Saturday, July 23, 2005

Crazy, but fun

It's been a crazy, but fun week at work.  I've already described my first night I'll start on what happened Thursday.  Gina & I got to work anticipating that we'd have the same patients & for the most part we did, only they had given Gina one of my patients so now I had 4 instead of 5, which was fine.  However, as the PCT was taking vitals, I find that my first patient's BP is too high, my second patient is complaining of chest pain, my third patient's BP is too low & my fourth patient is bleeding excessively in the abdominal area & the dressings are saturated & did I mention he's on a Heparin drip?  Time to prioritize - who needs my help the most?  Decisions, decisions.  I talk to my clinical leader...let her know what is going on.  As much as I really like this clinical leader, she is very laid back & doesn't really help a whole lot.  So I focus on my chest pain woman first, turns out it's more of an anxiety reaction than actual chest pain & it passes.  For my low BP patient, retake her BP manually & it's a little higher than what the dynamap was reading.  Ok, she's alright & she's non-symptomatic.  My high BP patient was my stroke patient so I wasn't too worried about it at that time.  My bleeding patient was my next priority.  I'll describe that a little later.

My hospital has decided to remodel the 2nd floor...which is split into 2 wings - north & south.  On each wing there are PCU beds & also on the other side of the hall way are ICU beds.  The nurses stations are tiny, there is barely any room to walk around if 2 people need to walk by one another - it's just a lousy layout.  So they've decided to remodel starting on the north side..which is where Gina & I and a couple of other nurses were working.  So at 11:30 pm, the charge nurse decides that now is the time our patients should be moved to the south wing.  Ughhhhhh....why now?  We had about 18 patients to move & it took about an hour & a half.  As soon as we were done moving the patients, the charge nurse sent our patient care tech to a different floor - so now, not only were we behind on our paperwork, we now had to take on the role of PCT (again) & get our vitals.  Fine, whatever.  I've now been on my feet for 6 hours straight...thinking I can finally sit down & get some paperwork done when my stroke patient's heartrate went from 110-120 up to 170-180 & her BP was 192/107.  I call the doctor - had to page him twice to get a call back.  He orders Lopressor 10 mg IV q15 min x 3 until HR is <120.  I said back to him & if this doesn't work do I call you back?  His reply "No."  Ummm, then what do I do?  So he also orders Digoxin 0.25 mg IV q45 min x this buys him time to sleep I guess.  I felt like I had no real support as far as what to do with this patient.  My clinical leader & an also this other ICU nurse was saying 10 mg is too strong of a dose - that they don't even push that much in cardiac patients in the ICU.  They advise me to push 5 mg & see what happens.  So I do that & now the patient's heart rate is jumping back & forth...from 110 up to 150, back & forth.  So I push another 5 mg & nothing changes but her blood pressure increases.  Sigh!  So I ask the experienced nurses for advice, they tell me to give the Dig inbetween the Lopressor doses.  Nothing changes with the Dig even after 45 min.  So I am advised to go ahead & push the 10 mg if I want.  If I want?  I want to know what is best in this situation.  It's like no one really wanted to help or take responsibility in assisting me.  So I went ahead & pushed the 10 mg.  Her bp went down to 159/84, but the heart rate was still erratic.  I decided to give it a little time, went to get something to eat really quick.  It was now about 4 am, I have yet to sit down & do any paperwork.  I take my vitals on my stroke patient....her heart rate continues to be in the 140's & now her bp is 170/110.  How?  With all that Lopressor...why is the BP still up?  The ICU nurse told me that with stroke patients, often they don't respond to medications because there is brain damage or a brain bleed & the brain simply isn't getting the message to react the way the meds are supposed to make the body react.  That made sense to me.  She had a scheduled dose of Captopril due so I went ahead & gave it.  That seemed to do the hour later her bp was 180/84 & her heart rate was in the 110's & she was sustaining it.

Meanwhile my bleeding patient- he was a transfer at the beginning of my shift from ICU.  He had some kind of strange rash so earlier in the day the surgeon had done a biopsy on his abdominal area & his left wrist.  We are talking about a tiny incision...but it was bleeding through gauze & abd pads - even with a pressure dressing applied.  I called the surgeon, he told me to change the dressing & reapply a pressure dressing.  So, with Gina's assistance (thanks Gina), we changed his dressing at least twice, applied as much pressure as possible with nylon tape - only to find that once again, it was leaking through.  So now it's about 5:30 am & I have yet to do any paperwork...grrrrr.  I somehow got through it, called the surgeon to update him on the bleeding patient.  Finished up giving report....I think I stayed about 20 min later than usual, but still pretty good considering how my night went.  My feet were so sore!!!

Returning to work last night, Gina & I saw that it was just her, I & another nurse on this floor.  3 nurses & the other nurse went on breaks a lot....leaving Gina & I responsibility of all these patients.  Even Gina made a comment like "We're 7 months out of school & they leave us with this responsibility."  No tech, no huc, no support, nothing. 

