Wednesday, August 17, 2005

Common sense isn't very common!


Another week of work done & over with. What a hectic week it was too - I think it may have been one of the most chaotic weeks yet. At the beginning of every shift, it was a mess - either the day nurse was running behind, problems with patients, multiple discharges, multiple transfers, multiple admits - you name it, it was happening. Why is it always at the change of shift when this stuff happens?

Gina & I were split up again on different floors. When I asked to switch floors, the reply was NO. Whatever! I get report, only 4 patients instead of 5, which is always nice. 3 out of the 4 are ones I have to keep a close eye on & of course my alert & oriented patient is leaving in the morning. Sigh - wish they could all be like he was.

He came in for chest pain over the weekend & had a cardiac cath done which showed a couple of his vessels were blocked & he either needed stents or heart bypass surgery. Our hospital is not equipped to do either, so he was going to be sent to another hospital to have the procedure done. I had to transfuse 2 units of RBC's...not a problem. Veryyyyyyy pleasant gentleman. I am beginning to favor these cardiac patients. Give me middle aged males with chest pain any day of the week.

My second patient was a gentleman that had been in for 2 weeks & had 2 chest tubes. He was a rather quiet guy, but also rather reckless. He was mad that we took his foley catheter out - most patients want it out right away, this one wanted it back in so he wouldn't have to urinate on his own. Lovely. I thought for sure he was going to end up "accidentally" pulling out one or both of his chest tubes. He was always moving around & was probably sooo tired of me constantly checking on him to make sure everything was ok. I don't like chest tubes - they just seem so odd to me. I know they work, they do what needs to be done - but the concept is still a weird one for me. Not to mention my fear if one did get pulled out. Luckily he was put on med-surg status the next day & transferred off the floor.

My third patient was a 92 yr old man with abdominal pain. We had suspected it was kidney stones or something going on with the kidneys. When I assessed him, he complained of nausea & pain. So I gave him 12.5 mg of Phenergan & 1 mg of Dilaudid. It took care of the nausea & pain, but it also made him act a bit odd. He was obsessed with his hearing aid. He'd take it off, change the battery, fumble with it & put it back on...over & over & over again. And if it wasn't that, he had me searching for his hearing aid case - which as it turns out, wasn't even at the hospital! It felt like that movie "Groundhog Day".....I'd leave the room, only to be called back 10 min later & go through the whole routine again. That's the thing with Dilaudid - you never really know how it's going to affect your patient's mindset. As it turns out, the GI doc & the surgeon were arguing over this patient's diagnosis. GI doc was saying it was an ileus & needed surgery.....the surgeon was saying it was a fecal impaction (ugh) & just needed a few nursing interventions to remove it (ughhhh). My second night with this patient - the orders were "Soap suds enema, check for fecal impaction & remove if able, Dulcolax suppository q6hour until you get results." Ughhhhhh! For those of you that aren't familiar with "check for fecal impaction" - it basically means stick your finger up the patient's butt & see if you feel any kind of blockage - if so, try to remove it (ughhhhhhh). I lucked out, my clinical leader did most of that...I just couldn't do it, not that I couldn't physically do it - mentally I just didn't want to go there. Not yet anyways. Needless to say, he was negative for any fecal impaction that we could reach. The suppository worked though - so no ileus. The surgeon was correct. However, this patient did have kidney stones & required surgery. I declined to take him back the third day as I already had a post-op patient coming back to me & didn't want to care for two confused, disoriented post-op patients. The sad thing though...this gentleman didn't make it back to my floor. He ended up going to ICU after the surgery because his COPD worsened his condition & they couldn't take him off the vent. I'm curious to see if he recovers.

My fourth patient was a handful. An older male who only primarily spoke spanish (put that on the list for me to learn). He was in for gallstones, but needed to be medically cleared by the cardiologist for surgery. He also has a history of dementia & clearly knew a little english - well, the bad words in the english language. He was fine the first night I had him - cooperative, took his medications, allowed us to take vital signs...not a problem. However, he didn't sleep at all! In fact, that first night - none of my patients slept. It was a strange night.

