Monday, January 15, 2007

Jinxed myself - darn it!

Ahhh, it's my own fault.  I had to brag about having such a good night Saturday night, didn't I?  Last night was the complete opposite.  I barely sat down the first 6 hours of the shift!  And even after that I was busy, busy, busy. 

I wound up with the same 4 patients I had the night before plus 1 new one.  She was my busy patient.  She had been transferred from med-surg earlier in the day because of high blood pressure.  When she was hooked up to the monitor, it showed she was in a-fib...usually she is sinus rhythm.  On top of that, her heart rate had been in the 180's before I got there.  And even more on top of that (haha), she had been admitted with a diagnosis of small bowel obstruction & was vomiting continuously this very unpleasant green/brown liquid.

So I received report that a Cardizem drip needed to be started.  Her heart rate at that point was in the 130's-140's as the day nurse had pushed two doses of Digoxin to try to slow down the rate.  The surgeon showed up next & ordered an NG tube and some antibiotics.  So I knew I'd need another IV site as you can't run anything with Cardizem.  Sounds simple enough, right?  Wronggggg! 

My first priority was getting that heart rate under control.  The doctor had ordered the Cardizem to run at 20 mg/hr.  That's a high dose!  So I got that up & running, luckily she was tolerating it well & her heart rate slowly came down.  Next on the list was getting that NG tube in her as she was vomiting a lot.  We're talking 1400 cc's just since the beginning of shift. 

Before starting that, I wanted to make sure my other patients were doing ok as I had report that one of them was acting bizarre during the day....sleeping with her eyes wide open (how do people do that?), acting inappropriately, disoriented.  I went to check on her & sure enough, she was sleeping with her eyes open...either that or she just stares into space with no response.  At least she was stable!  I checked on my other patients & then got back to the one getting sick.  She was alert & oriented, but fighting that NG tube being placed.  I talked her through it & before you know it, she practically filled up a canister with output....1200 cc's instantly from the NG tube.  So we put up a new canister & another 400 came out...wow.  By the morning, she had a total of 2300 cc's from the NG tube.  Add in the 1400 emesis at night & another 1700 emesis during the day....she had a lot of stuff not getting thru that blockage.  Next on the list....another IV so she could get her fluids & pain medication.  The first one blew, but luckily the second one worked out ok.  She was finally settled down & comfortable.  She's the sweetest lady.  Unfortunately she has bladder cancer & they can't do surgery...so she claims she's a "walking timebomb."  How sad.  I was so happy to see her feeling better.  She continued to tolerate the Cardizem drip until about 3 am...her heart rate had dropped to 45 for a few seconds, then maintained in the 60's.  So I placed a call to the cardiologist to get the rate lowered.  We dropped it to 10 mg/hr, but by shift change, she was back up to 129.  Perhaps 15 mg/hr would do the trick.  I left that to the day nurse to discuss with the doctor.

Around 3:10 am, my patient that was not acting appropriately....her heart rate went from the 50's to 130 instantly.  I went to check on her & she was sound asleep = not a good sign.  So I continued to watch the monitor & her heart rate would go down to 70 & then climb back up as high as 150 & repeat that cycle over & over.  I woke her up & took her blood pressure...it was stable.  She started to maintain the 130's-140's...so I placed a call to the doctor.  Guess what he ordered...Cardizem!  So I bolus her with 10 mg, then start the drip at 5 mg/hr.  Not more than 40 min later, her heart rate dropped to the 30's!!!  Uh oh.....so I shut off the Cardizem dripp & monitored.  She maintained in the 60's.  I called the doctor to inform him of the change.

At the same time that was going on, her roommate in the next bed...her blood pressure went up in the 190's systolically...whilesleeping.  Grrr!  Luckily she had a standing order for Vasotec if her BP went higher than 180.  I gave that, rechecked about 45 min later & she was back in the 150's systolically - which tends to be her norm.  Yay!

I also saw our nurse manager this morning.  She says to me "I hear you are the moneypit of compliments lately."  Huh???  She said she has heard nothing but good stuff about me & how the patients comment on how well I take care of them.  It was nice hearing that.  I also noticed on the board some compliment cards from former patients & one had my name on it.  It feels good to know that someone appreciates the hard work I do.  :)

That was my night....just non-stop stuff.  The good thing about it is that the night flew by.  I'm heading to bed & will be back at work tonight - hopefully it will be a better night! 

1 comment:

firewolfrn said...

Okay, I have a question. Do you work in ICU,  a step down unit, or med/surg? I work on med/surg and a cardizem drip would end up in the ICU. The floor is just not staffed for the titrating drips. I was just curious.