Stressed out about overnight urine output

[Ioreth, ADN, RN]

First off, I'm six months in. I know just enough to know that I know nothing. I did well in school, but now I'm second-guessing myself a lot and it is interrupting my sleep. I don't even know if what I'm stressing about really is something that was worth worrying about, or if I'm making mountains out of molehills.

Three nights ago I was giving report on a patient that had been on our unit for about a week. She had a perforated bowel that had been corrected, which involved several drains (most of which by this time were clamped) and many rounds of IV antibiotics and ongoing IV fluid. Our unit doesn't generally have patients with bowel preforations, but the hospital was full and so we got a lot of med-surg overflow. Despite not being our usual patient, I think we had been handing her needs pretty well. This patient had been on a normal diet for a few days and had a foley catheter out two days prior. The previous day, she suddenly started having diarrhea all day and chose not to eat at all because of the diarrhea. Day shift notified the physician who said to start measuring all output and notify in 24 hours if diarrhea is ongoing.

When I got shift report for the night shift on this patient, she was exhausted. All she wanted to do was sleep. The physician was at the bedside when I took report, so I made sure that he was updated everything I got in report and he seemed unconcerned. No new orders, just some discontinued ones that were no longer pertinent, but nothing regarding output - just monitor. I got the patient comfortable and let her sleep, beyond the usual interruptions to hang antibiotics and take vitals, etc. It was a really busy shift and we were understaffed so we each had 1-2 more patients than usual for this unit and mine were particularly needly. At 5 AM, I noticed that she hadn't had any output at all this shift, neither urine nor stool. I asked her if she needed to use the bathroom when I hung the 5 AM antibiotics, but she said she didn't need to yet. IV fluids were running all night at 75 mL/hr, with 200 mL/hr intermittent antibiotics. I mentioned it to my charge and she said not to worry about it but to let day shift know.

I somehow got everything that needed to be done taken care of with my other patients and felt great going into report. The patient with the perforated bowel was my last one to hand off. The nurse that I handed off to seemed very upset about the lack of output. She wanted to know why I hadn't notified the physician, why I hadn't bladder scanned the patient, why I hadn't just gotten the patient up and forced her to use the bathroom. All I could say is "I'm sorry" over and over again and I felt awful. I knew that a bladder scan was warranted, but I honestly was racing to get all the other stuff done, and it slipped my mind. The ongoing nurse looked at the previous day shift totals and was pointing to the unmeasured output, but completely ignoring the measured stools and telling me that the patient hasn't had enough output of any kind. I remember the day shift CNA mentioning that neither she nor the patient knew if urine was mixed with stool in those measured occurrences, so it was measured as stool only as a "best guess". I can't remember exact totals, but it was over 2000 mL. Then the ongoing nurse was asking me why a C-diff test hadn't been done. I could only answer that there hadn't been any output my shift. When we went into the patient's room together, she continued to talk about the problem of the low output and that I should have gotten the patient up. This was in front of the patient, and I felt like I was being humiliated purposely. The patient was still groggy from being abruptly woken and stated that she really didn't need to pee yet, but might be able to in a couple of hours. This nurse also went on to correct me on how to properly clamp these particular drains, which had been managed the same way by 4 other experienced nurses earlier in the week. Again, her attitude was suggesting to me (and to the patient) that I was incompetent.

I haven't been back to work, but this has been on my mind the entire three days since work. All I could think about was that it might have been dumping syndrome, but how do you even manage dumping syndrome? It might have been dehydration which is entirely reasonable with diarrhea, but I know that I checked oral mucous membranes and there were IV fluids running all night. I know that lots of patients just pee less at night and I know she peed just before I took report on her. I work again tonight and I dread interacting with that day shift nurse. She has a pretty stern demeanor and is generally difficult to read. I have seen her straight up bully other new nurses, but I've not been on the receiving end of that kind of treatment. I'm also dreading being in this patient's room, if she's even still there, because I feel like our raport was shattered.

I'm just a nervous wreck and I haven't really slept well because I keep thinking about this. I can't shake the feeling that I really screwed up here.

[smf0903]

I’m sorry but that nurse was out of line chastising you in front of the patient, groggy or not. Issues should be taken up outside of the patient’s room. It’s completely unprofessional.

That being said, sounds like your patient was *maybe* a bit dry. Yes she has fluids going but 75/hr is 900mL in a shift (give or take with antibiotics and any PO intake...which sounds like PO intake was pretty non-existent). You said she had at least 2 liters out for previous shift, sounds like a lot of fluid loss with the diarrhea.

