Wednesday, March 29, 2006

Still Deciding

Thanks to everyone that has sent me email or left comments in response to switching this to a private journal.  It's nice to know that you enjoy reading what goes thru my mind & the experiences I have in the nursing field.  I'm still trying to decide whether to make it private.  One reason I'm holding back is because some of you do not have aol accounts & when I switch to a private setting using an "aol" journal - I can only make it accessible to those that are also on aol.  That leaves out those of you who don't use aol as their internet provider.  So it's a toss-up between finding a different journal/blog web site that will allow a private setting that includes any email address or cutting off those of you who don't have aol from ever reading my journal again or simply leaving it under a public setting & hope that nothing I'm writing about could be used against me in the future.  I'll figure it out eventually.  Anyone have any ideas??? 

In the meantime, I will reflect on my last 2 nights of work.  Sunday was a rough night & definitely a reminder that psych nursing will NEVER be my thing.  It's also a reminder that for those who say "psych nursing will never be my thing" that you will indeed encounter many patients in a regular hospital setting that do have psych problems so pay attention in psych 

I had 4 patients that night.  My first patient was in with respiratory distress & respiratory insufficiency.  She weighs over 400 lbs & of course that can make it difficult to breathe.  She was given some Atarax before my shift started & that drug made her sleepy...she pretty much slept through the night - just the way I prefer it.

My second patient was a gentleman in with chest pain from a few days ago.  He was completely stable, but boy oh boy did he like to talk.  He was another one that slept pretty much the entire night - again, just the way I prefer it.

It freed me up to deal with my other 2 patients.  My third patient was a woman in her late 70's in with nausea & vomiting.  She had an NG tube although by the time I had her, the NG tube was clamped & only to be used if the vomiting returned.  Thankfully it didn't!  I was told in report she had received Dilaudid & Phenergan in the morning & has been confused ever since.  When I went in to assess her, she had pulled out her IV.  She was also pulling at her foley catheter & trying to get out of bed.  As much as I don't like a situation like this, I had to use them.  I applied the soft wrist restraints & of course she didn't like them. 

During all of that commotion, I got a new admit.  A woman in her late 50's with chest pain who got the pleasure of sharing a room with my confused patient = yet another reason all hospital rooms should be private rooms.  Someone alert & oriented should not have to share a room with a disruptive, confused person...however, our hospital was full & we had nowhere else to put her. 

My confused patient began to talk a lot....I mean A LOT.  Rambling on about all sorts of stuff that made no real sense.  My alert patient assured me that it was ok...the woman talking didn't bother her at all.  So we think that maybe if we turn off the tv & the lights...maybe she'll go to sleep.   Nope....she began screaming & yelling.  I tried talking softly to her, tried to reorient her...she didn't believe she was in the hospital...she said we were at my house & she didn't like my house.  Ummm, ok.  With that I put a call out to her doctor to let him know that she was in a confused state of mind & I needed something to calm her down & perhaps help her get a little bit of sleep.  He gave me an order for Ativan IV.  In most cases, this is a good solution, but with older patients you are pretty much playing russian roulette.  There is a chance it will do what it's supposed to do which is relax the patient & make them sleepy.  There is also a chance that it will do the complete opposite which is to cause them to become even more agitated.  Guess what my result was. 

She went from talking A LOT to talking very fast A LOT.  Her thoughts/sentences were making no sense & she would not stop talking at all.  She began kicking at us & attempting to get out of bed even with the wrist restraints we added ankle restraints.  I felt bad...I don't like restraining people to this degree, but if I didn't...she would have harmed herself.  Luckily my PCT wasn't busy & sat with this woman for over an hour trying to calm her down so I could get some of my paperwork done.  We were hoping the Ativan would kick in & she'd be off in dreamland soon, but NOPE...wasn't happening. 

