Post-Op concern

[GoNightingale, BSN, RN]

:redbeathe Hi folks, I'm a 2 year old nurse. Let's see in terms of profesional develepoment I guess i can really relate it to Erickson's stages of development for a 2 year old. I can stand on my two feet and walk independently on the unit, take a full patient assignment, but still need support for difficult assignments and I'm still searching for answers when I think I could of done better. So I'm looking for your counsel and seeking some answers from the terrific nurses out there. O.K. here it goes.... I had postop patient that had a low anterior resection with takedown of splenic fixture. The patient's abdomen was really, really obese to the point that what was going to be done laparascopically became an open surgery when the omentum actually blocked the visualization of some organs. Patient had a huge tumor (turned out to be sigmoid colon cancer) and the omentum adhered to the tumor thereby requiring adhesiolysis. O.K. Before they could even perform that surgery, they placed a stent (I'm not sure exactly how this particular procedure was done) on both ureters (6 french catheters) that went all the way up into or attached or something, to the renal pelvis. I was told this was to hold up the bladder or hold up something umtol the abdominal surgery was completed. They then removed the stents and placed a foley. I got the patient after all the frequencies had been completed on our unit. So I did all the routine things we nurses do for post-op patients. When I started the shift I looked at the foley and there was about 50cc's of blood. I said o..k. post op patient, it's expected-particularly in this case due to involvement of both the urinary tract and the rectum. Patient had continuous infusion running at 100cc/he. I thought o.k. let's continue to monitor since soon she should have more output due to fluid infusion. So as evening go by I see no urine in the foley, just that little blood visualized at beginning of shift. This was about 9 hours into my shift. I shared my concerns with the charge nurse since I have not had that "nursing experience" happen before. He said to irrigate the bladder using a 60 cc syringe and sterile water (the foley did not have a third lumen) because perhaps there might be a clot obstructing flow. He then said, if that doesn't work, do a bladder scan. When I did the scan, scanner showed only 47 cc's in bladder. So I called the surgeon. I figure between the patient's initial post-op status and my notification to the surgeon-it's close to maybe 17 hours that passed. The surgeon asked to transfer the patient to ICU, give LR in 1/2 hour. I'm on a tele floor. I am really upset that the amount of hours that passed may have harmed the patient. But I really did the best I knew how for my knowledge and experience. I know that 30cc's an hour is the minimum normal range for urine output, however, I kept hoping that the patient would show an output and monitored her closely. Could anyone please share some knowledge and wisdom into this scenario. I'm so concerned for this patient that I plan on going to visit this patient on my day off tomorrow.

Thanks everybody.:redbeathe

[Robinroo62]

I am also a 2 year old "toddler nurse". I work med-surge and on my floor we check I&O's about every 4 hrs when we take vitals. A lot of our drs will write orders to notify them if output is less than 120cc over 4hrs. Since it was a post op patient and they had a foley I would have called in the 1st 4hrs especially if they pt had bp issues as well. When bp is low the kidneys arent getting profused and can cause low output, or the pt could have been dehydrated from blood loss. Nursing can be very stressful and hoping that output will increase isnt goin to make a difference, If you ever have a concern about a pt dont hesitate to call the dr. Thats what they make the big bucks for! Sometimes we learn things the hard way, but I have a feeling this is going to stick with you and make you a better nurse because of it.

[GoNightingale, BSN, RN]

You got that right Robinroo62! Thanks so much for your honest reply and good luck in your career as we "continue to grow"!

[ScrubCap]

I have been a nurse for over eight years - my first position as a new grad was on a 50 bed GI med/surg unit, very high acuity. My advice for new nurses is to always give your surgical the highest priority - meaning that I watch over them like a hawk. Make sure that you know your facility's policy on routine post-op care. In most places, once you recieve a patient from PACU, you do initial vital signs and a head-to-toe assessment, then vital signs every hour X 4 then every 4 hours. I also do an assessment every four hours and monitor the dressing site, drains, edema, etc.

As for monitoring the I&O, I do that every 2 hours - because, like you stated, normal output is supposed to be 30 mL per hour. So if after 2 hours you noticed that you didn't have adequate output, you should first check your foley catheter (sometimes moving it around, "milking" it makes a difference); sometimes you have to deflate the balloon (without removing the catheter), push it in a little further, then reinflate the balloon with the correct amount. If the urine didn't start to come out after that, I would next do what your supervisor suggested (irrigate - although sometimes you need an order to do that) and bladder scanning. After all the interventions, I would call the surgeon to report the output and color. And when you call the doctor, make sure that you have the total output from the previous shift too - get all your ducks in a row and anticipate any questions he might ask.

I am surprised that during the surgery they did not put in a three way catheter, especially since they had inserted and removed ureteral catheters (which will always make the urine bloody and might result in the need for continuous irrigation). But at any rate, just keep in mind how important urine output is - and measure it every 2 hours. Even if the orders state "q shift" it's just good practice to monitor it closely every 2 (I was taught in a very "old school" diploma hospital-based program), especially since it sounds like your patient had very extensive surgery. Also, don't rely on your aid/tech to report inadequate urine output to you - they may not recognize the change, or simply may not be paying attention, and quite frankly, it is the RN's responsibility to be monitoring this anyway.

Like Robinroo62 stated, I think that this event will stick with you for a long time and that you will learn a lot from the experience. By the way, did you have a chance to visit this patient? How is she doing? Don't let this discourage you from your nursing practice, use it as a learning tool and know that it will make you a stronger nurse. Good luck!

[GoNightingale, BSN, RN]

Thank you so much Scrupcap for that thorough explanation. I really, really appreciate it. All of your advise is definitely right on target. After this incident, let me tell you, even the patients that aren't post-op I watch carefully for I & O because I now realize how important it is on patients with the acuity levels we have on our floor. After I transferred the patient to ICU, I spoke with a very seasoned ICU nurse and he said, not toworry. That yes, I should have called the physician earlier and to take it as a lesson but that this patient went into Acute Renal Failure and it happened regardless of when I made the phone call. The patient was very sick, had really not wanted the huge surgery she went through; but the family insisted. She actually requested to go to hospice. I was very sad since I had this patient prior to the surgery and she went from room air to respiratory compromise on 10L of O2 in addition to everything else.

Thank you Scubcap for your concern, and yes we move on and become stronger nurses!

[ScrubCap]

Thanks for giving us an update on the patient and you are more than welcome for the advice. It always seems like you get these types of patients when you already have a full load, are short-staffed, etc. As your experience grows, so will your intuition and you will become more attuned to when something isn't right with a patient. Early reporting to a doctor is always important, and even more so: DOCUMENTATION that you reported it to the doctor. I have had doctors blow me off for reporting various changes with patients that they told me were not a concern - it's almost an arrogance and they treat me like I'm stupid, and then later down the road the patients did develop complications but there was my documentation that hours before, I had reported it and the doctor did nothing at that time. Again, good luck in your future practice!