Saturday, November 8, 2008

Puts the Patience in Patient

Another week down - I only worked 2 nights this week, but the way my feet feels like I've worked 7 nights straight. I must find more comfortable shoes. Well, I did have super comfortable Skechers, but as most shoes - they started to not look squeaky clean. As clunky as Skechers are though, they are the only brand I have found that my feet are not sore after running around for 12-14 hours. So what do I do...throw them out & start wearing a pair of Avia and a pair of Nike. Yeah, silly me. I'm going back to Skechers for when I'm at work.

Wednesday night I was floated to med-surg to take care of PCU patients. We have something like 10 beds on the med-surg floor that are for PCU patients if our other 60 PCU beds are filled. I started out with 4 patients, discharged one and got 2 admissions. One of my admissions I was seriously worried about.

She was a woman in her late 70's admitted with TIA and cardiac arrythmia. The ER didn't elaborate on what the cardiac arrythmia was exactly...but I soon found out when she arrived on the floor with a heart rate in the 30's...hitting as low as 32 beats per minute. Normal is 60 to 100. Suprisingly, that didn't worry me as much as her "TIA"...she had right sided weakness to the point that she couldn't even raise her right arm. The CT of the brain was negative, but still....something wasn't right. Add to it that her speech was slurred. I was told by the ER nurse that the family believes she took too much Lopressor. Her dose is 50 mg twice a day, but they believe she was taking 100 mg twice a day. Big difference! Still though, what was causing her slurred speech and right sided weakness?

My clinical leader discussed with the nursing supervisor whether it was a good idea to keep this patient on the med-surg floor. They decided it was ok.....I'm not really sure why, but I couldn't really argue with them. Looking back though - I should have just called the doctor and gotten an order for ICU. Her heart rate alone with the possible Lopressor overdose would have warranted closer monitoring. Sure enough, by 3 pm the next day, she was transferred to ICU. I was on PCU the next night & ICU is just a few steps away. I noticed that her heart rate had made it up to 38...but she was having 3 second pauses. She also had a MRI of the brain, but I didn't see any results. I hope she'll be ok.

Last night was yet another crazy shift change. I probably should have done a couple incident reports, but it's getting to the point of why bother? It doesn't seem like they do anything with them anyways. The two issues were:

1) Surgeon ordered a patient be started on Heparin - order came in at 2 pm. It is now shift change & no Heparin ever started. Hellooooo...there is a good reason doctors order Heparin. The day nurse claimed he tried calling the doctor's office, but figured he'd round sometime tonight and he would talk to him. What? Talk to him about what...just start the Heparin.

The reason he wanted to talk to the surgeon was because we are coming out with this "new" Heparin protocol starting this coming Monday - it was what the surgeon ordered. The nurse didn't feel comfortable using the new protocol guidelines. I took a look at the new protocol (this was the first I had ever heard of it) and it was fine to use. It had parameters, we are good to go. What's the problem? Let's prevent those clots from forming!

Luckily, the surgeon rounded while the day nurse was still giving me report and I hear him say "Why hasn't this Heparin that I ordered 5 hours ago been started???" He must have been in a good mood, because he didn't even get mad about it - which is strange - because he has his moments of errupting. The day nurse shows him the new worksheet with the guidelines and tells him "you can't use this, it doesn't start until Monday." Hahaha...have you ever told a surgeon they can't do something? They have the biggest egos out of all the I warned the day nurse not to use those words with this doctor, because he will find a way to do what you are telling him he can't do.

Sure enough, he took the new protocol worksheet out of the nurse's hands, grabbed some scissors, cut out the parameters for this new low-dose Heparin protocol, taped it to a doctor's order sheet and signed it. Waaa official order to follow. The day nurse was stunned. He asked me "are you actually going to follow that order?" Ummm, yeah, what's wrong with it? It has guidelines & parameters - that is all I need.

2) Another patient with the same nurse - was started on the "alcohol withdrawal" protocol (I love these protocols - they basically take the thought process away from the doctors). Well, basically this protocol is done so the patient can be started on folic acid, multivitamin and reduce the effects of alcohol withdrawal. There are more things on the protocol, but those medications are important. Guess what....the patient hadn't been started on any of the medications.

For some reason, the pharmacy opted to make a banana bag with these medications instead of having the patient take them by mouth. It must have been a miscommunication or something, because this patient was fine to take the meds by mouth. No reason to hang a banana bag for 12 hours and run the meds in by IV. Anywayssss...I questioned him on it when I saw that the banana bag was ordered & hadn't been started. His reply was "It shows on the MAR that it's not suppose to be started until 9 pm." Huh? The patient has been here now a day & a half with the order and it hasn't been started? He didn't get it. He didn't understand why those medications are important for alcohol withdrawal. Sigh. I ended up getting the banana bag discontinued and switched the meds to PO (by mouth.

Needless to say, I didn't write it up even though harm could have come to the patient as a result of the delay of medications in both cases. I tried instead to explain to the nurse the reasoning behind both issues.

My patient needing the Heparin accidentally pulled out her IV prior to the Heparin being started. She was a tough stick to get another IV site, but she was a trooper. I told her she puts the word patience into patient. It made me stop & think....why are patients called patients? Ever think of that before? Most of my patients are rarely This one was though...thank goodness.

I had a new admit around 5 am. A woman in her early 30's with chest pain. When I asked her how long she had this chest pain, her reply was "3 years." Huh????? 3 years???? It definitely made me wonder about her.

Look at the time - I should be in bed!!! Have a good weekend everyone!


Teresa said...

busy, busy, busy... I remember the med/surg ward and being GLAD I wasn't a nurse just because of all the "rules" ~ to me if a patient required something, they required something...the nurse has to cover her butt, the hospital's butt and the dr/surgeons butt all at once! the word lawsuit is just too easy of a thing that is spouted off about. I'm glad there are people like you that have a independent brain in their head, having the courage to actually question something that doesn't seem right. Blessings* Teresa

Julie said...

Hi, my name is Julie and I work on a post heart surg. floor. Nice to have run across your journal. Gee. I know some day nurses like that.