After about 3 hours of this woman continuously talking, she drove her alert roommate to the edge & over.  It wasn't long before they were arguing & calling one another names.  The confused one was saying some really awful things to the alert one.  I felt terrible about this & tried to find a way to get relief for the alert one.  There were no other rooms available.  I offered her the ICU waiting room as there was no one in it that night, but she refused.  I put another call out to the doctor to update him & to get an order for some other type of medication.  He ordered Haldol IM.  I prayed it would work, but apparently God was busy that night as this changed her mood from not so nice to just plain mean & nasty.  Nothing was working.  I thought for sure she would tire herself out & at the very least stop talking for at least 5 minutes...but that didn't happen.  She would not shut up at all.  I've never seen anything like it.  12 straight hours of talking.  I was amazed that her O2 sat remained at 95% with as much talking as she was doing. 

I was glad when I saw the day nurse show up.  At about the same time, the patient's doctor showed up also.  Often times when the doctor shows up, strange behavior disappears & I was hoping this wasn't the case.  I wanted him to see what we had been dealing with all night.  Nothing changed - she continued to act very bizarre.  The doctor ended up transferring her to the ICU as he knew that her behavior was very abnormal from how she usually is.  He diagnosed her with delirium & suspected that perhaps she was going into sepsis.  They attempted to do a brain CT, but nothing they gave her would sedate her enough to stay still for the test.  She continued to talk all day & they had to keep her in restraints.  I am curious to see if she was septic or what was causing her to behave like that. 

I felt terrible for my alert one should have to deal with that.  Luckily the next night, there was a new admit...another older lady that was as quiet as a mouse. 

Not much to really report about my second night...nothing much was going on & the time ticked by so very slowly.  I'm not complaining though...nights like those are welcomed & preferred to stressful nights. 

I went to my nephew's baseball game tonight - he was pitching & they won.  He's got another game tomorrow night & also another one Friday night...I'll be going to both games.  He only has another month or two left of baseball & then he graduates.  I can't believe he's all grown up.  When did this happen?  In fact, today was my brother & sister-in-law's 19th wedding anniversary.  We were reminiscing about what we were doing 19 years ago.  Boy, does the time go by fast.  I had just turned 18 & was spending my weekends at our condo at Daytona Beach...ahhh, so long ago.  To relive those days would be

Anyways, I'm not scheduled to work until next Tuesday.  I love the flexibility that I have with my work schedule.  I may pick up Thursday night...we'll see.  :)

Saturday, March 25, 2006

Set to Private

A friend of mine recently told me of someone that he knows that got in trouble for having an online journal related to healthcare.  So just to stay out of trouble...I wanted to let all of you know that I will be setting my journal to a private setting sometime next week.  If you would like to continue to read my journal, send me an email & I will include you on the private setting.  Thanks!

Thursday, March 16, 2006

Let's Push Them Out the Door

I put in my 3 days at work this week....3 days in a row.  I had a variety of patients.  Luckily no one was critical or progressively getting worse.  They all were getting better...which means they get discharged & I get all new patients.  I prefer to keep patients I'm already familiar with...who doesn't? 

I like to think that I connect pretty well with my patients.  I was told in report that this one patient of mine was out of control, would not follow safety instructions, they put him in a Posey vest & wrist restraints, etc.  I was warned by the other nurses what a handful he was & to expect to spend a lot of time in his room.  What a way to start off my first night.  I have come to learn though...that this is not always an accurate picture.  There are times where I am told "so & so is a difficult patient"...only to find that they were pleasant & cooperative with me.  Maybe I'm the "patient whisperer"...sort of like what the horse whisperer is for  Nah...I'm not that conceited.  Back to this patient I was describing...I went into his room to assess him & found that he was not the person previously described to me.  He was a charming gentleman...who at times may have been slightly confused, but overall...very pleasant & cooperative.  He thanked me often for treating him so well.  By my third night, they had transferred him to med-surg...which is good for him.  It means he is getting healthier & ready to leave the hospital soon.

