Please help new grad - situation with pt (long)

[mstigerlily]

I am a new ADN grad, started working in a busy postpartum unit in in February of this year, I work nights.

I have always been the type of person to have a "sense" about things and when I ignore it, I am usually sorry later. Could be as benign as driving to at ATM, I get a "feeling" and the machine eats my card. Or as serious as just "knowing" this person is dangerous or is very ill.

For example, I was on my first week of orientation I disagreed with my preceptor on the care of a pt. She said the woman was just "whining", I felt the woman was not properly assessed or taken care of by either her or the MD which did a quick 60 second check. This lady had been restless, c/o pain, teary, slight fever in the 99's. Told me her first c-section scar got infected and she had to go "back to the hospital". Well, two days after she went home she was back in the hospital - septic from an infection. I felt something was wrong but didn't persist.

Sooooooo, you would have thought I would have learned from this situation but in practice I find myself intimidated by doctors and impressed by nurses who have much more experience than I. There is so much I don't know, experiences I haven't had yet. I look to our charge nurse and our mentor to help me. Well, Wednesday night I worked and when I came in the day shift RN immediately said this patient was having troubles and the doctor had been called. This day shift RN has at least 20 yrs experience but has recently returned to the floor after management for many years. She is also new to the postpartum unit.

I came in at 1900 Wednesday night. Day shift RN explained the patient had a lady partsl hysterectomy so no incision, lady partsl packing and a foley inserted. Patient was a 32 y/o and had been c/o pain and feeling of pressure in abdomen. Pt had a hx of IBS, 3 children. Foley was not draining much urine and there were white flecks in urine, which was cloudy. Pt had labs done prior to surgery (Wednesday am) which were WNL. Pt was receiving Clindamycin IVPB q8h. Day RN had pulled the Foley, pt stated she obtained relief from pressure, then RN reinserted, pt stated pressure returned. Foley was draining, but not much. About 30-50cc per hour which we know is adequate but didn't seem like enough given all the fluid this pt had received. Day RN stated this patient was receiving Dilaudid 0.5 mg IV q2h as ordered. At this point I had a bad feeling and called my charge RN to let her know I was going to need assist with this patient. She stated she was busy but would send mentor up to assist me.

I went in and did my assessment with day RN present. Pulses were fine everywhere, pt had pressure stockings on. All VSS were at baseline for pt before surgery, during surgery and all day - no changes. Lungs were clear all fields. Abdomen seemed soft but slightly distended, particularly bladder. Abdomen was slightly tender to touch but not overly so. We did a bladder scan to find 200cc inside (I also rechecked this later in the evening around 2200 with same results - approx 200cc). When I listened to abdomen I heard no bowel sounds at all during the 3-4 minutes I listened but I heard a strong pulse (heartbeat) in all quadrants which I had never heard before. I quietly mentioned this to the day RN and she stated, "I noticed that too". This worried me but I finished my assessment. Stat H&H was ordered over phone to be ready when MD arrived. Hgb was 9.1 down from 12.9 presurgery with an estimated blood loss of only 100cc in surgery! We put this on front of chart to discuss with MD. This worried me quite a bit..

While waiting for MD to arrive, day RN stated she would be there for another half hour so I decided to at least check in with my two other patients who had not been assessed or seen and it was 2000.. Again I voiced concerns about pulsing in abdomen to day RN. Day RN stated she didn't know what this meant. Pt was not emaciated or very thin, she was a normal weight - so what did this mean, I thought? Day RN had no anwers for me. Mentor arrived, went in to assess pt, I mentioned my concerns to her as well re: low H&H, pulsing in abdomen, low urine output, retained urine in bladder, flecks in urine, pressure in abdomen, unrelieved pain. She didn't see anything of note, advised me to wait for MD to arrive.

MD arrived around 2030 to assess pt when I was in doing another assessment of my other pts. Day RN still there so she was with him, she was transcribing the new orders when I went back to nurses' station so unfortunately I never got to talk to MD directly but upon reflection I felt it was more appropriate that day RN speak with him since I had only seen pt once for initial assessment and Day RN had been with pt all day. MD ordered 500cc bolus given over 2 hrs, then to continue 125cc/hr of D5LR, a k-pad (heating pad) to abdomen and repeat H&H in morning. I was not happy when I heard these orders, I had been hoping he would order some sort of scan to search for fluid in abdomen or repeat H&H sooner than the AM. I inquired to both day RN and mentor why this bolus would help and what about H&H, pulsing in abdomen and urine output/retention? Many reasons were given: sometimes you can hear pulsing in thin people, urine output met the minimum, etc. So...

