No Order

[Davey Do]

Friday night had a patient who said she had experienced some dysuria in the evening and was currently, in the wee hours, experiencing anuria. I got a bladder scan of 366 mls and contacted the NP who gave me an order for a straight cath. The patient was to be followed up by the day NP.

I passed on the information on in shift report. That evening, it was reported that the NP had followed the patient up, prescribed some meds. The off going nurse also mentioned that the patient had been bladder scanned and cathed x2 with the amounts given.

Later in the night, the patient again c/o anuria, so I checked the orders. My order for the straight cath was the last one entered.

I thought of a line from the movies "Treasure of the Sierra Madre" and "Blazing Saddles".

Oh! And Joint Commission was in the building!

Do I hear a *DING!*?

[Daisy4RN]

""Do I hear a *DING!*?""

Personally when I hear that Joint Commisssion is in the building I think I hear Ding Dong...just sayin...

[NurseBlaq]

Cathed not once, but twice without an order AND Joint Commission in the building? Oh my!

[JBMmom, MSN, NP]

At least you're not the one that would be answering to the Joint Commission for those actions! I hope that nurse you took report from just forgot to put the orders in and can fix it when they return. If they gave you bladder scan results it must have been done at least.

[Sue Damonas, BSN]

Davey Do, can I can a harrumph out of you? LOL!

[turtlesRcool]

This is really bizarre to me that there would only be a one-time straight cath order. In my experience when a provider goes to order, there's an ongoing order set that pops up, like bladder scans Q6hrs with straight cath for greater than 350ml. Are you sure you need a separate order each time a cath is performed? My guess is the day nurse saw the order you got, figured the order was active, and acted accordingly. Without knowing the actual wording of the order, it's hard to say, but my first thought is that the order might have been ambiguous enough to lead your colleagues to think they were following the NP's original order.

[TriciaJ, RN]

On 7/1/2019 at 8:03 AM, turtlesRcool said:

This is really bizarre to me that there would only be a one-time straight cath order. In my experience when a provider goes to order, there's an ongoing order set that pops up, like bladder scans Q6hrs with straight cath for greater than 350ml. Are you sure you need a separate order each time a cath is performed? My guess is the day nurse saw the order you got, figured the order was active, and acted accordingly. Without knowing the actual wording of the order, it's hard to say, but my first thought is that the order might have been ambiguous enough to lead your colleagues to think they were following the NP's original order.

That's what I thought, too. Did they take the order to mean straight cath prn for above a certain bladder scan amount?

[Forest2]

Probably thought it was a continuing order and no time to actually visualize the order. It happens.

[xoemmylouox, ASN, RN]

At the hospital I work at we have a nursing judgment protocol that allows us to bladder scan & straight cath a full 24hr for retention (or sx of) before we need an order. Perhaps that is something you can suggest at your next meeting. This was put in place to reduce the number of foleys since the providers tend to give an order to anchor a foley vs bladder scan & straight cath (or at least they said that was the situation). I LOVE this protocol.

[myoglobin, ASN, BSN, MSN]

Several lines of thought here:

1. Yes, some facilities may have protocols.

2. At our facility it is the responsibility of the provider to enter the order CPOE (we are not allowed to do so) unless it is a telephone order. Thus, we can "remind" the provider/resident that they "still need to put that order in", but we cannot enter it for them. Thus, we would reflect it in our notes to protect ourselves "spoke to Dr. X who ordered straight cath. on patient due to lack of urine output.".

[Davey Do]

On 7/1/2019 at 10:03 AM, turtlesRcool said:

This is really bizarre to me that there would only be a one-time straight cath order. In my experience when a provider goes to order, there's an ongoing order set that pops up, like bladder scans Q6hrs with straight cath for greater than 350ml. Are you sure you need a separate order each time a cath is performed? My guess is the day nurse saw the order you got, figured the order was active, and acted accordingly. Without knowing the actual wording of the order, it's hard to say, but my first thought is that the order might have been ambiguous enough to lead your colleagues to think they were following the NP's original order.

Excellent posts, all of you!

When I went back to look at my original order, sure enough it said "continuous" without specifics. The nurses that followed me probably saw just that and cathed the patient whenever she felt uncomfortable.

I wanted specifics, so I contacted the NP and got "bladder scan and cath PRN q6hrs if volume >500ml". I told the NP that the patient was uncomfortable with a scan of 366ml. The NP said, "Yeah, well, we want that bladder to stretch out a bit".

All went well: The patient was able to hold out relatively comfortably until the scan came back at a volume > 500ml and was appreciated to be relieved.

The patient had been discharged by the time I worked my next shift and was to f/u with a urologist. As I understand, a continuous cath drainage system was offered, but the patient opted out of it.