I had another patient that was supposed to be discharged on Monday.  Turns out her potassium level was 2.9 "after" receiving 80 meq of potassium during the day.  The doctor was informed & the discharge was put on hold.  It's a good thing, because the next day they did a surgical consult regarding possible gallstones & sure enough, she had them & had surgery on Wednesday afternoon.  She came back from surgery/PACU around 6:30 pm.  On the chart, she had discharge orders from both her primary doctor & the surgeon.  I was surprised.  Ummm, hello...she just had surgery a couple of hours ago & is still out of it due to the anesthesia & pain want me to send her home in this condition?  Not to mention that her potassium level was 3.1 & had not been addressed and also the patient did not want to go home in her current condition.  I called the doctor, he ordered potassium PO & send her home.  It seemed too soon for my comfort, but ok.  I gave her the potassium, only for her to get nauseous & throw it up.  Well, that bought her another night at the hospital because now she needed potassium given the IV route & that takes 4 hours.  She was happy to stay.  Which also makes me wonder about these patients that don't want to leave the hospital.  95% are eager to get out of there as soon as possible.  Except the two patients I had...this one & another one that had a heart cath done...they didn't want to go home.  I felt like I was pushing them out the door.

My heart cath patient....her heart cath was positive...but since she is in no condition to have surgery to resolve it, the doctor wrote out some meds & then said "Ok to discharge."  I had to wait until 10:30 pm because she needed to remain lying flat after having a heart cath.  I questioned...shouldn't I make sure she is stable "after" getting up & moving around.  Nope, patient is allowed up at 10:30 & send her home.  I felt awful because this is an elderly couple that probably wasn't even use to staying up past 9 pm, much less be driving around after 11 pm.  But they had no choice...she was finally left at 11:15 pm. 

I got a new admit this morning...basically a drug seeker using the excuse of having chest pain.  He's worn out his welcome at other hospitals & now ended up at my hospital.  He stated all of these pain meds that he was allergic too...they were the less potent pain meds & obviously he was probably immune to their effects.  Every 4 hours he was claiming to have chest pain so he could get the pain mediciation.  I'm not one to judge these patients...if the patient wants pain meds & the doctor has ordered it...I am not about to ignore his claims of feeling pain.  I'll give the pain medication.  Because as we all learn in nursing school...only the patient can tell you that they are exerpiencing pain.  He was so dramatic though, that it wasn't even funny.

Oh well...I had other patients, but I'm getting sleepy & heading to bed.  Take care!


Thursday, March 9, 2006

Signs of a Stroke

A good friend of mine sent me this via email.  I thought it was important enough to share on here...


    During a BBQ a friend stumbled and took a little fall - she assured everyone she was fine (they offered to call paramedics) and only tripped over a brick because of her new shoes. They got her cleaned up and got her a new plate of food - while she appeared a bit shaken up, Ingrid went about enjoying herself the rest of the evening.

Ingrid's husband called later telling everyone that his wife had been taken to the hospital (at 6:00pm, Ingrid passed away.)  She had suffered a stroke at the BBQ - had they known how to identify the signs of a stoke perhaps Ingrid would be with us today.

It only takes a minute to read this--

Recognizing a Stroke

    A neurologist says that if he can get to a stroke victim within 3 hours he can totally reverse the effects of a stroke...totally. He said the trick was getting a stroke recognized, diagnosed and getting to the patient within 3 hours which are tough.

    Thank God for the sense to remember the "3" steps.  Read and Learn!  Sometimes symptoms of a stroke is difficult to identify.  Unfortunately, the lack of awareness spells disaster. The stroke victim may suffer brain damage when people nearby fail to recognize the symptoms of a stroke.

     Now doctors say a bystander can recognize a stroke by asking three simple questions:

1. *Ask the individual to SMILE.

2. *Ask him or her to RAISE BOTH ARMS.

3. *Ask the person to SPEAK A SIMPLE SENTENCE (Coherently, i.e., "It is sunny out today.")  If he or she has trouble with any of  these tasks, call 911 immediately and describe the symptoms to the dispatcher.

    After discovering that a group of non-medical volunteers could identify facial weakness, arm weakness and speech problems, researchers urged the general public to learn the three questions.  They presented their conclusions at the American Stroke Association's annual meeting last February.  Widespread use of this test could result in prompt diagnosis and treatment of the stroke and prevent brain damage.

    A cardiologist says if everyone who gets this e-mail sends it to 10 people; you can bet that at least one life will be saved.



Tuesday, March 7, 2006

It's My Birthday

Happy Birthday to me...Happy Birthday to me...Today is my 37th b-day!  I can't believe it.  I definitely do not feel like I'm 37...which leads me to we ever really feel the age that we are? 