I was still disturbed about this patient but she seemed stable. O2 sats and all vitals good and she seemed relatively comfortable so I went to finish assessments of other patients. Day RN left, mentor stayed with me most of evening on and off. At 2300 MD called to check on patient. I told him that her dose of dilaudid was giving some relief but not completely - and that she still c/o pain/pressure in abdomen. Told him I was concerned about her. He stated to "give it a chance" and medicate as ordered with heating pad. MD felt that the pain in abdomen was due to her IBS. "How could this be?" I thought to myself. "She has no bowel sounds and hasn't all day so how could the pain be due to bowel spasms?" But I didn't say this because again, I thought: do I know more than the MD?

So at this point, her VSS still stable and condition basically unchanged but still I felt uneasy. The mentor told me the Operations Supervisor was coming up in a few minutes. I said, "OH great, to assess pt?" She stated, "No, to bring heating pad." Still, I thought, maybe I'll ask her to take a look at the patient too, just to assess. She arrived, chatting busily on phone, dropped heating pad and wheeled around and left. I could have said something but thought, "Oh well I don't want to bother her"

At midnight after phone call with MD, spoke to charge RN in person this time telling her about foley not draining/retention, H&H low, pain meds not working well, pt uncomfortable, white flecks in urine, Mentioned that I was afraid our director would say I didn't advocate for pt, what could I do, should I do more? She stated MD had assessed pt so I was covered and in addition, mentor had assessed and been with patient several times.. I thought, "Maybe I'M covered but I want the PATIENT to be covered" but I didn't say anything.

Continued with evening, at one point pt stated she felt dizzy. Mentor was with me and we pPut o2 on, her sats were fine, she felt better. Not surprised she was dizzy as she hadn't eaten in nearly 48 hrs and was taking IV dilaudid. Checked for bowel sounds, still nothing but pulsing present, no changes in VS. At 0100 went to lunch but brought my food back to desk so I could keep an eye on her, kept her door open so I could even see in door while charting/eating, etc. The midnight dose of dilaudid/nubain seemed to help her rest and I was hoping she was on the mend.

At approximately 0200 I was dealing with another baby who had a bili of 12.1 coombs + at 44 hrs. I thought it could wait till morning, charge RN advised me to call MD at 0300, who was not pleased. When I gave my report at approx 0400 I again addressed my concerns with charge RN regarding my primary pt but she stated again, "Mentor assessed pt. What did she think?" So I basically shut up. Kept thinking what do I, a lowly new grad with four months' experience know? Do I know more than the MD who saw the lab results, assessed her belly and took a look at her and saw nothing? Better than the charge RN and mentor? So I just watched pt closely. Heating pad provided little relief so I kept bringing her warm baby blankets from warmer to hold to her stomach. This kept me coming in about q30 minutes to give her new ones so this was ok by me. I kept door to her room open through rest of night.

Between 0300 and 0500 pt seemed to be doing better and I got busy with all the charting I didn't do. Mentor recommended I medicate pt with higher dose of dilaudid to see if she obtained relief but I was afraid it would mask symptoms. She ended up having 4 doses of 0.5 mg Dilauded during my 12 hr shift and I felt that was a lot for someone young with a minor surgery. I didn't want her to be in horrible pain but I wanted to see if something suddenly got much worse. So I told mentor no, I was not going to increase the dose/frequency and gave her my reasoning.

6am, the lab did their draw, not a stat draw just timed. At 7:15 they called to say pt's hgb was 6.4. It had dropped from 9.1 to 6.4 in about 10 hrs overnight while she sat in bed. Day RN and I discussed who should call MD (this took about 60 seconds) - she said she should since she would be there when MD arrive. I said I should since I had been with pt the last 12 hrs. I immediately paged MD then, while waiting for a callback, notified charge RN of situation by phone. MD called back and I quickly told him concerns, lab results. He said, "Sounds like she is probably bleeding" I stated, "YES, I THINK SO. WILL YOU COME IN?" He stated he was coming "soon". "WHEN?" I stated. He assured me within the hour... then mentioned he "might" want to take her to the OR. He was ready to hang up when I said, "DR X - DO YOU WANT ME TO PREPARE HER FOR SURGERY??? Order tests?" He said, "Oh yes, type and cross for 2 units" so I immediately put in this order to the lab stat and called to make sure they were coming.

