Thursday, June 2, 2005

Another week down

Another week of work completed.  Yay!  It was a pretty good week too.  Gina & I were on the same floor, which was nice - makes it easier to have someone you know & can depend on around to help out. 

My first night I had a patient that had been hit by a snow plow when he was 20 yrs old which left him paralyzed from the neck down.  He was also unable to speak.  He moaned a lot & was able to look at you & look around, but couldn't actually communicate with anyone.  Makes me wonder if he is there mentally or not.  I cannot imagine what it would be like to be trapped in my body & unable to communicate.  Anyways, he came into the hospital about 2 weeks ago for pneumonia.  His family takes care of him at home (he's close to 50 yrs old now) & he had absolutely NO sign of skin breakdown.  His family does a remarkable job of caring for him.  Unfortunately his mother (who was his main caretaker) passed away about a month ago.  His father & sister remain very much devoted to caring for him, but I imagine after awhile it must really take a toll - between the hardwork, the stress & the lack of sleep.  I really don't know how they do it, but I suppose no one knows how they would do it until they are faced with having to be in that situation.  All I had to do for him were his physical assessments & hang any IV medications.  The family did the rest.  I can definitely see where the customer service side of nursing is needed as this patient's father clashed with my clinical leader one night.  I was able to hear both sides of the story & it was amazing how differently they perceived one another.  Regardless, I did my best to smooth it over so that there would be no further incidents & I encouraged the father to voice his concerns to the hospital administration.  His complaints should be addressed & taken care of.  I had this patient all 3 nights & it was a good experience for me.

My second patient was a man with a really long-worded disease that I can't remember but it ends with dysplasia.  Basically it's the "broken bone" disease.  His bones are so fragile that they easily break.  I believe he came in for chest pain, but after doing a chest x-ray, they found a mass & were doing further tests to figure out what it was.  He was a pleasant gentleman.  He ended up being transferred to med-surg the second day so I only spent that one night caring for him.  He explained a lot about the disease he had.  I think it's pretty neat to actually meet people with conditions that you've read about or studied while in school - especially rare conditions. 

My third patient was the one that kept me on my toes.  She was a 57-yr old female with end-stage renal disease.  After she had dialysis at home, she fell & fractured her skull.  Along with that she has diabetes.  I would feel comfortable calling it uncontrolled diabetes.  My first night with her was fine.  Her blood sugar was something like 340 - treated her with regular insulin, no problems.  The next night the doctor had changed the type of insulin she was taking & the dose as well as starting her on Prandin.  Did an accucheck at bedtime & it read 506.  Not good at all, in fact - rather high.  A fasting normal glucose level is somewhere between 70 & 99.  Since she wasn't fasting, I did expect it to be a little higher, but definitely not 506.  I gave her 12 units of Lantus (long-acting) insulin as ordered.  Rechecked her blood an hour later & it was 440.  Getting better, but still not enough for me to feel comfortable with so I went ahead & covered her according to the sliding scale which was 12 units of Novolog (faster-acting) insulin.  She was somewhat lethargic, but I wasn't sure if that was due to her glucose being out of whack, the skull fracture or the fact that her electrolytes were screwed up.  I kept a close eye on her & rechecked her glucose level around 4 am.  The accucheck machine read "hi."  I rechecked it again using a different accucheck & it still read "hi."  So I put in an order for a stat glucose level from the lab.  They called me back about 45 minutes later & informed me that her gluclose level was 899.  Eeekkk!  One of the other nurses who has also worked in the ICU said to me "I don't think I've ever had a patient with a blood sugar that high."  How comforting...not!  I called her primary Dr., explained the situation to him & his reply "Doesn't she have a consult with an endocrinologist?"  Oops...yep, I forgot.  He says "Call that doctor" & hung up.  It was a little difficult reaching the endocrinologist, but with the help of another nurse (M.B.)....we managed to track down the Dr. who ordered some more insulin sub-q.  That helped her get back down into a better range as the morning shift was taking over.  When I came back that evening, she was doing ok - more alert, but still a little out there.  Checked her evening glucose & it was 261 - that's not too bad.  Gave her the prescribed medications as well as a snack of graham crackers & milk (per dr's orders) & then left her to get some rest.  I went back in to check on her & she was saying some wacky stuff & seemed a little agitated.  I was told that was the norm for her.  I decided to recheck her glucose level around 4 am...just to be sure she was ok.  Her level was 59 (I can't  Now it's too low.  Gave her some graham crackers with peanut butter & some more milk.  Rechecked an hour later & she was 116 which was pretty good.  I'm still wondering how in the world her earlier gluclose level was at 899.  It's not as though she had been eating anything other than the 2 graham crackers I had given her.  Bizarre! 

My 4th patient was a man in with chest pain.  During assessment, he mentioned that his back had been itchy - turns out he had red spots all over it.  I called the dr. & described the spots as well as I could "multiple red, itchy spots all over his back - smaller than a dime, but not pinpoint."  The Dr. had no clue what I was describing.  I'm sure there are better ways to describe his condition, but that was my best way.  Anyways, the Dr. ordered a dose of Solumedrol & the patient seemed to respond pretty good to it.  He ended up being discharged the next day.

So with one patient moved to med-surg & another discharged, that allowed for me to have a couple of new patients Monday night.  I had a 62 yr old woman in with shortness of breath & chest pain.  Her cardiac enzymes were negative & other tests still had to be run in order to figure out what was going on with her.  My other patient was a gentleman admitted with Altered Mental Status.  He also had MRSA in his urine (infection).  I tried to spend a little extra time with this gentleman as it was clear that he wanted/needed the attention. 

Gina & I were able to watch a Code Blue on the med-surg floor early Monday morning.  This is one of the main reasons I don't want to work on med-surg....the way this patient was discovered not breathing is when it was time for vital signs.  So who knows how long ago he truly stopped breathing, you know?  I would be so paranoid if I were working with patients that were not on telemetry (heart monitors), because I'd have (generally) no clue ahead of time that something wasn't right.  Needless to say, he did not survive.  :(

I went out to dinner earlier tonight with my friends...Happy Birthday Maria, Dorene & Julie (yes, I know it was a month ago for you Julie, but still...Happy Birthday).  We went to Red Lobster & ended up talking for 3 hours.  It was a really nice time.

I'm tired now, heading to bed & hoping to relax the next few days (my days off).  It's been very rainy out, so definitely a good time to relax.  My back is a little sore, but 99.99999% better than last week.  Yay!



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