Who's to blame?

[TangoLima]

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.

[sunnycalifRN]

Sounds like you had a busy couple of nights. A few thoughts for you. When a patient returns from surgery, the patients needs new orders. If I read correctly, you had no orders, so you can't really do anything without orders . . . you've got to bug the surgeons until you get post-op orders.

As far as the tube feeding goes . . . with most bowel surgery, especially resection, the bowel tone will not return for days . . . hence, the patients are NPO. Putting that patient on tube feeds is irresponsible . . . the "residuals" you kept getting were due to ileus . . . secondary to manipulating and cutting the bowel.

just my 2 cents

[TangoLima]

Just to be clear, the patient came back from surgery at the beginning of day shift, and I inherited the patient much later after the tube feeds were already in progress. I was the one who STOPPED the tube feeds, and discarded the "residuals". I do realize that post-op orders are required, but that was at least 10 hours before I came in to work.

It just seems like I walked into a big mess started by someone else, and I was too frazzled to put the whole picture together. I do feel like I stopped any further damage done to the patient, but I just know that he did not receive the best care. I wish the surgeon had written orders, and I wish the day nurse had been more proactive in requesting post-op orders, and not starting tube feeds without an order.

I'm just wondering if I will have any culpability in this? Do you think I will be written up or disciplined?

[sunnycalifRN]

TangoLima,

Sorry, I misread your post, it's like a book!

You really did inherit a mess! I think the day shift nurse screwed up initially by initiating post op care without orders. But, when you realized there were no orders, it's on you to get them. As with everything in nursing, you've got to document in your charting to protect yourself. I don't know if you will catch any flak for this. I still am not clear about what happened with that patient.

[sunnycalifRN]

Not being familiar with your hospital, it's hard to give feedback. But, how can day or night shift be taking care of the patient if you don't have orders? TPN was started, where are the orders? Sounds like you work in "the Wild West"!

[Flying ICU RN]

Regardless of which shift one works or what is or is not passed on in handoff report, the on duty RN is ultimately responsible to insure that the appropriate interventions are in progress for the current patient status. The moment you become aware that either something is missing, or something is wrong, is the moment to correct the situation to the maximum level that your clinical priviliges allow, (the "Prudent Nurse" standard), always applies. Key to the outcome for you when things go wrong, is the patient outcome. The degree of adverse outcome determines the degree of scrutiny, and or repercussions. That's a long winded way of saying that things will either get swept under the rug or blown out of proportion.

[grandmawrinkle]

Definitely would have questioned during report why this patient had tube feeds running already after abdominal surgery, but I've been doing this a lot longer than you have. You were right in stopping the feeds. I would have called and made a stink about not having any post-op orders written as well. I don't know why this day shift nurse that you got report from would have restarted the feeds without an explicit order in a million years. (Be scared of people like this -- put it away in your brain for later!)

I also don't understand why when you called the surgeon the first night that he didn't tell you that he was probably going to take the patient to the OR. He should have at least given you NPO orders. Did you send him to the OR with feeds infusing? (Couldn't blame you if you did, nobody said anything to you about the OR at all.)

I used to get all wigged out about patient experiences in my first year of ICU practice as well. I would even dream about work, my patients, etc. It's part of the learning curve. Give yourself a break. First off, you did a good thing with calling re: the evisceration in the first place, and you eventually picked up on the post-op feeding error. You are coming along just fine.

And, if you come back and look at these posts later, any idea why in the heck your first patient still in the ICU after 3 nights? IMO, if you can complain that much, you're too sick to be in the ICU. Unless the guy had big time complications, even given his other medical hx, he should have been turfed to the floor as a 40YO POD 3-4 CABG (probably should have gone on POD 1 in most hospitals.) (Personal pet peeve of mine, sorry.)

[detroitdano]

We've got a few nurses like the one you mentioned, don't want to hear what you're saying, think they've got it figured out before you say their age and code status.

This is why I always come in and recheck the MAR, every order back to admission if I had not had them before (and if I did, just that day's), check consults and rec's, etc. Sadly you can't trust other nurses all the time, and if it was one of the evil witch type ones that we all know, even more reason to not trust them.

I once had a nurse told me she rechecked some labs and she didn't. I checked them myself after realizing this after shift change, and they had a troponin that was through the roof.

I think you're doing fine as a nurse, you did everything you were supposed to on your shifts and communicated to the right people (PA's, charge nurse, ANM) about the incident.