By Sara B.

As a new grad, I oriented first to postpartum/mother-baby care, for about 3 months, and then to labor for another 3 months. About a month after I finished labor orientation I took a postpartum eclamptic pt on mag- she had seized at home about a week out from delivery. She was 1:1, so I had no other pts, but the floor was really busy. I did have a more experienced nurse available as my resource though. I kept our policy in hand, and thought I was doing a good job. She had been feeling really "magtastic" (as I call it)- flushed, weak, miserable- since the mag was started. About 2 or 3am I was no longer able to elicit patellar DTRs, deep tendon reflexes. I know now that I should have called the doc right then, but her urine output was still adequate/unchanged, her respiratory rate was unchanged, so I continued to monitor her. And did not bring this change in her status to the attention of my resource. I showed her my flowsheet but it was for a question about how often to have the pt pump, since she was really tired (clue #2 that she was getting mag toxic, she was really lethargic). I thought since her UO & RR were good, it was OK. 7am rolls around, my relief is a no-call-no-show so I offer to stay until 8:30 when someone else could take her over. Doc calls for report, orders a mag level immediately. My relief takes over before the results come up. Therapeutic value for our lab is under 8, her mag level was at least 10!
I learned this a couple days later, when I was called in for a "meeting" with my clinical coordinators and manager. The meeting started with my manager asking if I still felt that labor & delivery was where I wanted to be, and ended with me in tears but back on orientation for 3 months as a sort of probabtion.

I learned a good lesson though. Luckily the pt did not suffer any lasting harm, the mag was shut off as soon as the mag level came back and she was fine. Everyone was actually puzzled as to why she got mag toxic so quickly on a standard dose (2gr/hr) . The next time I had a pt on mag, as soon as she had the slightest change in reflexes (I think she was 2+ to start and they diminished slightly in the middle of the night) I called the provider and got an order for a stat mag level. Of course in the AM when the doc covering that midwife called for an update and I told him the mag level, he bit my head off- "who ordered a mag level? I didn't order that" but bit his tongue when I explained (he's a complete jerk anyway). And even this past week, when I had a pp pt on mag, I dragged the midwife out of bed to come do an assessment on our pt when things changed. I've learned my lesson, and I never hesitate to tell my story to a newer nurse if I think it will help them. I nearly lost my job over it, but more importantly, I risked my patient's safety. And I never want to feel like that again.
__________________
~ Sarah B
Birth Center RN

Case 2

________________________________________
Most places I know of do not do routine magnesium levels. They seem to "lag" and not always stand accurate to patient responses. I learned a valuable lesson: YOU CANNOT RELY ON MAG LEVELS TO DIAGNOSE TOXICITY IN YOUR PATIENT. If you do, you are in trouble. (maybe). You need to assess-assess-assess. Another story:

Had a girl who had been on mag for a week---- pretermer who was 33 weeks' or so with definate threatened preterm labor going on. She had tolerated it very well and never had a single problem w/the mag drip the whole week. She was also fine when I did my a.m. assessment on her at 0700. Well around 0830 or 0900, the social worker came from her room to talk to me and said (*I WILL NEVER FORGET THIS*): "your patient is talking very strangely; she is slurring her words, does she have a speech impediment or something?" (the social worker had never seen her before---thank goodness for that lady)

UMMM no!!!!!! No speech problems I know of!

I went in there and the patient managed to tell me, (and yes, she was very slurred) she felt very "heavy" in her chest, like an elephant sitting on it. She had zero reflexes and her face WAS INDEED slanted very strangely to one side. She did NOT look like that when I assessed her as I came on my shift (about 1-2 hours' prior).

Well of COURSE I turned off the mag, got O2 sat on, put O2 on via mask and called the dr, who ordered a stat mag level. It was 5. something----(this was years ago, do not remember the level but NOT NEARLY TOXIC). WHAAAAAAAAAAT?????

Anyhow, I got the calcium gluconate drawn up, and asked dr if I could push it (I was talking to dr in patient's room). She said "no just wait and see what happens".

I am not lying, within 15-20 min of turning off the mag drip, the patient began to return to normal. No more facial or speech symptoms and she was able to tell me, her chest felt MUCH BETTER. Thankfully, she never dropped her sats below 99%.

So I caution you, never, ever rely on mag levels to do the job. I think that is why many places have moved away from doing this. Assessment is the only way to truly diagnose a toxic or allergic reaction to magnesium.

Lesson one: do not rely on mag levels to help you here.

And the lesson I also learned? DO YOUR ASSESSMENTS HOURLY as long as the person is on mag and for a few hours after ward!!!!! Some become "toxic" at much lower levels than others. (this really is Nursing 101---assessment has never been more important than it is when your patient is on a medication like mag sulfate (or any tocolytic).

See I how I learned things the hard way??? I really nearly quit OB that first year.