Would you have done anything different? VERY LONG!

[DR2004RN]

I had a horrible day on Saturday! I was giving a pt FFP for an INR>4. She needed to get her INR down so she could get a GFF placed because she had a clot in her right thigh. I started the FFP around 0930 and the I.V. started leaking and when saline was flushed through the line, she c/o burning, so I had to restart an I.V. and then start the FFP again. It was about 0945 then.I started it out slow, about 25ml/hr, and got vitals just the same way I do for blood. I have only done FFP one other time prior to this, so I asked another experienced (almost 30 years) nurse and she and I checked out the hospital policy for FFP. I stated that we could start the FFP out slow for 3-5 minutes then if no reaction, could advance to 200ml/hr or as fast as pt. could tolerate. The policy also said that rate could be slower if potential for circulatory overload is present. The patient has colon ca with mets to the liver, she had edema from her waist to toes, and had diminished lung sounds but they were clear. She denied any SOB, but I still wanted to be cautious. After about 15 minutes though, she was still fine so I increased her rate to 50ml/hr. I checked vitals Q15 min x 1 hour then q30min x1 hour and then q1hr. In the meantime, I had 3 other patients who needed assements, meds, and a nursing student who was asking me a lot of questions because her instructor was helping other students. Then another doc wrote for another one of my patients to have phlebotomy done. I knew I would be insanely busy. I had been on the phone with the surgery resident, letting her know that the FFP had been started, I had to give my FFP patient some vit k stat.

Okay so the first unit finished about 1200 and I set the pump to flush the iv line with saline before starting the second unit. I then got supplies around to do my phlebotomy, and started on that. When that was completed, I then went back in to check on my FFP, by this time it was around 1315 the line was flushed so I went to the desk to get the paperwork for the next unit of FFP. While there, I spoke with the nursing student again, spoke with a physician about the nursing students patient, talked to a physician who had called about FFP patient, and went and checked on the nursing student's patient,(again clinical instructor was with other students.) Then I finally went down stairs to get the second unit of FFP. It got started about 1415. Again starting slowly and advancing gradually. Patient was to get another INR after second unit if it was less than two then we were to call the surgical resident.

Then the surgery attending called about 1515 to yell at me and say that I had cost the hosptial thousands of dollars becuase he had to call the cardiac cath team in twice and send them home twice because the FFP was still not done. He told me he had called the nursing supervisor and the Head of the entire nursing department. And when could he expect his INR? I said it would be done around 1615 when the second unit finished. I also let him know that I had three other patients that needed me and he told me that I should have asked for help. Well the only other nurse that was working up front with me was assisting the MD's with a central line placement on one of her patients. Needless to say, I went in and sped up the infusion of FFP and it finished at about 1545. I got the INR and called the MD with the results around 1600. She was theraputic so then around 1700 she went for her procedure.

Looking back through the chart, the patient had not been NPO the night before, and the doctors knew she had eaten both breakfast and lunch that day. My question is why did the MD call the team in before he knew what the INR was? What if she had still been above 2? Then the team would not have been able to do the procedure then anyway and still would have been called in for nothing. I don't know how that was my fault. I felt as though the potential for circulatory overload was there so I was thinking of the patients safety. She came back from the procedure around 1800 and was complaining of SOB that she said started when they laid her flat on the table. She was satting 97% on room air but I put her on O2 anyway, and called the doc. When I listened to her lungs, she then had some crackles in the bases. This was around the end of my shift and so the next nurse told me to go home and she would take over which I did. Yesterday, I noticed that the patient had an EKG done and cardiac enzymes which were WNL. I only worked 7a-11a yesterday, but the doc was getting a CT to rule out a new PE when I was leaving. I am worried that I am in big trouble with my nursing director. She is sort of a "yes" woman and tends to do everything to please the "higher ups" and dosen't back the nurses up. My fellow co-workers said they would not have done anything differently and do not feel that the delay was my fault. I was thinking of the patients safety and I feel that my actions were justified. What would you have done differently?

[traumaRUs, MSN, APRN]

I think you did fine also. You were conscientious in that you looked at the policy manual to find out the policy for the FFP administration first. I will say though that in other settings (ie ER, ICU), FFPs are run in as fast as posible in order to preclude bleeding. In this case though, I think you did fine. The only other option would have been to call the doc and ask him to write an order allowing the FFPs to run in faster due to the potential for clot migration.

I would relax - you did nothing wrong.

[gonzo1, ASN, RN]

I wouldn't worry about the surgeon being mad. Most likely he wasn't really mad about you supposedly costing the hospital money (bullcrap) but rather about being delayed in doing her stuff so he could leave.

There is no way to set patient care to a clock because things always happen to change the planned day.

He sounds like a three year old throwing a tantrum to me. Just use this as a learning experience and forget about the nasty surgeon. Most are nice, but everynow and then you will run into one who thinks he is God.

I don't think I could have managed your day any better. And you were following policy and thinking of your patients safety. You are to be applauded for both.

[Sunflowerinsc, ADN, RN]

Sounds like you are caring and concerns about your pt's and had a hard assigment without much help.I am wondering about the policy for giving FFP. Every place I have worked and given FFP ,they have been given wide open after starting slowly and mointored for reactions. We give them rapidly 200-300 ml hr,and the maximum time to infuse is 2 hours after thawing. I guess other labs and hospitals may prep them in some other way and can be stable thawed longer?

[nuangel1, BSN, RN]

i to think you did fine.you had a busy assignment.but i will also say after working in er and icu we too run it slowly for 15 min per policy then if no reaction we run it wide open .but it also depends on how it is ordered and what is the reason it is being given.also sometimes with any blood products lasix can be given in between units.

[MrsB]

You have to remember that when working at a facility that has residents, that they will at all times attempt to blame the nurse to get out of hot water with their attending. It is up to you to stand you ground. If there was a problem with how long you were taking to give the FFP, then the resident you spoke with early in the day should have discussed that with you. He did not, but he probably told the attending he did. As far as the attending making all the "calls", I would suggest you make a detailed note for yourself for reference if he does make those calls. This way, if they call you in the office 2 months from now, you will be able to recall all the important details. And, the next time a MD yells at you for taking too long, offer him the option to do it himself!

[K98]

I think you did just fine. If Dr. Windbag wants to huff and puff, let him. If he strokes, send him flowers.

[DR2004RN]

I think you did just fine. If Dr. Windbag wants to huff and puff, let him. If he strokes, send him flowers.

LOL!!!:lol2: