very kind and understanding, and I don't want to be the odd man out. But I'll admit to wondering how even a new nurse didn't know how to determine a source of bleeding.

KatieMI, BSN, MSN, RN

Specializes in ICU, LTACH, Internal Medicine. Has 8 years experience.

As everyone else has already said, the OP did fine for her patient.

If I'd called an MD and said "I don't know" about the bleeding, I would have been slaughtered. All places are different.

If I'd called and said "I did this, and this, and this, and I don't know, he/she wouldn't have liked it, but my butt would be intact.

"I don't know" is possible, but you have to qualify it with everything you did to try and find out.

All responders have been very kind and understanding, and I don't want to be the odd man out. But I'll admit to wondering how even a new nurse didn't know how to determine a source of bleeding.

I kinda understand not finding the source down below, there can be "circumstances" making that digging into bleeding flesh really difficult. But treating "fever and pain" with Norco while saturation drops and heart is pounding 140 times/min is just about textbook example of chapter on "How to stop imagining yourself as a clinical thinker, or The shortest cheatlist of how to avoid license loss and murder charges".

fibroblast

Has 5 years experience.

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

So that makes it ok to ignore the pt. in decline and new nurse who needed her assistance?