Anyways, the second night with this patient was not so wonderful. He was very defensive, didn't want us near him, tried kicking the tech while she was trying to put on the blood pressure cuff. Of course he'd tense up & we'd get a false blood pressure reading. It took 3 or 4 of us to contain him just to get his blood pressure. He was calling one nurse a "ho", telling me not to "f" with him, yelling things out. I just had to laugh - not at him, just at the situation. We put restraints on his ankles so he couldn't kick us & eventually had to put restraints on his wrists because he was trying to punch. He wanted to bite, so needless to say - he didn't get his PO medications because I wasn't about to put my fingers near his mouth. Plus I wasn't sure he'd even swallow them if I did get them into his mouth. He had his moments of being really nice, so I took the restraints off for a few hours. Then he went back into this odd behavior. He was cleared for surgery & had it done Tuesday early evening. He was back to the floor by about 8 pm & moaning out in spanish "Oh my god." I didn't know if he was in pain or what the deal was. His heart rate was between 130 & 170 - I didn't like it. I called his admitting doctor, got an order for Lopressor 5 mg IV. I gave him that - it had really no effect on his heart rate. So I thought maybe pain was causing the high I page the surgeon. He happens to be in ICU, peeks his head around & says "I ordered him pain medication, Lortab 5 mg PO." I said "the patient is somewhat lethargic & he has a swallow evaluation for tomorrow, so I don't feel good about giving him a medication by mouth." He replies "If he can't verbally tell you he's in pain & he can't swallow, then he gets nothing." How rude! I said "His heart rate is between 130 & 170." He replied "It's not pain that's causing it, it's his a-fib, control his a-fib & you'll control the heart rate." Then he went on to tell me how he does this type of surgery all day long & most people go home & the pain isn't that bad, etc. I've had my gallbladder removed - the pain is bad if you have no pain medication. Oh well, my next resort was to give the patient some Digoxin to try to get a handle on the a-fib. That helped a little...brought his heart rate between 90 & 130 which they tell me is normal for someone with a-fib. All I know is that I had him the previous two nights & was not dealing with a heart rate that high, but ok....if neither his admitting doctor nor his surgeon is that concerned about this heart rate, then why am I so concerned? As long as they were both very aware of his present condition...and I charted it, that's all I needed to feel ok with the situation. I kept checking on him, would hold his hand, rub his arms & forehead because he seemed so alone. He was no longer moaning & he slept a lot of the night, but I still felt the need to give him some emotional support.

The second night when I got to the floor, it was a mess. The day shift nurse was running around frantically, transferring my chest tube patient to med/surg & she had a new admit who had been there for over an hour that she hadn't assessed. I told her not to worry about it, that I would do the assessment & fill out all of the paperwork. I had to assess him anyways & she was already running way late. He was a very pleasant gentleman who came in with what else = chest pain. I'm telling you.....the majority of chest pain complainers are very pleasant people. We clicked immediately, got through the assessment & the 39408304 questions we need to ask the patient. Got him situated & off to bed he went. No c/o pain through the night - gotta love these patients!

I also got another new admit about an hour later...take a guess at what his diagnosis was.............chest pain. Ahhh, another wonderful patient. He also had been experiencing numbness on his right side so he was also being examined for a possible CVA (stroke). Just needed the neuro doc to clear him for a stress test. Got through the assessment & the 39408304 questions that needed to be asked & off to bed he went. No complaints of pain through the night which was a blessing since the other two I had kept me busy most of the night between the hearing aid routine & the punching & kicking.

The other nurses on the floor were getting slammed with discharges & admits. It was ridiculous - why does this always happen at the beginning of shift? I don't think the ER should be allowed to transfer a patient between 6:30 & 8:30. Give us time to get report & see our other patients before you start adding more, right? Common sense isn't very common!!!!!!

