Peg prep for surgery tomorrow A.M.--patient ends up in ICU by end of shift

[TallGirlAni]

Hello to all, and i just wanted to write about my patient and his situation on my shift tonight. I am a new grad (Dec 2005) and this is my first RN job. I have been employed here since Feb 6 of this year. Forgive me for this long post.

I get report at 15:30 at the start of my shift. 83 year old pt has been admitted to our post-surgical/ortho floor for peg prep for surgery tomorrow morning: colovesicular fistula. He has started drinking his gallon of Colyte. He has a history of diverticulitis, and an MI in 2002. He is on a clear liquid tray, and he will be NPO at midnight.

When I round to his room to get a set of vitals, he is in the bathroom, so I come back to check on him. I am awaiting the arrival of another patient fresh from recovery. After I get my other patient settled in, I get a page that my Peg prep patient has alarmed me from his bathroom. No aide on our floor tonight. So, I go to his room, and there is loose stool on his bed, floor, and all over the bathroom. So, as I am getting him and everything cleaned up, I realize that he is not clear, so I hand him the cup and instruct him about the process and that I must see the results after he goes each time, so that I can deem him clear, and start the antibiotics. He is not very happy because he has a walker and cannot get to the bathroom in time. So, I round up a bedside commode and I make sure his call light is in reach and that he is relatively comfortable. Linens, gown, and socks are changed. I tell him to push his call light when he wants to sit back in bed. I have diaper pads, draw pads ready. I took his vital signs, did my head to toe, and then I encouraged him to continue to drink. He was miserable, but a trooper. He was asking me if he could have an enema, instead.

I did page his doctor, who happened to be the surgery resident on-call for the evening, anyway. I told her that patient was not close to being clear, and that he was having a miserable time drinking this and expelling it from his system. If he could get an enema, instead? She said she would let her chief know and get back to me. Plus, he was first case in the a.m. and I needed to get him clear to get the abx in him. I had even called pharmacy to let them know so that we could figure out how we could time the antibiotics once he started them. He also had a foley in and urine output was low. We irrigate the foley for an obstructions, none that we could find. No iv access and no iv fluids ordered.

I am also conferring with other RNs on my side of the floor, for any suggestions.

He finally finishes the gallon at 21:00 and is clear, but still needing the bedside commode. I have another RN checking with me to clear him. He is really feeling miserable at this point. While still on the bedside commode, I change his socks and his feet and lower extremities (from the knees down are purple--no hx of arterial or venous insufficiency. Then, he starts vomiting--clear emesis). So, I have the other RN stay with him, I page the Doc and she is getting ready to drive over (she is not in-house).

Vomiting resolving, we get him into bed, take vitals, and BP hypertensive, P=61, heart rate irregular. Lungs crackles. We get the crash cart ready at the bedside. Trying to get an PIV in, but he is a very hard stick. Put the AED patches on. The urology resident, who was knew the patient and was going to be involved in his case tomorrow was on our floor and came in to help out. Now, pulse is 140. A-fib. EKG done stat, Portable Chest Xray Stat, Paged MD again to come in quicker. Now, he starts to desat to 80%, so another RN puts a non-rebreather on at 6L and his sats climb back up to 98%. Pulse now bradies down to 50, then 40, then 39, patient is alert and oriented, scared senseless. I just pushed the code button. Better to be safe. Code team arrives. MD arrives. One resident is trying to get an ABG, but having a difficult time getting one. So, nursing superviser is calling to get a bed in the ICU. Bed obtained, doctors evaluating. Fluid overload and the A-fib. Urology resident irrigates the foley some more and deems it patent as far as she can tell. Bladder scan reveals 62 cc. (we previously irrigated it with 60 ccf). Report called to ICU, and I brought patient down.

As a new nurse, I hearing from the more seasoned nurses about the complications a peg prep can cause, especially with cardiac patients. He had been previously cleared by cardiology for this surgery.

When I transferred him down to the unit, I saw that his feet had returned to their normal color, he was more comfortable, and his vitals were stable.

It was a scary situation for me, and I had some intuition throughout the shift that this patient was one that I wanted to pay close attention to--hence the phone calls to the MD throughout the night.

I was grateful for the support that I had from my fellow nurses, and that I knew enough to come and get them and anyone else that could help out before I had submerged myself underwater...

I just wonder if I hadn't taken off those socks and seen those purple feet and legs--if the room had been darker, etc. I learned some valuable lessons tonight, and am grateful with a good outcome. Any suggestions to further my learning experience? Any similar stories?

[prmenrs, RN]

I am very impressed! I think you did a great job.

GI preps like that can really be hard on the pt. I would be very worried about electrolytes the whole time, esp w/an 83 y/o pt. If my mom had to have one, I'd be hanging out w/her all day (which would just drive her nuts,by the way).