And sorry, you can’t run a c-diff if your patient didn’t poop for ya ?‍♀️ No two ways around that one LOL

I wouldn’t sweat it. We have a lot of patients who don’t pee during our shift (nights) or go all night and then pee like the dam burst. People tend to look at their 12-hour slice of the pie without taking into account the full picture and/or trends. Sure you could have bladder scanned her, but honestly I don’t think I would have been alarmed given the scenario you described.

Next time that nurse tries to pull something like that in front of the patient tell her you’ll discuss it further outside of the room. Sounds to me like you did just fine, don’t let people treat you like that.

[Tweety, BSN, RN]

I hate those kinds of shifts and they do haunt us.

I wouldn't wait until the next time but let the nurse know that you feel she acted inappropriately and bothered you. We have to stand up for ourselves. If you say nothing you've given them permission to treat you like this.

I would disagree with the above (and your charge nurse) and say a 12 hour shift, especially given the situation is too long to go without urine output. You might have missed something. I would have told the patient that 12 hours was too long to go without urine output and would she please get up and try to urinate even if she said she didn't have to go. Then if she didn't go, I would scan the bladder. Perhaps there was no urine output. It does sound like they were dehydrated and with sleeping didn't take in any oral, but even so might have needed an extra fluid bolus for support. Or maybe, like I've seen you get them up and they urinate plenty and all is well. How would you know.

What you did correct though was collaborate with your charge nurse, who gave you advice, and you were aware there was a potential problem.

We live and we learn.

[brownbook]

In my opinion that nurses is kookoo bananas. But seriously she is just plain mean.

As smf0903 said you, and that nurse, need to look at the whole picture. She HAD been urinating after the surgery and Foley removal. MAYBE, she was a little dry.

Patient's don't die, or even get seriously sick, from being a little dry. Especially since their doctor is checking their I&O. Patient's don't die from not urinating unless a tumor is blocking their urethra, their kidneys have both suddenly stopped working, or something was done seriously wrong during surgery. I doubt that was the case here.

You did nothing wrong except ask the wrong question. You should be asking advice on how to deal with a bullying nurse.

[KatieMI, BSN, MSN, RN]

1). It was not a "dumping syndrome". Please read about this condition so you understand what you're thinking about.

2). In the world of clinical medicine, to "fix" mind about just one thing, whatever it might be, automatically means making at least one mistake and usually more of them. It doesn't matter if it is "output", blood pressure, Hb or whatever else. If a nurse, or physician for that matter, starts to "fix" on this thing alone, he or she stops to think. Always treat the patient, not the number.

Now, 75 cc/h of IV fluid will give only 1500 cc/24h. 200-300 cc plus/minus will not move the big picture that much. So, you were dealing with dehydration. If patient's vital signs were stable, then the dehydration was mild/not significant hemodynamically and could happliy wait till morning rounds. If vitals were changing, that would be a call for immediate action.

Secondly, there is a common sense. Most healthy people pee last time before bed at 10 to 11 PM and next time at 6-7-8 AM when they get out of bed. Does it mean that they all "have no output!!!" through the night? Also, how bothering and pestering the patient all night long to squeeze out that pee to satisfy someone's sense of "doing my job as a nurse" could positively affect patient's health?

Thirdly, every C.diff test done just because "nursing concern" cost $500. Most of them are done without clinical indications.

The fact you were criticized in front of the patient was an example of woefully unprofessional behavior, in addition to everything else that nurse thought wrong way. In my book, it was an example of workplace bullying.

Overall, you did most of the stuff correctly, although maybe on instincts' level. The nurse who criticized you did it, that is to say, suboptimally. You did fine. Work on your clinical and analytic skills and learn how to stay your ground as a clinician - it is immensely helpful in so many instances.

[Tweety, BSN, RN]

26 minutes ago, KatieMI said:

Secondly, there is a common sense. Most healthy people pee last time before bed at 10 to 11 PM and next time at 6-7-8 AM when they get out of bed. Does it mean that they all "have no output!!!" through the night? Also, how bothering and pestering the patient all night long to squeeze out that pee to satisfy someone's sense of "doing my job as a nurse" could positively affect patient's health?

Key word being "healthy". This patient is not healthy. Also, it's not about pestering the patient all night long, but at the end of a 12 hour shift (and do we know the patient urinated at exactly 7pm). Yes, please leave the patient alone and let them rest.

Dehydration in such a patient can lead to some serious issues, so in my opinion it's best to deal with it when you recognize it and treat early rather than later. So yes, it's about "doing my job as a nurse".

[brownbook]

28 minutes ago, Tweety said:

Dehydration in such a patient can lead to some serious issues, so in my opinion it's best to deal with it when you recognize it and treat early rather than later. So yes, it's about "doing my job as a nurse".