My third night was ever more of a mess - one of our nurses forgot she had to work. How do you forget you have to work??? So we had to pick up her patients until she could get into work (2 hours later).

One of my chest pain guys was discharged, my other two were in surgery - so I declined taking both back...only wanted to handle one post-op. So I was given two other patients - one who was being discharged & one who was going to hospice the next day, she was on comfort measures only - which was a good thing because it was so super busy that I didn't have a lot of time to devote to anyone that truly needed anything right away.

I worked on assessing the other two patients of mine, worked on getting the one discharged as he had already been waiting for awhile (why the day shift nurse doesn't get the paperwork together when she knows he's going to be leaving....I don't know...maybe she's too busy also? Who knows?). Luckily he was a calm, patient gentleman. Got him out the door, get my post-op patient with the high heart rate back, other nurse finally shows up - give her my hospice patient, my clinical leader says "I have a new admit for you & an ICU transfer coming your way." Ahhhhhhhhhh.....give me a minute to catch my breath! I'm calling the doctors for my post-op patient to get his heart rate under control, getting report from the ER nurse & luckily the ICU transfer wasn't in a rush to be transferred - it bought me a little time to get these other things done. I take care of post-op guy - he's doing ok & I can focus my attention on the new admit.

This was a gentleman that had a history of CVA's & TIA's who came into the ER because his speech was delayed. He was able to think fine, but took a few extra seconds to say what he needed to say. He was veryyyyy pleasant & quick-witted. I was going through the assessment & the 3908103 questions I have to ask on the assessment form & one of the questions is "Have you ever fallen at home?" His reply "The last time I fell, it was for my wife 35 years ago." Awwwwwww!!!!!! Is that adorable or what? And on top of that - his admitting orders were basically nothing - an EKG for the AM & a neuro consult. That's meds, no tests, no labs. Kinda scary though - what kind of admitting doctor doesn't order anything for his patient? Not a doctor I would want to have! I passed onto the day shift nurse the meds this patient is on at home & he would definitely need them ordered, but since he only takes them in the morning - I saw no need in waking the doctor up at night to get the order. This guy was a sweetheart.

I can't say the same about my ICU transfer. Luckily he had been downgraded to PCU status while in ICU, so they started all of the PCU paperwork over there = less work for me to do. :) He got over to me between midnight & 1 am. I was told during report that he was in restraints because he has an NG tube & will pull it out if I give him the chance. He was in for a CVA (stroke) & it had done damage. Well, during the transfer over to my floor, he had somehow managed to pull out the NG tube even with his restraints on. So we put those mitt type restraints on so even if he was able to reach anything, he couldn't be able to grip it & pull it out. He didn't like it. I had also been told during report that when this patient is given Haldol - it knocks him out for a long period of time & the generous ICU nurse had given him a dose about an hour quote the nurse "He should sleep all night for you." Famous last words! The guy barely slept a wink. He kept yelling out & would tell me to take the NG tube out, take the gloves off, he had to go to the bathroom. If he said it once, he said it 100 times. As soon as you would give him a reason as to why we couldn't do any of what he was asking, he'd ask the question again. It took me a little time, but soon enough I saw that reason wasn't working with this patient. I gave him 1 mg of Ativan hoping that would relax him. It didn't really have much of an effect - at least not during my shift. Watch - he probably slept all day.

That was my week of work - nothing too gross (except the fecal impaction check), nothing too gory, nothing too stressful. I was either in an exceptionally good mood or I'm just learning to deal with the craziness of working in a hospital & having to react to the unexpected - or maybe both. I wasn't frustrated or agitated at all. In fact, I probably laughed more than usual. Maybe I'm learning to not take it so seriously - all you can really do is the best you can do & if that's not enough, then too bad. It's the reality.

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