"Use your nursing judgment"

I don't know how many times I was told that in school - "you have to advocate for your patient & use your nursing judgment."  Well, I encountered a situation like that the other night at work & I'm still thinking about it today. 

I worked on Wed & Thurs night.  Not too much going on Wednesday night - one patient dying from multiple conditions, she only weighed about 60 lbs.  So very frail & delicate - only 51 years old.  I felt for her, she was in pain & there was no relieving it.  She was already taking multiple pain relievers around the clock.  It was another one of those situations that there truly wasn't anything I could do to make her feel better.  Repositioning & talking to her only did so much.  I don't like when my patients are in pain, but I am seeing more clearly that there will be times when all the pharmacological & non-pharmacological methods will not relieve a patient's pain.  She was discharged the next day to hospice. 

My second patient was an older woman with small cell carcinoma that eventually spread to her bones & other organs.  She had a lot of edema in her legs & ascites in her abdomen.  She had a paracentesis done during the day & drained 5,000 cc's - which is 5 liters.  That is a lot of fluid.  By the second day though, it was all back.  She said her legs felt like weights, she could barely even move them.  3+ pitting edema.  She wasn't in any pain though, which I thought was odd.  Perhaps she is simply used to the pain, I don't know, but never once did she complain of pain or discomfort.  We restarted her heparin drip a few hours after she returned from her paracentesis - only to discover from the am labs that her PT & PTT/INR were way out of wack.  A call to the doctor & the Heparin was dc'd.  Came back Thursday night to discover that she was bleeding internally somewhere & they were giving her Vit K (to counteract the coumadin she had been taking).  This is the patient that I had to use my best nursing judgment on - I'm not going to go into too much detail regarding it, but it's the first time that I realized a decision that I had to make was ultimately "my" decision.  I had no instructor to fall back on, my preceptor was saying you have to make the decision - you can't do it because I'm telling you to do it - you have to make the choice.  It could have been a simple call to the doctor at 3am, but I was told doctors would get pissed off if you call them at that time for something so simple - yet it was something that required a doctor's order.  I went ahead & did it, while anticipating that we'd get a doctor's order for it later.  The evidence behind my decision was there, fully supporting that my choice was a good one & definitely called for.  I talked to my clinical leader about how to document what took place & she also used the words "best nursing judgment" & that there will be times when you truly have to use it.  I went ahead & documented my decision. 

My third patient on Wednesday evening was basically a grumpy man.  There was no real pleasing him.  His family was complaining about how it seems like he never has the same nurse 2 days in a row - they wanted to know why.  He was discharged on Thursday, so I had a new admit Thursday night.  An older gentleman complaining of chest pain.  His cardiac enzymes were negative, he had no further c/o chest pain & slept most of the night. 

Now it's Saturday morning & I am off until Wednesday night - yay!  Not much to really do though, it rained all day/night yesterday & it's supposed to be like that again today & tomorrow.  I could go shopping, but there really isn't anything I need.  Guess I'll just chill out here at my house for awhile.