This is going to be a long post, so thank you if you take the time to read it. I am concerned that this may come back to bite me at some point. So that you know, I have been a nurse 2 years, and been in the ICU almost 5 months.
I had the same 2 patients for 3 nights in a row. Patient #1 was a 40 yo fresh post op. Hx of ETOH abuse, smoker, chronic pain, addicted to Xanax and Lortab. And did I mention he still hadn't cut the umbilical cord? Classic manipulator, babied by his mommy, enabled, etc. Diagnosed with unresectable pancreatic cancer, had a double bypass operation, poor prognosis. For pain, had a spinal Dilaudid epidural, Toradol 15 mg Q6, Dilaudid 1 mg Q4, Ativan 3mg Q8. Of course, none of this helped his "pain" and he was on the call bell every 30 minutes for pain, can't sleep, ice chips, mouth swabs, too hot, too cold, wanted to call his mommy, wanted his head up, head down, etc. etc. Oh, and he's going to have to talk to the doc in the morning about his pain meds because this is not what they agreed on.
Patient #2 was a 76 yo with Hx of laryngeal cancer, trached, pegged. At some point, had a gastrectomy and PEG converted to Jtube. Had problem with repeatedly pulling out his PEGs and Jtube, ordered a new Jtube on-line and attempted to reinsert. Ended up with about 11 inches of bowel evisceration requiring resection and new Jtube insertion 1 week prior to my first night with him. No one liked taking care of him because he was constantly agitated, squirming around in bed, pulling at everything, required 4 point restraints.
The first night I had him, he was on tube feeds via the Jtube, tolerating well, +BM, good bowel sounds, etc. Abdominal incision was draining A LOT of ascitic fluid, and had been for the previous 3 days, so I was just trying to manage keeping him clean and dry. At around 2 AM, noticed a small section of bowel protruding through the incision and around the staples. Covered with a moist dressing. Notified the surgeon, who said "Thank you" and hung up. About 3:30 AM, the OR called me to let me know he would be going to surgery at 6 AM, and had the surgeon notified me and give me orders? Well, NO!!! So, tried to get all the pre-op and anesthesia orders, paperwork, etc done. Patient was poopy, tried to clean him AGAIN. Then, he vomited and aspirated, suctioned his lungs, mouth. Gave pre-op meds. Critical bilirubin, notified surgeon and primary. All this while Patient #1 was on the call bell every 30 minutes, trying to keep Patient #2 from pulling his foley or trach out or falling out of bed, and the OR called me at least 4 times.
Anyway, got the patient off to surgery, and gave report to a much more experienced RN. She had no patients at the time, but was going to receive the patient directly from the OR and recover him. She didn't even really give me the time of day, didn't focus on what I was telling her, wouldn't maintain eye contact, etc. A lot of the day nurses do this, and I find it very distracting, and makes me flustered.
So, I get the patient back on the 2nd night, after repair of the evisceration, and he's vented via trach. The day nurse states she restarted the tube feedings at 20 ml/hr and to leave it there because "he said just leave it there and he would check on the patient in the AM". I'm assuming she was talking about the surgeon. I go to do my initial assessment and find that the tube feeds are going through the NGT. I think that was weird because he has a Jtube, but ASSUMED the surgeon didnt' want to use the Jtube for some reason, so I leave it running. At 2100, I check residuals, and find 200 ml of green/brown thin fluid. I talk to the charge nurse (because I'm new) and tell her I'm going to stop the tube feeds, return the residuals, and check again in an hour to see if any progress was made. So, I check again in an hour and find 225 ml. Oh, and I notice some of this same green fluid leaking out from his trach stoma. Suction his lungs, but no fluid in the lungs. I'm not about to return any of this back to his stomach and I discard the 225 ml. I asked the charge nurse if I should notify the surgeon, and she says not to call just because I stopped the tube feeds. But, I did notify the PA who was on call for the primary, and he just said to hold the tube feeds for the night. Did I mention that Patient #1 is still on the call bell every 30 minutes or so for his rediculous requests? So, I check him again at 3 AM, found he has another 200 ml residuals and I discard this. Did my chart checks earlier in the shift, but didn't do any of my filing until 6:30 in the morning, and of course the OR just stuffs all the operative documents in the front of the chart. So, I give report the the oncoming RN, yet another nurse who I can't stand giving report to, but that's another story.
Anyway, I'm driving on the way home, and my mind finally has time to start thinking everything through. That's when it dawns on me the following:
#1: I didn't notice any post-op orders when I did my chart check
#2: Tube feeds were restarted very quickly following surgery, and if they were supposed to be restarted, should have been restarted via the Jtube, not NGT. The Jtube was covered by an abdominal binder, so wasn't visible unless you knew it was there, and the day nurse didn't pay attention to my report when I told her he had the Jtube.
#3: The NGT was probably supposed to be set to suction, and the green fluid was stomach secretions, not true residuals. And did I mention they were backing up and leaking out of the trach stoma????
#4: When I was frantically trying to file the operative documents, I filed some orders, but didn't really pay attention to whether there was anything specific from the surgeon about post-op care
So, I'm freaking out at this point, and I called the ANM and explained all this to her. I was so upset that I had a hard time sleeping.
When I get back to work for the 3rd night, the first thing I do is check the chart to see if I missed anything. There are absolutely NO, NO, NO post-op orders from the surgeon. The NGT is now set to suction, and the patient is on TPN, not tube feeds. The patient is OK. So, patient #1 who hasn't slept for the last 2 nights and constantly on the call bell, finally passes out and sleeps, and I'm able to give patient #2 more attention, medicate him for pain Q2, and he finally settles down and rests, and I feel like I really did right by him.
The ANM said she would talk to the other RN about what happened. I'm just so worried that this is going to come back and bite me in the butt somehow. While I do admit that I didn't put all the pieces of the puzzle together at the time, I DID stop the tube feeds. Thank goodness I checked residuals when I did and didn't let it slide until later!!! Plus, the day nurse obviously did not check for post-op orders, or else she would have filed them under the orders section. There was no order to restart the tube feeds in the first place, and if there were, I would have restarted them via the Jtube. And isn't it standard to set the NGT to LIS after abdominal surgery? Plus, the day nurse had the patient for at least 10 hours, and didn't have any other patients!!! I feel like I walked into a bad situation, but because I was so frazzled by patient #1, I just didn't have time to think through everything, and I didn't fix everything the day nurse missed. If I had put it all together, I would have called the surgeon and asked for orders.
Anyway, how much should I let this bother me? Do you think I will be written up? Is this reportable? Am I a horrible nurse who doesn't belong the ICU? I'm so upset by this!!
Sorry for the long post, but I felt like I needed to lay it all out.