[EDGRADNURSE]

Oh my gosh, you did SUCH an excellent job! New grad, no less! That patient was very lucky to have you as his nurse.

[dayshiftnurse]

tallgirlani,

you did an amazing job! i have been a nurse for 3 years and hope i will be able to function as astutely on a med/surg ward soon :balloons: :balloons:

[SharonH, RN]

Hello to all, and i just wanted to write about my patient and his situation on my shift tonight. I am a new grad (Dec 2005) and this is my first RN job. I have been employed here since Feb 6 of this year. Forgive me for this long post.

I get report at 15:30 at the start of my shift. 83 year old pt has been admitted to our post-surgical/ortho floor for peg prep for surgery tomorrow morning: colovesicular fistula. He has started drinking his gallon of Colyte. He has a history of diverticulitis, and an MI in 2002. He is on a clear liquid tray, and he will be NPO at midnight.

When I round to his room to get a set of vitals, he is in the bathroom, so I come back to check on him. I am awaiting the arrival of another patient fresh from recovery. After I get my other patient settled in, I get a page that my Peg prep patient has alarmed me from his bathroom. No aide on our floor tonight. So, I go to his room, and there is loose stool on his bed, floor, and all over the bathroom. So, as I am getting him and everything cleaned up, I realize that he is not clear, so I hand him the cup and instruct him about the process and that I must see the results after he goes each time, so that I can deem him clear, and start the antibiotics. He is not very happy because he has a walker and cannot get to the bathroom in time. So, I round up a bedside commode and I make sure his call light is in reach and that he is relatively comfortable. Linens, gown, and socks are changed. I tell him to push his call light when he wants to sit back in bed. I have diaper pads, draw pads ready. I took his vital signs, did my head to toe, and then I encouraged him to continue to drink. He was miserable, but a trooper. He was asking me if he could have an enema, instead.

I did page his doctor, who happened to be the surgery resident on-call for the evening, anyway. I told her that patient was not close to being clear, and that he was having a miserable time drinking this and expelling it from his system. If he could get an enema, instead? She said she would let her chief know and get back to me. Plus, he was first case in the a.m. and I needed to get him clear to get the abx in him. I had even called pharmacy to let them know so that we could figure out how we could time the antibiotics once he started them. He also had a foley in and urine output was low. We irrigate the foley for an obstructions, none that we could find. No iv access and no iv fluids ordered.

I am also conferring with other RNs on my side of the floor, for any suggestions.

He finally finishes the gallon at 21:00 and is clear, but still needing the bedside commode. I have another RN checking with me to clear him. He is really feeling miserable at this point. While still on the bedside commode, I change his socks and his feet and lower extremities (from the knees down are purple--no hx of arterial or venous insufficiency. Then, he starts vomiting--clear emesis). So, I have the other RN stay with him, I page the Doc and she is getting ready to drive over (she is not in-house).

Vomiting resolving, we get him into bed, take vitals, and BP hypertensive, P=61, heart rate irregular. Lungs crackles. We get the crash cart ready at the bedside. Trying to get an PIV in, but he is a very hard stick. Put the AED patches on. The urology resident, who was knew the patient and was going to be involved in his case tomorrow was on our floor and came in to help out. Now, pulse is 140. A-fib. EKG done stat, Portable Chest Xray Stat, Paged MD again to come in quicker. Now, he starts to desat to 80%, so another RN puts a non-rebreather on at 6L and his sats climb back up to 98%. Pulse now bradies down to 50, then 40, then 39, patient is alert and oriented, scared senseless. I just pushed the code button. Better to be safe. Code team arrives. MD arrives. One resident is trying to get an ABG, but having a difficult time getting one. So, nursing superviser is calling to get a bed in the ICU. Bed obtained, doctors evaluating. Fluid overload and the A-fib. Urology resident irrigates the foley some more and deems it patent as far as she can tell. Bladder scan reveals 62 cc. (we previously irrigated it with 60 ccf). Report called to ICU, and I brought patient down.

As a new nurse, I hearing from the more seasoned nurses about the complications a peg prep can cause, especially with cardiac patients. He had been previously cleared by cardiology for this surgery.

When I transferred him down to the unit, I saw that his feet had returned to their normal color, he was more comfortable, and his vitals were stable.

It was a scary situation for me, and I had some intuition throughout the shift that this patient was one that I wanted to pay close attention to--hence the phone calls to the MD throughout the night.

I was grateful for the support that I had from my fellow nurses, and that I knew enough to come and get them and anyone else that could help out before I had submerged myself underwater...

I just wonder if I hadn't taken off those socks and seen those purple feet and legs--if the room had been darker, etc. I learned some valuable lessons tonight, and am grateful with a good outcome. Any suggestions to further my learning experience? Any similar stories?

No suggestions, you did a fabulous job!