When I got to work, I saw my name on the board with 5 patients while Gina & the other nurse only had 3 patients.  What?  Not fair!  It turned out that one of my patients was being discharged, so I was down to 4.  I didn't get the bleeding patient back, they had given him to Gina.  I started to ask for him back when one of the day nurses said "You don't want him back, he's not acting right."  Ok, then I don't want him back, plus he's at the end of the hall & my patients are all in rooms in the middle of the hall. 

I ended up with my stroke patient again - her heart rate remained in the 110's during the day, as soon as I started getting report, it jumps up to the 160's...ugh.  Why me???  It went back down on it's own.  They discovered she did now have a bleed in the brain, so her time is very limited.  The admitting doctor & the family wants to turn to Hospice.  The neuro doctor seems to think rehab is still possible.  Come on, doctor!  She is non-responsive, what is rehab going to do for her?  The family refused a feeding tube & refused any feedings via the NG tube.  So it's only a matter of time.  The doctors decided to make her med-surg status.  So I removed the heart monitor - more for my sake than hers.  I mean it's supposed to come off when they are med-surg status, but I knew if I left it on & saw her heart rate climbing again, I'd want to do something for her.  I couldn't just sit back & watch it climb, you know?  They got her a room on the med-surg floor & the transfer was made.

My second patient spoke spanish only - I speak very, very little spanish.  We had no one on the floor that spoke spanish.  I ended up resorting to getting the cleaning lady to help me because my patient was in distress.  She had been pulling on her foley catheter & caused her urine to get a little bloody.  She thought she was dying & wanted to write a note to her family saying good-bye.  Thanks to the cleaning lady, I was able to reassure her that the blood in her urine did not mean she was dying. 

My third patient was med-surg status too.  Very pleasant man - I wish all of my patients were like him.  He was admitted with a suspected gluteal mass.

My fourth patient was med-surg status also & I ended up transferring him down to the med-surg floor.  He was an 81 yr old male with alzheimer's & dementia.  I felt for him....just watching him made me a little sad. 

When I got back from transferring my two patients, I was told I had an ICU transfer who was also of med-surg status.  Somehow he accidentally got transferred to ICU after his cardiac cath rather than med-surg even though the orders specifically said med-surg.  The thing was though...if I transferred my remaining two med-surg patients to the med-surg floor, I would have to go home.  I didn't want to go home since it was now 1 am.  My charge nurse & clinical leader were ok with keeping those 2 patients on the PCU floor. 

I ended up getting anotherpatient around 5:30 am...a c-diff patient.  Those are not my favorites - if anyone has been around a c-diff patient, you know exactly why I say that.  For those that don't...a c-diff patient has a lot of really stinky diarrhea.  It is not a good situation especially when the patient is immobile. 

Inbetween all of that, I was also helping Gina out with her 3 patients.  One was slowly dying, heart rate in the 40's.  Another was going into hospice care today...a really sweet gentleman that kept yelling out over & over "Please just let me go"....meaning let him die.  Heartbreaking!  I kept going in there to hold his hand & try to say a few comforting words.  You could tell his time was getting close to the end. 

And her last patient was the bleeding patient I had the night before.  He woke up around 2:30 am, confused & disoriented.  Turns out he's an alcoholic & was having dt's.  He was getting rude & aggressive.  He wouldn't listen to Gina telling him to get back in bed.  Finally we were able to get him to at least sit down - we didn't want him pulling out his IV that had Heparin going.  He was just out there with what he was saying - talking to himself, telling us this wasn't a real hospital.  He kept asking "Where are the techs?"  Gina & I were thinking "that's what we'd like to know!!!!!"  He wanted to know where the on-call doctor was, why were we keeping him prisoner, was picking/biting at his IV line.  This was a 62 yr old man that was not like that at all the night before when I had him.  Of course I jokingly blamed Gina for doing something to him as well as Jack the ICU nurse who had transferred him to me.  Gina called the patient's wife to have her come in, hoping it would reorient him a little bit.  He was mad that Gina called his wife.  He started yelling.  There we were again with no real assistance.  The other nurse was telling Gina to call security if we needed help - which is a joke if you saw our security guards.  They are usually little old men that couldn't do much to help anyways.  His wife came in & sat with him, he went back to sleep & wasn't too much of a problem - thanks to his wife being there. 

Around 5:30-6 am, Gina's patient with the heart rate in the 40's had to be transferred to ICU.....that was our night.  I had fun through it all though.  I admire the ICU nurses - they are so full of knowledge & quite helpful whenever we have any questions.  That's one reason I like being on the second floor - right next to ICU.  I want to be knowledgeable like that one day too - where I have the answers rather than all the questions.  I know it takes time & experience...but that's what I want to be like one day.

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