Well I went home late around 0815, lab had just come to type and cross and MD was on route and the same day RN was back on shift assisting pt. Pt was informed of possibility of surgery, consents were being signed. I called when I woke up later that day around 1330 to check, day RN stated pt went to OR and was bleeding internally and lost about 600cc of blood just sitting in her abdomen. They were not able to find active bleeding at that time. Our director of women's services had met with Day RN stating she didn't provide good care and stated she wanted to speak to me also. I was shaking but I called her back to get it over with and speak to her. She felt I had let the patient down and wanted to know precise sequence of events.

I have been thinking about nothing else since. When that woman's husband left that night, he told his wife, "You're in good hands" and went home to sleep, He and his wife (pt) trusted me to advocate for her and I basically just provided comfort care (companionship, medication and positioning/heating pad). All night this pt laid there bleeding with pain not completely relieved. I let her suffer needlessly and she could have bled out. I didn't advocate for her like I should of, I KNEW something was wrong and didn't call that doctor and insist he come back in or order more tests to help her. I feel so bad. I know exactly where I went wrong looking back, what I want to know is tips for being persistant and advocating for the pt without being afraid people will laugh or yell at me if I am wrong. My assessment skills were right on from the beginning, my intuition correct, my interventions good, just my follow through was bad.

Advice?

Melissa

[pricklypear]

OK...deep breath!! I think you did FINE. Let me get this straight...did the pt's condition change overnight after the doc saw her in the evening? I know she got dizzy, but did the pain increase significantly? Did her BP drop? HR increase? Abdomen become more distended? It doesn't really sound like much changed from your post.

You say you "should have called the doc back"... what would you have told him? What do you think he would have done? Here's what I think..he would have ordered another H/H. Which would have been lower than before obviously..and said "well, it sounds like something's bleeding. Give her 2 units and keep her NPO for surgery in the morning." Same outcome. Unless she was seriously compromised, he probably wouldn't have taken her until morning anyway.

You sound like a fantastic nurse, by the way..:)

The director of Women's Services thought you let the patient down? How?

[mstigerlily]

No pt's condition didn't change. Pain still there, helped but not relieved with IV narcotics. Vitals remained stable up until 0700 that morning when we got the low H&H, abdomen same.

So yes, that's why I didn't call him back. I didn't know what I would say that was a change in her condition. What I really wanted to say is how could you see the same things I saw and not be worried about her? But how could I say that?

Our director is very conservative and very strict, a litle scary actually. She said that the pulsing in abd was a warning sign (I didn't know what it meant but I asked charge/mentor and day RN they said nothing), and that "pumping IV narcotics into someone all night without relieving their pain is a danger sign, a sign your body is trying to tell you something." She also said a 32 y/o woman with a surgery this minor should have been doing much better at this point and that I should listen to my instincts and if I didn't get the results I wanted I should move up the chain of command, even to page her at home if necessary!

Melissa

OK...deep breath!! I think you did FINE. Let me get this straight...did the pt's condition change overnight after the doc saw her in the evening? I know she got dizzy, but did the pain increase significantly? Did her BP drop? HR increase? Abdomen become more distended? It doesn't really sound like much changed from your post.

You say you "should have called the doc back"... what would you have told him? What do you think he would have done? Here's what I think..he would have ordered another H/H. Which would have been lower than before obviously..and said "well, it sounds like something's bleeding. Give her 2 units and keep her NPO for surgery in the morning." Same outcome. Unless she was seriously compromised, he probably wouldn't have taken her until morning anyway.

You sound like a fantastic nurse, by the way..:)

The director of Women's Services thought you let the patient down? How?

[pricklypear]

Let me assure you... you did NOT let that pt down. She was assessed by her doctor at the beginning of your shift. You were instructed to continue with pain meds AS ORDERED, which you did. It's not up to her, it's between you, the patient and the doc.

The only way your manager's response would be justified is if your patient's condition was deteriorating, and you couldn't get the doctor to intervene. Her condition remained stable. I bet that doc knew she might be bleeding when he came in that evening, but was going to give it some time to see if it corrected itself. It didn't. Complications happen. You did what was required of you. The only thing that may have changed if you had "gone up the chain of command" (for no good reason, I might add) is that the doc may have had to defend his position (pointlessly), and may have been forced to take her to surgery in the middle of the night. Not everything needs to be done emergently. As long as the pt is stable, she's better off going to surgery in the morning.

