Pre-op thinks I sent them a mess

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Sorry, this is pretty long!

I had a patient with a bad diabetic wound ulcer on her foot and was also on dialysis. Ortho-wound was consulted and he planned to do surgery that same day (like he has for every patient I have ever had him consulted for) and the patient was also suppose to get dialysis in the morning. Her BP was normally in the 90's but that morning SBP was 80 and she was asymptomatic. I called the hospitalist first because nephro had yet to see her and half the time the specialists are like "I haven't seen this patient yet." Well hospitalist says to call nephro and I do and he says since she is asymptomatic he will wait to see her before doing any orders.

I call dialysis to let them know and tell them I will call once the doc comes - well 45 minutes later they are taking her down because doctor decided he will see her there. They give her albumin but BP drops to 40 after 5 minutes of dialysis even though not taking any fluids off. Doc says send her back up and will try tomorrow and his note says the hypotension is probably due to the food wound. The wound nurse told the surgeon about the BP so I let pre-op know about her BP and that the surgeon is aware and they say they will let anesthesiology know.

Patient comes back up to me about 3 hours later (she got a US of her leg done too). I took her off the 3L of O2 since she said she only wears that when getting dialysis and she was 97% on RA. She was alert and oriented but nauseated and had 2 bouts of emesis in addition to the two she had earlier in the day. Zofran wasn't cutting it so I gave her IM phenergan which ended up sedating her. When pre-op called for report I let them know that. Hospitalist was a little concerned about her breathing and so ordered STAT ABG where she was found to be slightly metabolic acidosis. After this time the PCT got her vitals and they were all stable - BP had actually come up to 115 and although her O2 was 93% I put her on 1L due to the sedation.

Well I get back from lunch and the hospitalist calls to say he and nephrology talked and decided she needed to be dialyzed and so told me to "call a rapid and use that to get her to ICU" so he didn't have to have a doc-to-doc with the intensivist and get her a bed that way. I told him they were actually taking her to pre-op (apparently he didn't realize she was doing surgery - I never know when these doctors bother to talk to each other) and I asked if he wanted me to cancel it. He said no but for her to go to ICU after. I call pre-op and tell them patient needs to go to ICU after.

I then get a call from pre-op saying patient had BP in the 60's and was not stable and their anesthesiologist was pissed. Watching their notes they wrote they said how she was consistently in the 60's, had to be given a shot of epi. They stated patient was completely unarousable and put her on a NRB (not sure about that one because all their charting had her in a 93-97 range and they only put it on for a short period). They then put in a note she was put on pressors for BP. And then they kept her down there for quite awhile. I called ICU to give report over 1.5 hrs after pre-op had a bed since no one called me and she was still down in pre-op.

Ultimately I feel bad because it looks like I ignored this patient but I felt like I kept pre-op abreast of what was happening. I let the doctors know about BP of which neither one of them were concerned. She had a very high WBC coming into the hospital (she was a sepsis diagnosis) from the previous night but all her vitals were WNL except the BP and I felt the mentation was directly attributable to a medication that I have seen zonk people out. When giving ICU report he says sometimes the transporting of a patient can be what makes the decline suddenly happen - which might be why her BP tanked even more on way to pre-op.

But I hate thinking a) I failed my patient and b) another unit/nurse thinks I just screwed them over.

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Read the last couple of lines because if there is a big long tome, I don't read it...

But this usually says it all...

"But I hate thinking a) I failed my patient and b) another unit/nurse thinks I just screwed them over."

because people write what is most true at the end of their posts....

Learn from your mistake and move on...you're in very good company.

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I see the validity in your comment but I guess I don't know how to learn from my mistake because not sure what I would do differently. I tried to alert the relevant parties to what was going on and nothing happened to make me think "my patient is getting worse."

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I see the validity in your comment but I guess I don't know how to learn from my mistake because not sure what I would do differently. I tried to alert the relevant parties to what was going on and nothing happened to make me think "my patient is getting worse."

Learn from your mistake and move on...you're in very good company.

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Specializes in Critical Care.

There doesn't appear to have been anything wrong with the care you provided, the patient was going to the ER because they had a septic wound so the anesthesiologist shouldn't have been surprised when it turned out the patient was indeed septic. Avoiding the promethazine would have mitigated some of the issues, but it wouldn't have made them not septic.

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Learn from your mistake and move on...you're in very good company.

you are making no sense

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Specializes in ICU/community health/school nursing.
Ultimately I feel bad because it looks like I ignored this patient but I felt like I kept pre-op abreast of what was happening. I let the doctors know about BP of which neither one of them were concerned. She had a very high WBC coming into the hospital (she was a sepsis diagnosis) from the previous night but all her vitals were WNL except the BP and I felt the mentation was directly attributable to a medication that I have seen zonk people out. When giving ICU report he says sometimes the transporting of a patient can be what makes the decline suddenly happen - which might be why her BP tanked even more on way to pre-op.

But I hate thinking a) I failed my patient and b) another unit/nurse thinks I just screwed them over.

You neither ignored nor failed the patient. Nor did you intentionally screw the unit over. If the nurse on the other unit had the luxury of time to look and see, you did a lot of interventions (it's not your fault that nothing you put into motion was able to be done timely). As Old Dude would say, shake it off and move forward.

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Specializes in Critical Care; Cardiac; Professional Development.

I don't see a "mistake" here that is obvious. If you charted all the things you typed out above, then the individuals caring for the patient in pre-op are letting off steam at your expense. It is unfortunate. This is why having solid nursing practice is so important to our mental well being. There is nothing like the firmness of mind in knowing you did everything you should have. From what I am seeing, you did. The only question mark to me is whether your charting reflects it accurately. If it does, then there is nothing more you can do. You can't make them read the chart and you can't make them feel better about a patient who is obviously dealing with sepsis or some other issue that is unpredictable.

Take a deep breath, square your shoulders, recognize you are a good nurse and send the Pre-op folks some vibes for grace, as they obviously need it. :p

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Specializes in ICU/community health/school nursing.

Take a deep breath, square your shoulders, recognize you are a good nurse and send the Pre-op folks some vibes for grace, as they obviously need it. :p

^Beautiful!^

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Specializes in NICU.
Read the last couple of lines because if there is a big long tome, I don't read it...

But this usually says it all...

"But I hate thinking a) I failed my patient and b) another unit/nurse thinks I just screwed them over."

because people write what is most true at the end of their posts....

Learn from your mistake and move on...you're in very good company.

How condescending can you be? In that "big long tome" that you couldn't be bothered to read, there was lots of information that meant your response was completely off-the-mark.

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You made no mistakes. Ideally a anesthesiologist worth his pay check sees a patient on the floor prior to the patient coming to pre-op.

I work pre-op, it really makes me mad that these oh so smart and perfect pre-op nurse and anesthesiologists, who are one on one with a patient, and have known her for 15 minutes, would dare to think you were some lame, stupid, med/surg nurse who didn't know what she was doing!

They are egotistical idiots who have been living their ivory tower waaay to long.

You handled a very difficult situation very well. Thank you med/surg nurses. I couldn't do what you do.

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Specializes in ICU.

The biggest fault I see in this scenario is the behavior of the doctor who felt that the patient needed ICU level care but didn't want to put in the work to get the patient there. That provider should be written up for that. It's unnecessary and dangerous behavior, and I can tell you that it happens all to often. I don't think you did anything specifically wrong in this situation, though as soon as he said that bit about ICU I would have called the rapid just to be safe even if the patient was leaving soon.

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