I'm usually a lurker but something happened at work and I really need some feedback. I work on a peds floor and our ratio can run from 4-8 kids per nurse. Summer is 4 and the rest of the year is probably 6-7. There's a pretty wide range of kids with some ought to be in PICU types thrown in for fun.
Here's what happened. I got report from the day nurse (let's call her X) and she told me the pt, a 2 month old baby with serious neuro damage from group B strep memingitis, had not voided all day. The last recorded void was mine from 5AM that morning. Pt has lots of associated complications d/t the neuro damage--thermoregulation issues, diabetes insip., electrolyte imbalances. Day shift had not been busy and I think X had 4 low acuity pts. As she is giving me report I asked her if the doctors were aware that the baby hadn't voided and was told that they were. She further said she gave the DDAVP as ordered. Red flags started going off in my head since I couldn't understand why she'd give DDAVP when the pt hadn't urinated. The DDAVP order should have been written to be given based on the urine specific gravity but it wasn't. However if the baby didn't void I don't understand why she'd give it?
Residents came on the floor. I talked to them about these issues and asked some questions. They said they had no idea of the situation and had not been informed until an hour ago of what had been going on. Turns out the DDAVP shouldn't have been given (I hadn't but X had) and a diuretic was ordered (not the one that would have been my first choice because it wasn't fast acting but that's another issue). I go in to assess the pt after getting report. It's about 8 at this time. Pt temp is 90.2 and he looks like a totally different baby than the one I had last night. I didn't freak out. Let my charge nurse know (she's awesome), grabbed the warmer, talked to the docs-basically telling them what labs were needed, reassured the understandably scared parents, and went from there. Parents were at home earlier caring for the healthy twin. Looked at 4 PM vitals. Everything WNL but I know X hadn't been in (cannot prove it) but that's irrelevant at this point.
Get the temp stablized-takes 4 hours. Draw the labs. Sodium is 130, CRP is high, and pt is neutropenic. VBG shows pH okay and confirms the sodium level. Father takes baby out to feed at 7 AM-temp had been stable and I had been decreasing the temp in the isolette slowly throughout the shift. Temp drops quickly by several degrees in the 30 minutes the baby is out even with swaddling. Repeat labs show no improvement. Baby goes to PICU during day shift.
I'm sorry this is so long but I am wondering if I did enough and if what I did do was right. I've only been a nurse for 1 year and have had some heavy situations but this one really scared me (I didn't show it but I came home and cried). For those of you that are probably a lot smarter than I am--How responsible is the day nurse?
Am I wrong in thinking she should have done a lot more? We use computer charting and I always write a clinical note if something significant happens. There was no clinical note from X nor I & O recorded for the shift. Seems like a very important thing to me in at pt like this. X isn't a great nurse but this is a new low to me. I have to see her tomorrow and I am dreading it because I'm really angry. Any feedback would be great-my coworkers and charge nurse agree and are very supportive but the nurse manager is useless. There have been other issues but none this severe. I've gotten very good evals and get along with everyone. I like flying under the radar and staying out of the NM's office is one of my main goals. Pts are great but NM sucks.
That's a good point and I'm going to go in early to get my documentation together. Hopefully I'll never need it but I think I'd feel better having it. Thanks for the sage advice!
Specializes in Med/Surge, Psych, LTC, Home Health.
Wow... having an ADULT not void within 6 to 8 hours is a big red flag, nonetheless a child!
Having said that, I actually know little about caring for critically ill infants and children. I do have some peds experience, but it mostly involves caring for children with fairly minor respiratory issues, head injuries, and failure to thrive... conditions that COULD potentially become severe, but at the time the child is just being monitored. Anyway, so I can't comment on too many of the specifics from your post.
However, you sound like an excellent and compassionate nurse, who is able to really keep their head together. Curious, why do you have a crappy NM; you didn't say in your post.
My NM is pretty crappy. I had a situation when I first started. I had to take a pt down to MRI on a monitor since chloral hydrate was ordered. Happened right at the start of the shift-doc yelling, CR monitors not working, Murphy's Law in action. Gave report to the two nurses that were on the floor. One stable pt and one not so stable resp pt. Come back and the nurse whom I gave report to on the resp pt says "Your pt was retracting. He was breathing pretty fast." I asked her what was done and she said nothing. I asked her if she called the doc, gave a tx, etc. Let charge nurse know. Nothing seems to happen.
Fast forward a couple of weeks. There is an oncology pt and for some reason it is unassigned. They ask her to take it and she refuses. Turns out she isn't allowed to have that pt because a mistake was made. Now I'm aggravated because I have my full assignment + 1. Decide it's time to go see the NM. Let her know my concerns and she says "I've never seen you like this. Is something else going on?" Trying to do the whole pushing back thing like I'm the one that's in the wrong. I stay calm and explain my concerns. She then uses my all time favorite management line "What can you do to solve the problem?" I tell her what I have done and outline the results. Still calm but started to wonder why I've bothered. She says "How do you know that these issues haven't been addressed? I don't have to come to you to tell you what I've done." I tell her that whatever action has been taken has made no difference in how things are. Finally give up because I think I might flip out if I had to sit there for even one more minute.
The aforementioned nurse is still the same. Lots of complaints from other staff members and no action. I guess that's my hesitation with this situation. I feel like bringing serious issues up to the NM result in me getting frustrated or talked to. The whole blame the messenger thing I guess. Has any one else run in to this?
Specializes in Peds Cardiology,Peds Neuro,Pedi ER,PICU, IV Jedi.
vamedic4,
Thank you so much for your feedback. I wrote everything down in a clinical note and my charge nurse was there. What are your thoughts on the day shift RN who had the pt?
Let's just say that if she were my child's nurse she'd be looking elsewhere for employment, as it sounds like she can't deliver the standard of care that is necessary.
you sound on top and ahead of the game w/your assessments and interventions.
great job!
i can't emphasize enough, however, the importance of meticulous documentation.
if your notes are concise, articulate and comprehensive, then 'one' should be able to develop a list of questions, i.e., why did/didn't this happen? why was this given/or not? what happened/didn't happen on the previous shift?
you need to focus on your actions, even when they're a result of another's inaction.
document interactions w/drs...re concerns, new developments, etc.
your notes will tell it all, even w/o mentioning anyone else.
as for your nm, you can always relay your concerns.
You raised some good points about documentation. I had my charge nurse help me with the clinical note and didn't use the X's name. She said the same things you have--basically stick to the facts and document everything. Much harder than I thought it would have been but it was probably due to how upset I was feeling. Thanks again for all of the support--sent an email to NM requesting a meeting. Will let you all know how it goes.
Thought I'd like to update this thread with what happened to the pt. Pt went to PICU the next day. Wound up being septic. Eventually went to CHOP and that's the last I've heard. Nothing has happened to the nurse so far but supposedly NM is addressing the issue. NM called to ask if I wanted to talk, calling me honey, etc. Was very busy that night-hanging blood, admits, etc so declined. Still mixed if it's worth it to speak with her since past interactions in similar situations have sucked. Winds up being worse for me than the other person. Thanks for all the support!
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annaRNC
49 Posts
Hi Linda,
That's a good point and I'm going to go in early to get my documentation together. Hopefully I'll never need it but I think I'd feel better having it. Thanks for the sage advice!
Anna