I had dinner with my parents & one of my brother's at Red Lobster.  I love that place.  Then my brother & I went to watch my nephew Eric play baseball & met up with my other brother & his wife.  Eric pitched tonight...we left at the top of the 7th inning because it was cold & windy.  They were winning 10-3 so I figured the game was practically over.  Eric hit a home run...yay!  He's so good.

Tomorrow night I'm going out with a couple of my best friends for dinner.  Then Friday night I'm going out with another friend to celebrate my b-day.  It's more like a b-day week than a b-day day.  I'm glad I didn't schedule myself to work this week! 

Saturday, March 4, 2006

I was due

I worked 4 nights in a row this week.  I was planning on doing 5 or 6 in a row, but my 4th night wore me out.  I was due for a stressful night.  I haven't really had one since the code blue back in the beginning of January.  It seems like when it rains it pours.  Either that or I simply don't really stress when I have one patient having problems...but when I have 3 out of 4 with serious problems....I start to stress.

Luckily I had one patient that remained stable, because I really didn't have much time to focus on her.  She was in with pneumonia & I had been taking care of her for the last 3 nights.  I was familiar enough with her to know that once she got her evening meds, she would most likely be fine throughout the night - other than when she requested pain medication. 

The other 3 patients of mine were new admits.  My first one came in with a diagnosis of congestive heart failure.  He only spoke spanish.  Why they didn't give him to a nurse that speaks spanish...I don't know, but he was mine.  Everything was going along fine with him...I gave him his meds including a sleeping pill & pretty much expected him to have a nice night of sleep.  About a 1/2 hour later, he sat up to use his urinal & his heart rate jumped up to the 180's.  I brought my tech (she speaks spanish) in with me to tell him to lay down & luckily his heart rate went back down to his norm rather quickly.  I had given him some blood pressure medications & Digoxin, so I figured once those kicked in, he'd be ok. 

On to my next patient...this guy seems like he came from that tv show "House."  He was a medical mystery, that's for sure.  He also came in with chest pain.  He was on the low-risk pathway.  As I was reviewing his medical history, he tells me he's been in 3 head-on car accidents.  He wasn't expected to live after the first one, but after something like 40 days in the hospital, he & his wife made it through.  He also has a cerebral aneurysm that is inoperable.  He has a history of seizures.  He had a stroke about 15 yrs ago that put him into a coma for 3 months.  He came out of it & was completely flaccid on his left side.  A year later it resolved itself.  On top of all that...he's been hit by lightning TWICE.  I felt like I was talking to someone that should be in that movie "Final Destination."  Talk about escaping fate time & time again!  I get him settled in, review his orders & bring him his meds...he tells me he feels pain but he doesn't know where it's coming from.  Huh??  He can't even describe the pain to me, it's just there.  I'm picturing in my mind what a phone call to this patient's doctor would be like...."Umm, yes Dr., this patient is having some pain but he doesn't know where & he can't describe what it feels like."  I put some oxygen on him & told him to breathe in through his nose.  After a few minutes, he said the pain was gone.  Ok, good.  On to my next patient.

I get this woman in her late 60's from the ER.  Again, she only speaks spanish.  Why she wasn't assigned to one of the nurses on our floor that speaks spanish, I don't know...but she got me.  Her daughter was with her & carried around a notebook full of all her mothers past medical tests.  It was very organized, I was impressed.  She got to the floor around 11:30 pm & was having trouble breathing, she was sweating, had a terrible headache...basically she was a mess.  I got her a breathing treatment, her blood pressure was 177/ I gave her one of her blood pressure medications that the ER didn't bother to give her.  Then I notice that while in the ER, she had a positive D-dimer (a test that can be an indicator of a pulmonary embolism).  The ER did not follow up with a CT they are supposed to.  So I call the doctor at midnight to get this test ordered.  He didn't request it stat, so we put the order in & figured we'd have it done in the morning.  The guy that works in CT scan called & said that it's usually done stat, but it's my call...what did I want to do.  We decided to go ahead & have it done now rather than wait - just in case - but fully expecting it to be negative.  So she goes down at 1 am for the CT scan.  You think I'd be able to sit down & catch up on some paperwork. patient with the elevated heart rate earlier in the night....well, he's sound asleep but for some reason, his heart rate is sustaining 140 to 150.  There is no cardiologist even consulted.  So I call the admitting doctor who of course is not on call....I get one of his partners.  This is one of the doctors that I really cannot stand.  Anyways, he calls back....I tell him what's going on & he begins questioning me why there is no cardiologist on the case.  I wanted to say "Ask your partner why he didn't order a consult for a cardiologist!!!!!!"  He gives me a vague order for a cardizem bolus & if needed, a cardizem drip.  Then tells me to find out who the patient would like for a cardiologist & put out a consult if necessary.  The patient has no idea who his cardiologist is, so I go ahead & give the him the Cardizem bolus.  It seemed to be working...ok, time to do some paperwork. 

