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new nurse advice. screwed up?

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Patient: 40 something year old Jane-Doe. No medical history.

Is post operative. Underwent general anesthesia. Had a ureter stent placement and stone removal.

BP 80/50 HR 41 100% on 2L cannula.

subjective: Looks pale. She said she looks pale, also. Feels groggy. A bit swollen/edematous in the arms.

States "was an athlete BACK IN THE DAYS. My blood pressure runs low, but not that low. I never had my heart rate measured." In the ER, base line was 100s/60s and her HR was 70s. Maybe because of pain?

Should this warrant a "Hello Doctor! Explain above. That's it." Or should I have left it alone? I ask because the patient was OK when I left a couple days ago. My Charge Nurse said she'll be OK. Don't need the MD. But my director wants to talk to me about this. So I think something happened to the patient. I go back in tomorrow.

Thanks. Should I have made the call?

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What were you taught about post-operative assessments in nursing school?

Does your unit have a policy for the assessment/care of the post-operative patient?

What were the physician's orders for their patient?

Yes, it was appropriate to call the physician promptly for those vital signs and assessment.

Edited by Susie2310

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I would have called. We can be ok with a SBP in 80's in the ICU, but the MAP is only 60 with a BP of 80/50. It really should be over 65. The combination of BP, HR, how the patient looked and felt would have had me paging the doctor right away. If she was groggy it could have been from the anesthesia, but my guess is it was from poor perfussion. She had irregular vitals AND was symptomatic. A lot of times if patients have vitals like that in the ICU and they aren't symptomatic we'll try some fluids and continue to monitor, but it's a different story when they are symptomatic.

If that was my patient I'd be notifying the doctor, asking for an order to trend her hemoglobin, and getting an order for a bolus to see if that helps.

ETA: I'd also be doing an EKG stat.

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Patient: 40 something year old Jane-Doe. No medical history.

Is post operative. Underwent general anesthesia. Had a ureter stent placement and stone removal.

BP 80/50 HR 41 100% on 2L cannula.

subjective: Looks pale. She said she looks pale, also. Feels groggy. A bit swollen/edematous in the arms.

States "was an athlete BACK IN THE DAYS. My blood pressure runs low, but not that low. I never had my heart rate measured." In the ER, base line was 100s/60s and her HR was 70s. Maybe because of pain?

Should this warrant a "Hello Doctor! Explain above. That's it." Or should I have left it alone? I ask because the patient was OK when I left a couple days ago. My Charge Nurse said she'll be OK. Don't need the MD. But my director wants to talk to me about this. So I think something happened to the patient. I go back in tomorrow.

Thanks. Should I have made the call?

Were her vital signs only taken one time? When I have an "on the fence" situation, I tend to monitor very closely to see if they return closer to normal, stay the same, or get worse. Orders already in place make a difference when deciding to call/not call, too.

There are times when my charge says there's no need and I call anyway. They're fallible like the rest of us, so if you're not sure, err on the side of caution.

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I would have called. A HR of 41 while awake is concerning. Sleeping would be one thing. Even groggy she was awake. That combined with the BP, I would have called.

Don't you have call orders?

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You have a hypotensive and bradycardic patient who is pale and reports being groggy.

She should have had pre-op labs performed and a pre-op EKG, I would call anesthesia and request an order for atropine, stat EKG, a fluid bolus, and a push dose of neo if needed. I suspect that if she has a benign physical exam that she is having common side effects from the anesthesia, but could also be unstable and needs treatment and for the medical provider informed. Assuming that they had a ureteroscopic approach then I doubt she is having bleeding (and you didn't remark on an abnormal GU exam in post-op), but I don't think a hemogram is a bad idea.

Hopefully the surgeon or anesthesia found out and this is a learning moment rather than the patient having a bad outcome.

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I would've called if I had concerns after a thorough assessment which would have garnered more information than we have here. Listen to patients carefully, but use caution in taking up their explanations for assessment findings that concern you as a nurse responsible for the big picture. Consulting nursing colleagues is helpful when they can suggest interventions or share assessment findings or explanations that you may have overlooked or not understood. A simple statement that someone would be okay probably wouldn't have reassured me as much.

Though we all should try to be prudent with our phone calls, there usually isn't a huge downside to consulting the physician/admitting service when there is a legitimate patient concern.

Maybe a learning moment as mentioned above.

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Hey girl, after your assessment and you knew something was wrong but your lead said otherwise still follow your gut feeling. It's the safety of the patient is what is most important and if the doctor yells at you for bothering him & giving him suggestions at least you documented and you did your best to keep the patient safe. Esp for post op there should be a policy and procedure to when things go down the toilet. I hope all is well! Take care:)

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"My charge nurse said she'll be ok." No, that's your license and the patient's life. The pt very clearly stated her baseline and her own concerns. Your assessment was spot on. However, yes you should have made the call. I don't care WHAT the doc thinks of you for calling. Learn from it and move forward.

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Patient: 40 something year old Jane-Doe. No medical history.

Is post operative. Underwent general anesthesia. Had a ureter stent placement and stone removal.

BP 80/50 HR 41 100% on 2L cannula.

subjective: Looks pale. She said she looks pale, also. Feels groggy. A bit swollen/edematous in the arms.

States "was an athlete BACK IN THE DAYS. My blood pressure runs low, but not that low. I never had my heart rate measured." In the ER, base line was 100s/60s and her HR was 70s. Maybe because of pain?

Should this warrant a "Hello Doctor! Explain above. That's it." Or should I have left it alone? I ask because the patient was OK when I left a couple days ago. My Charge Nurse said she'll be OK. Don't need the MD. But my director wants to talk to me about this. So I think something happened to the patient. I go back in tomorrow.

Thanks. Should I have made the call?

The low BP and low HR both should have raised an alarm, especially if in the ER she was higher and from the looks of it her HR was considerably higher in the ER, for signs this low I always notify MD, chances are she probably just needs some fluids but a kidney issue, edema in the arms and even having general anesthesia would have my ears pricked and saying "someone needs to know about this" because ANYTHING could be going on. So yes, this absolutely warranted a call to the team.

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