[mstigerlily]

Thanks for responding to me and saying I sound like a good nurse. I am feeling a little bit better. It's funny when I first started in February I felt so confident, like I knew it all. With every shift I feel the weight of responsibility on my shoulders - the unstable patients, the chore of calling the docs in the middle of the night and WHICH ones to call and when. When is it ok to wait till morning? Sometimes docs say, "Why are you bothering me?" other docs will say, "Why didn't you call?" Argh!

Thanks for taking the time to read my post, I know it was really long :))))

Melissa

Let me assure you... you did NOT let that pt down. She was assessed by her doctor at the beginning of your shift. You were instructed to continue with pain meds AS ORDERED, which you did. It's not up to her, it's between you, the patient and the doc.

The only way your manager's response would be justified is if your patient's condition was deteriorating, and you couldn't get the doctor to intervene. Her condition remained stable. I bet that doc knew she might be bleeding when he came in that evening, but was going to give it some time to see if it corrected itself. It didn't. Complications happen. You did what was required of you. The only thing that may have changed if you had "gone up the chain of command" (for no good reason, I might add) is that the doc may have had to defend his position (pointlessly), and may have been forced to take her to surgery in the middle of the night. Not everything needs to be done emergently. As long as the pt is stable, she's better off going to surgery in the morning.

[CritterLover, BSN, RN]

Melissa,

I wanted to echo pricklypear's posts. It sounds like you did what you were supposed to do.

The only thing I might have done differently would have been to let the doctor know "she just doesn't seem right to me." But having that kind of confidence in your intuition comes with experience, and I doubt it would have changed anything right then.

Also, surgery hurts. Having a patient be pain-free isn't always possible (if you want them to remain breathing). Our goal for pain management should be to get the pain to a point where the patient is "OK" with it. As I'm sure you know, everyone has their own level of pain that they can tolerate (for lack of a better word). On our favorite "scale of 1-10," some are ok with pain that is 4/10, where others need it to be 2/10 or even less. You said you were able to ease her pain. Was she OK with where her pain level was, or did she keep asking you for more pain meds? If she was OK with it, then I wouldn't have given her more dilaudid, either. But if she wanted more and VS were stable (RR>14), I would have given her more. Had you called the doctor about her pain and hadn't given her the max dose of dilaudid, he would have wanted to know why you hadn't given her the max dose first. My point is that I don't necessarily agree with your manager when she says "pumping IV narcotics into someone all night without relieving their pain is a danger sign, a sign your body is trying to tell you something." While it is true that giving someone a ton of pain meds and not relieving their pain can be a warning sign, I really don't think you gave her enough dilaudid to be considered "pumping her full of narcotics all night."

What I think of as an "ominous sign" is more along the lines of someone who you are giving so much pain meds to that they are just breathing enough but are still in serious pain (may appear to be sleeping, but moan whenever they move just a little, may have tears, are especially still because any little movement causes great pain, and so on). Now THAT is a sign that something else serious is going on.

I also wanted to point out that "insisting" that a doctor do something may not get you very far. It is his call, remember? True, you can go up the chain of command, but as pricklypear pointed out, that is really only appropriate if the patient's status is deteriorating, and her's wasn't.

You did your job: you had her ready for surgery in the morning. She had her surgery and they stopped the bleeding. And would you really want a surgeon that had been up all day and had to be dragged out of bed in the middle of the night operate on you? Only if absolutly necessary, right?

[fab4fan]

Remember this the next time you feel like you can't say something because you don't have anything specific, just a "gut feeling" that something is wrong with the pt.

I'm one of those "gut feeling" people too, and every time I ignore it, I regret it. Once the docs get to know you, they'll know that if you say, "Something seems wrong, but I don't really have anything specific to back it up" they need to see the pt.

Don't beat yourself up; there were a lot of other people who had more exp. than you and they didn't pick up on anything. Just don't let someone talk you out of advocating your pt.; it does get easier as you have more years under your belt.

[fab4fan]

mstigerlilly wrote:

dilaudid/nubain

Please tell me this pt was not getting dilaudid and nubain...BIG BIG no-no.

[BandEmom]

With four months of experience you did a great job!! I understand the feeling of wanting to trust your gut, but not doing that because of intimidation. I am so disappointed that no one supported you. YOU were the patient's #1 advocate.

It was obviously a slow enough bleed that the VS stayed normal, or others would have caught on too. You have great instincts that will take you far in your career.

((((((((((hugs)))))))))))))

L.