Yeah, right!  My patient from CT scan is back & doesn't want to sleep.  She's sitting up on the side of the bed.  I was worried she'd fall off.  I cannot get her to lay down back in bed & I cannot spend the rest of the shift babysitting her to make sure she doesn't fall.  I take a chance & leave her be only to get back to my work area & find out she has not one pulmonary embolism....but two.  Great!  One in the left lung & one in the right.  Ugh!!!!!!!  I call the doctor again to update him - I'm sure they love these calls at 2 am.  He's pretty much sound asleep & not saying much.  Asks me to repeat what I just said to him.  I swear, they need to come up with a better system than waking doctors up to give orders.  He eventually wakes up enough to order Heparin & tells me to call the pulmonary doctor also.  I call her even though she has yet to see the patient.  She's not happy, but she's a little more alert enough to have me read through the orders & the medications...then tells me it's ok to start the Heparin. 

At about the same time as this is going on, my patient on the Cardizem...well, his heart rate is back up to the 140's even though he's sound asleep.  So it's time to hang the Cardizem drip.  We get that going & I think he'll be fine through the rest of the night.

I get the Heparin for the patient with the pulmonary embolism's & have the nurse that speaks spanish explain to the patient what is going on & how important it is for her to remain in bed.  We set up the Heparin & the patient is now refusing to lie down.  She wants to sit's easier for her to breathe.  The last time I had a patient who was requesting to sit up to breathe...she coded & died.  I was worried this might end up being the same situation.  I finally get her to lay down, Heparin is running....ok, now I can sit down & do some paperwork. 

Nope, my patient on the Cardizem in a matter of 2 hours now has a heart rate in the 60's.  Then for a few seconds, it drops down to 45.  Time to turn off the Cardizem.  He remains anywhere from 45 to 75, going back & forth. 

I go in to check on my patient on Heparin.  She's now sitting up on the edge of the bed (grrrr) & complaining of chest pain.  She's speaking in Spanish...I don't understand a word, so I get the other nurse.  She is saying it isn't chest pain so much as all the coughing is making her muscles ache.  She's also having trouble breathing.  I call respiratory for a breathing treatment & give her some pain medication & continue to observe her. 

My patient that was struck by lightning twice...well, now his heart rate went from the 70's to the 40's...only the rhythm isn't normal.  I assessed him, he was asymptomatic & his heart rate goes up to the high 50's...I can deal with that since he is in sleep mode.

Now it's time to get some paperwork done quickly.  I do not like staying past my shift...even on crazy nights.  As I'm attempting to get this done, now I have the doctor calling me about the Heparin...not one call, but two.  I managed to get all the paperwork done.  Gina helped me out with going over the orders to make sure everything was entered for the new admits.  That helped a lot.  Trust me, I was counting down the time for the end of my shift. 

I go in to check on my Heparin patient...she's finally laying down & sleeping.  Everyone seems to be stable....time to give report.  As I was giving report on her, Gina tells me this patient is complaining of pain.  Luckily the doctor showed up & went to assess her.  I could not wait to clock out!!!  :)

I had been planning to work Friday night, but after a stressful night...I knew I needed some R&R.  Last night I went to watch my nephew Eric play baseball.  As it turns out, at the end of the first inning, his team was winning they took him & the other good players on his team out of the game so some other guys could play.  Oh well, it was a beautiful night & it was nice to be anywhere but at the hospital. 

Have a good weekend!