Question about something that happened

[wanjik]

Hi all,

thanks in advance for your replies and I love you all

Ok, so last night I received report from a nurse on patient A. Patient A has had a craniotomy to remove a tumor and now he has three incisions with sutures which are clean, dry intact. The nurse informed me that one of those incisions was leaking csf but that the Dr. was aware, there were no new orders and so all we were to do was place 4x4 sponge gauze over the incision to contain the leak. She said that the dr. stated that it would leak for about 24 hours. So over the course of my shift I faithfully changed the gauze whenever it got wet. It wasn't getting drenched, but the wetness was irritating the patient so I changed it three times during my shift.

Half an hour before shift change I was changing the gauze when the dr. walked in. I showed him and the gauze and the patient's wife said something about the incision dripping "so much!" The dr. glared at me from across the room. I told him that I had been informed during change of shift that he was aware. He said no, no one had informed me. I could tell he was irritated. Fortunately all he did was order some supplies so he could add some more sutures. I documented in my closing note that he had been made aware of leak and that supplies ordered were at bedside.

My question is, wha would you guys have done differently? What do you do with a csf leak? what not to do?

[RedhairedNurse, BSN, RN]

I don't trust what anyone tells me when it comes to 'the doctor is aware.' I will look in the progress notes myself to see if the doctor is aware, if I don't see it mentioned in the progress notes, I will call the doc myself.

As far as CSF leaks, I don't know the answer to that question. Sorry.

[meandragonbrett]

When somebody tells me that a physician or the team is aware of whatever problem....if I don't see any orders that address that issue or a progress note written by a team member....I call the team and let them know. You know how bits and piece of information don't get passed along in report? Yeah, well, you can't always trust the person you get report from....not saying they're a bad nurse or anything.

[jnrsmommy]

On the flip side, what if the covering MD was told, but was not passed on to the primary/surgeon? Have definitely had it happen where I know that Doc B was told about something, then proceeded to almost get my butt reamed by Doc A b/c he wasn't informed (again, charting CYA).

[wanjik]

Thanks guys. Great advice about checking the progress notes. Will pay more attention to that next time.

[htrn]

Just remember, it is so much easier for them to throw us under the bus than to admit their own or their colleagues mistakes :-)

[dishes, BSN, RN]

Maybe you can use the experience as an incentive to become more knowledgeable about the risks associated with CSF leaks and treatments. Hopefully your knowledge and experience will give you confidence to care for patients with this complication in the future. It is ok to re-contact the surgeon, even if it is just to let them know that the CSF leak is persisting and you wonder if there are any more orders.

regards

dishes

[Snickerdoodles]

If she really did talk to him, I would think she would have written something somewhere, a nurses note, or something just to cover her own behind!

"Dr. is aware. Change dressing PRN. Md will see patient in AM."

[Virgo_RN, BSN, RN]

If I could find no documentation that the physician had been notified, I would notify him or her myself, and document that I did so.

If the physician told me to cover the incision with 4X4 gauze, I would write that as a telephone order.

With a CSF leak, I would monitor for changes in vital signs, c/o headache or any changes in LOC, and s/s of infection.

[wakaro]

Sorry about that situation my dear. Have not been to this site for a long time but am back. Nice to see another Kenyan on site. Anyway, kind of a past scenario,but i totally agree with most comments here. Red flag, first and foremost if the previous nurse had reported to the doc where was her documentation, i would check in nurses notes.

secondly, this has always been in my nursing practice, so long as i feel uncomfotable or something is not right will always, always pick a phone and call the doc. I work at night, and you can imagine sometimes, how some docs will be if called at night. It does not matter to me safety of the patient first, they are paid and are responsible for these patient. Just say hey, doc X, just letting you know patient D, has csf leak, which per previous shift was reported to you, but am concerned about it. Dont forget to document all your actions and findings. CHEERS

[carolmaccas66, BSN, RN]

I was caring for a patient in rehab who had had extensive neurosurgery and who was slowly recovering. We were told that if ANY leakage of CSF was noted - or any fluid was leaking from his sutures - we HAD to notify the surgeon immediately, anytime of the day or night. Even though I am told on here CONSTANTLY 'you only have 2 years experience', it doesn't take a genius to figure out that action has to be taken with a CSF leak. Leaks can cause infections and probably a drop in BP too, amongst other serious complications. The nervous system isn't getting nutrition and obviously isn't going to function as well.

I MYSELF would have pulled the doctor aside after calling him, and asked him if he knew that the leakage was constant and what did he want done? You have to be responsible for your own practice and judgement in the end, not what other people tell you.

Do you think this was good nursing care of this patient?

[canoehead, BSN, RN]

OP- I would have looked for her documentation and then asked her "could you document that the doc has been informed?" You can point out that statement if someone shows up and says they didn't know. Sometimes being asked to document an issue brings out a little more clarification, like they took report from someone an hour ago and didn't actually speak to the doc themselves, the doc got distracted and left before writing orders, or it's getting worse so another call wouldn't hurt. All those things you'd want to know, of course.