S/S of bleeding

WalkieTalkie, RN · May 21, 2009

Was she hypotensive? Tachycardic? Complaining of abd pain, nausea, cramping, etc? Why was she in the hospital? Why was she getting the blood transfusion to begin with?

Stuff like this can literally happen over a few hours (or less depending on the severity). It's likely that you did nothing wrong, but if you ignored signs or symptoms of bleeding, then it's a different story. This kind of stuff happens all the time, and rarely is it the fault of the nurse. I'm always at the receiving end of things in the ICU, so I see stuff like this on a frequent basis.

allnurses Guide · May 21, 2009

If someone's Hb is dropping enough to require transfusion, and you don't know where the bleeding is, it's a good idea to check the patient frequently - including looking at the abdominal girth. I wouldn't worry about malpractice - you did get the patient to ICU. Just take this and use it to learn from.

Be_Moore · May 21, 2009

As the above posters said, you probably aren't going to be in huge trouble. The reason is if said patient wasn't sick enough to go to the ICU on your shift, then what's the deal? If the MD's had ordered PRBC's to be infused, they were obviously aware that said patients Hct was down and were likely suspecting a bleed somewhere. But if the patient was not terribly tachy and not hypotensive there wasn't reason to go ahead and send them to the Unit. So what likely happened was either A) She decompensated on dayshift and the nurse had the xfer to the unit, which the MD's were likely expecting in the back of their minds. B) The labs came back for the day looking sketchy, and the MD's decided to xfer for protective reasons. Or C) The nurse who had the patient ****** and moaned and got the patient xferred because of fear of decompensation.

In the unit we get patients from all 3 scenarios above. As long as the patient didn't appear to be actively dying on your shift (BP 90/50 or less, HR 120+, massive Hct drops) then it's not like you should've transferred the patient on your shift.

Daytonite, BSN, RN · May 21, 2009

I wouldn't worry about this. You are not the only person who was assessing and watching over this patient. So was her doctor. Nurses don't make the decision to move patients to the ICU. Doctors do. Her doctor was also responsible for watching her progress or failure. Abdomens don't become distended without something going on over time. This was not something that you failed to do. Patients have internal bleeding from unknown places that docs can't find all the time. One of the things about medical nursing that you will need to accept is that the doctors do not always have the answers or the cures. Patients will have undiagnosed problems that will become sudden crises sometimes on your shift and sometimes on another persons shift. It happens.

Your responsibility is to call the doctor immediately if something about the patients condition changes. Then, you are covered from litigation.

Virgo_RN, BSN, RN · May 21, 2009

If her UOP had been running low, this would not have alarmed me either, providing that the physician was aware of the continuing low UOP. If I could not tell from the progress notes that the physician was aware of this and if the nurse reporting off did not notify the physician, I would most likely call just to make sure they knew. I've seen situations where a patient has a situation, the physician is called and orders received, but the situation does not resolve and the physician is not called back again and informed of this. This is not good practice.

However, what were her VS? Was she tachy? Was her BP low? Were there any other signs of active bleeding during your shift that you did not follow up on? Did you assess her abdomen at the beginning of the shift and check her for any bruising in the periumbilical area (Cullen's sign) or the flank area (Turner's sign)? Now, being new, you might not know what to check for. But this is where having an assessment that you can take to the bank comes in. That was one of the first tidbits of advice I received from an older nurse who has been nursing for over 30 years. She said to always do a head to toe that you can bank on, meaning, be thorough, look under those covers, check every orifice and crack, and if you see anything out of the ordinary that you're not sure about, get a more experienced nurse to take a look.

NewNurseAlert · May 21, 2009

Thanks for the responses, I do feel better.To answer some questions, her bp was 80's/40's, had been for days. Her pulse stayed 70s-80s. She was admitted for presumed sepsis and labs came back positive for C-diff, she had been passing watery stools all night. Her abdomen was covered with a dressing from recent surgery, so I did listen and palpate at the beginning of the shift, it was soft. At about 9pm she asked for pain meds for her back and belly. I assumed the belly pain was rt her incision, all she could have was tyelonal because her bp was so low :uhoh21:. About an hour later I reported the low output to the charge which resulted in the bolus which resulted in the abd distention. I did tell the charge that the pt wasn't acting right, she looked weak and puny. ugh so much to learn...

beachbutterfly · May 21, 2009

I had a patient who was getting a blood transfusion, had an internal bleed and went to the ICU. She had hardly any urine output, but I didn't pass that on untill the end of shift report, because it was well known she has renal failure, her output has been low for days. I went to assess her at the end of the night and her abdomen was huge. They did labs and x-rays and whisked her away, and here I am scared of medical malpractice- ignoring s/s of bleeding. I am new, and scared.

I'm confused are you a student just like your nickname suggest or are you a new nurse? Anyway I'm sorry that this is happening to you (granted you are still new to this field),this should be a lesson for you to never be blindfolded by your patient other preexisting conditions and dont ever assume about your patient health status as well never forget that many conditions produce universal symptoms just take for example pleural effusion,MI,or pulmonary embolism they all produce very similar symptoms (the most obvious ones are of course dyspna and chest pain).That is why we nurses need to think in multiple dimensions and approach the medicine from all the multperspectives and follow up throughly our patient's health status.

NewNurseAlert · May 22, 2009

I'm a little of both, I'm interning. I'm working on improving my patient load, I'm scared an incident like this may reflect poorly on me. All I can do really is learn andhope for the best. I just can't help but wonder if I could have intervened earlier.