[mstigerlily]

Yes, she did have dilaudid and nubain prescribed.

The MD wrote the order for Nubain when he assessed her that evening to stop the itching from the Dilaudid. The day RN wrote the order, pharmacy processed it as it went into the Pyxis system. The mentor gave the first dose for me because I was in with another patient, I did give a second dose myself some time during the night.

Also I went into the unit last night to update my charting because with all the flurry I didn't write a closing note in the chart - and I noticed while there were new orders, she still had dilaudid and nubain ordered. Please give me more info so I can avoid any drug interactions in the future.

Melissa

mstigerlilly wrote:

Please tell me this pt was not getting dilaudid and nubain...BIG BIG no-no.

[BETSRN]

Thanks for responding to me and saying I sound like a good nurse. I am feeling a little bit better. It's funny when I first started in February I felt so confident, like I knew it all. With every shift I feel the weight of responsibility on my shoulders - the unstable patients, the chore of calling the docs in the middle of the night and WHICH ones to call and when. When is it ok to wait till morning? Sometimes docs say, "Why are you bothering me?" other docs will say, "Why didn't you call?" Argh!

Thanks for taking the time to read my post, I know it was really long :))))

Melissa

You are learning that NONE of us RN's know it all. The ones who think they do are too complacent and should get out of nursing. NEVER be afraid to go up the chain of command, just because someone senior to you thinks it is unnecessary. Follow your gut instincts. Don't ever be awed by others. Do what is in your heart.

Personally, with that first drop in her H&H I think something should have been done.

Never be afraid to "bother" a doctor. They get paid to get bothered. If you get chewed out, so what? You'll have done the right thing.

Too many nurses are afraid of physicians. That's why they get away with what they do at times.

[mstigerlily]

I came on at 1900, the day RN had just given her a 0.5 mg dose of dilaudid. The dosage ordered was: 0.25 for mild pain, 0.5 for moderate, 1.0 for severe pain, all q2h. I gave subsequent doses of 0.5 at 2130, 0100, 0500 and assessed her pain hourly. So yes, she had 4 doses in 12 hrs - not excessive I guess. She was always uncomfortable but after being medicated she rated her pain at 3-4 down from 7-8 so the meds were helping but not as much as I would have hoped. She was rather restless and although she did doze some of the evening, she would wake up when I came in, even if I tiptoed and she just couldn't get very comfortable no matter what position changes or comfort measures we tried.

Melissa

Melissa,

I wanted to echo pricklypear's posts. It sounds like you did what you were supposed to do.

The only thing I might have done differently would have been to let the doctor know "she just doesn't seem right to me." But having that kind of confidence in your intuition comes with experience, and I doubt it would have changed anything right then.

Also, surgery hurts. Having a patient be pain-free isn't always possible (if you want them to remain breathing). Our goal for pain management should be to get the pain to a point where the patient is "OK" with it. As I'm sure you know, everyone has their own level of pain that they can tolerate (for lack of a better word). On our favorite "scale of 1-10," some are ok with pain that is 4/10, where others need it to be 2/10 or even less. You said you were able to ease her pain. Was she OK with where her pain level was, or did she keep asking you for more pain meds? If she was OK with it, then I wouldn't have given her more dilaudid, either. But if she wanted more and VS were stable (RR>14), I would have given her more. Had you called the doctor about her pain and hadn't given her the max dose of dilaudid, he would have wanted to know why you hadn't given her the max dose first. My point is that I don't necessarily agree with your manager when she says "pumping IV narcotics into someone all night without relieving their pain is a danger sign, a sign your body is trying to tell you something." While it is true that giving someone a ton of pain meds and not relieving their pain can be a warning sign, I really don't think you gave her enough dilaudid to be considered "pumping her full of narcotics all night."

What I think of as an "ominous sign" is more along the lines of someone who you are giving so much pain meds to that they are just breathing enough but are still in serious pain (may appear to be sleeping, but moan whenever they move just a little, may have tears, are especially still because any little movement causes great pain, and so on). Now THAT is a sign that something else serious is going on.

I also wanted to point out that "insisting" that a doctor do something may not get you very far. It is his call, remember? True, you can go up the chain of command, but as pricklypear pointed out, that is really only appropriate if the patient's status is deteriorating, and her's wasn't.

You did your job: you had her ready for surgery in the morning. She had her surgery and they stopped the bleeding. And would you really want a surgeon that had been up all day and had to be dragged out of bed in the middle of the night operate on you? Only if absolutly necessary, right?