A casual acquaintance, elderly, generally healthy, woman, was in the hospital for four days due to dehydration. We all realize it can be serious.

To be honest some of her story didn't make sense...sometimes lay people's health stories don't make 100% medical/nursing sense. But she and her son said the doctors said she was just dehydrated. She said she drank a lot of Pepsi all day, so no more Pepsi, just water, but I digress

In this case, I cannot agree that one 12 hour night shift, not peeing all night, in a patient who was receiving IV fluids, was worth forcing a patient out of bed to pee! Nor being castigated by the day shift nurse.

Even if the day shift nurse had a valid concern, they way she handled it was wrong, wrong, WRONG.

[Ioreth, ADN, RN]

I'm about to go to bed to try to get some sleep so I can hopefully be awake tonight, but I thought I'd add a little more info.

Quote

1). It was not a "dumping syndrome". Please read about this condition so you understand what you're thinking about.

This patient had a surgical history of an altered upper GI tract. I don't feel comfortable going into any more detail than that for concern of identifying the patient. However, you're right that it is unlikely that it was dumping syndrome at this stage. When I can't sleep for thinking about work, all kinds of things come to mind, some of them less probable.

Quote

If patient's vital signs were stable, then the dehydration was mild/not significant hemodynamically and could happliy wait till morning rounds. If vitals were changing, that would be a call for immediate action.

The patient had unremarkable normal, stable vital signs that didn't change at all through the shift. I had 4 sets of vitals.

My best thought was that the patient was mildly to moderately dehydrated due to low PO intake and high output in day shift. I'm having trouble sleeping because I felt like I had been a "bad nurse" for not doing all the things that the oncoming nurse had talked about.

Edit: added quotes, but having trouble getting them to sit properly. Quotes were from KatieMI.

[Ioreth, ADN, RN]

Thank you all who have replied. You've given me lots to think about. Even though I've seen this nurse behave rudely to new nurses, I honestly didn't think it applied to me. I thought that I had simply screwed up horribly. And maybe I did. In any case, this gives me a new perspective.

[LibraSunCNM, BSN, MSN, CNM]

It's normal to beat yourself up as a new grad and to learn from your mistakes. Heck, I still do it and I'm nowhere near new. You had a lot on your plate, sounds like you had too many patients, and you missed something. As others have pointed out, it wasn't something critical, although it would have been worth addressing at some point either at the beginning or end of the shift. The way the other nurse treated you was wrong, but not uncommon, unfortunately. Each day will get a little easier and the embarrassment will fade. Learn from it and don't let it get you down. The fact that it's still bothering you means that you're conscientious and thorough. You're also human, and none of us are perfect and we will make mistakes, especially when new. I hope you get some sleep!

[Tweety, BSN, RN]

19 minutes ago, brownbook said:

A casual acquaintance, elderly, generally healthy, woman, was in the hospital for four days due to dehydration. We all realize it can be serious.

To be honest some of her story didn't make sense...sometimes lay people's health stories don't make 100% medical/nursing sense. But she and her son said the doctors said she was just dehydrated. She said she drank a lot of Pepsi all day, so no more Pepsi, just water, but I digress

In this case, I cannot agree that one 12 hour night shift, not peeing all night, in a patient who was receiving IV fluids, was worth forcing a patient out of bed to pee! Nor being castigated by the day shift nurse.

Even if the day shift nurse had a valid concern, they way she handled it was wrong, wrong, WRONG.

Fair enough.

I won't belabor the point, but that's not how I practice. You gotta have urine output on my time. Even if it's known the patient has dehydration it's worth knowing whether or not treatment during the 12 hours has been effective and perhaps updating the doc.

I think my mind goes there because a couple of months ago this happened to me. Night shift passed on a patient that was nauseated and took no po fluids, on IV fluids and didn't urinate. Turns out he was in acute renal injury (and a ileus) and wound up in ICU towards the end of my shift.

But most of the time when I ask them to urinate before I leave, all is well. But I sleep better knowing all is well.

[LibraNurse27, BSN, RN]

I would have bladder scanned at end of shift but you are new and you noticed the lack of output and got the charge nurse’s opinion so you did everything right. It’s hard to make your own judgments when you are new and for advice from an experienced nurse. But likely if the patient was dehydrated and had high output on days she just needed fluids and didn’t need to pee yet.

As stated above, how can anyone collect a c diff specimen without any bowel movement?? Don’t stress! If that nurse was worried about bladder scan she could have done it, takes 5 mins! And could have told you her opinion nicely and not in front of the patient. I’m sorry that happened to you.