2.27.2008

Back in the Saddle

Our clinical focus for our first week back in med/surg was "Leaders and Management". Some questions posed to us in our weekly topic related to the differences between leadership and management, the interdependence of leaders and followers, and the unsuitability of new graduates for management positions. Personally, my goal was to get through the day without any catastrophes!

I had a lot to ponder after the end of my last med/surg rotation in the winter. Some of my little quirky problems with spatial relationships combined with anxiety related to my personal life, resulting in mistakes that I shouldn't be making at this point in my development. My goals for getting back into the swing of things included getting as much input from the staff nurses about how to document correctly in this new environment, as well as familiarizing myself with the IV pumps. My history with IV pumps includes a number of amusing and not-so-amusing anecdotes, and after a semester of gravity and a semester of peristaltic pumps, I'm on a unit with volumetric pumps, which I haven't had to deal with during practicum yet. I made it a point to stop by the lab to practice with the unfamiliar pumps. The overarching goal for me lately has been improving my organizational skills. I'm warming up to the idea of pre-printing a sort of form/check-list to keep me on task. Although I balked at this at first, since we have all computerized charting, keeping some organized notes on paper seems more useful to me now than it did when all the charting was done in bedside notebooks.

Patient X was a gentleman brought in from a convalescent home for an infection related to diabetes. The peripheral vascular disease that accompanies diabetes had deprived one of his toes of nutrients to the point where it had to be amputated. Diagnostic imaging showed demineralization and other changes that were interpreted to be indicative of osteomyelitis, a bacterial infection of the bone. Bone infections are nasty, and are difficult to treat because chemotherapeutic agents don't diffuse through bone readily. The loss of a toe is a cheap price to pay to avoid sepsis! Especially if you're in your 90s. I quipped to the instructor that he didn't look a day over 80. Patient X also had a coronary artery bypass graft and mitral valve replacement about 13 years ago. He was also sporting a history of atrial fibrillation, hypertension, hyperchloresterolemia and non-insulin-dependant-diabetes. Hard of hearing and visually impaired. I got back into the habit of speaking loudly and slowly pretty quick!

The first thing I did when I met Patient X was a pain assessment. I know vital signs take priority, but I was just introducing myself and orienting the patient before collecting the equipment, and figured I might as well collect the info as I get it. Right off the bat, 8/10 pain at the amputation site. Resolved to 0/10 once I took the guy's sock off. Tadaa! I felt like I was off to a good start. My priorities in taking care of this guy included neurovascular assessments of the extremities, monitoring his pain and reactions to pain medication, promoting mobilization of pulmonary toilet (to prevent pneumonia and atelectasis) and making sure he's not sitting in the same position long enough for tissue breakdown to occur (especially important considering the age and diabetes-related changes to his vasculature). He would have gone home on that day, but while getting up to go to the bathroom he got dizzy, and his pulse dropped into the 40s. He became the lucky winner of an extra day in the hospital! Cardiac enzymes were drawn (CK and troponin) and an ECG were performed. These came up normal, so the thinking of the MD and PA on the scene was that Patient X was just sensitive to opiate analgesics. His constantly pinpoint pupils were another clue. I hit him with the penlight to make sure his pupils were reacting and accommodating. It was hard to tell, since they were so small, but I -did- see them move.

Pharmacotherapy for Patient X included two strong antibiotics, an interesting medication for fibromyalgia, seizures, and diabetic neuropathic pain (what Patient X was using it for). Although the mechanism of action is unknown, it's thought to act on calcium receptors in the peripheral nervous system. He was also getting lovenox. His PT and INR were high, but not in the therapeutic range. He has an aspirin allergy, so I was wondering if the lovenox was just DVT prophylaxis or if it was also regular anticoagulant therapy for him (because of the A-Fib, anticoagulants are often prescribed to prevent clots from forming in the atrium). This was something I should have asked around about, but I didn't get to it.

His children and granddaughter came in to visit during the evening, and I included them in reinforcing the incentive spirometry and the importance of adequate fluid intake. Chatting with the family between tasks served to give me some backround information on Patient X's baseline level of functioning and living situation. Socializing with the family also, I believe, made them feel welcome and gave them the impression that their elder was being cared for in an attentive, personalized way. I enjoy interacting with families. Most of the time.

I got to do some wound-care for Patient X, which I was excited about. Wound-care lends itself to some interesting and challenging procedures. I think I could have executed it better. I didn't have everything I needed at the bedside when it was time to change the dressing, something I've been instructed to work on numerous times. Getting through it with the instructor's help was good for my confidence, though, I just felt like I should have been able to change that dressing more independently. The important things I noted were the presence of granulation tissue and sensation in the wound-bed, both good signs that the amputation site was getting the perfusion it needed to heal.

When the surgeon removed the first dressing to observe the site, he pulled the dressing away rapidly. The tape tore the fragile skin on the bottom of his foot, so our replacement dressing used curlex wrapped up to the ankle to distribute the weight across a larger surface area. My co-assigned nurse, who was floating to our unit from oncology, replaced the dressing later with the taped kind he had originally due to a miscommunication. This gave me some things to ponder. I didn't want to disagree so bluntly with the RN who's been so friendly and accommodating with me so far, and taking the dressing off -again- to redo it wouldn't have made any sense, so I solicited advice from my instructor and other members of the team, and as a result I'm pretty sure the next dressing change he gets won't be taped to the bottom of his foot. This was an unexpected manifestation of our clinical focus for the week.

By the end of the day, Patient X was having difficulty urinating and producing stool, despite the colace and senna he had been getting. Out of curiosity I bladder-scanned him and saw that he had 255ml in his bladder. I wasn't sure exactly what to do with this info so I just reported it to the next shift so they could watch for changes and assess his urinary output.

The second day of the clinical experience, Patient X had gone back to the convalescent home. Over the course of the first day, his heart rate and blood pressure returned to baseline, although his pupils remained pinpoints the whole time I was caring for him. I wonder how they looked when he was discharged!

Patient Y was absent for much of that first day. All evening all I knew about him was that he had some kind of GI band procedure, and that he was still in the PACU. I'd find out more when the PACU called up to the unit with Report. His absence for most of the shift gave me extra time to monitor Patient X and help out the PCAs here or there on the unit.

Patient Y's case, when I thought about it, was actually a first for me in my short time practicing as a student. The band procedure was an ostomy closure. After three months of having a temporary colostomy appliance necessitated by diverticular disease, it was time to reconnect the GI tract and start using it again! Reflecting on this later, for all of the people that I've cared for with temporary and permanent ostomies, this was the first time I've cared for someone who had one reversed.

Patient Y wasn't out of the woods yet, however. Once you're up there in the 80's, in my limited experience, it seems as though surgically induced Ileus takes a while to resolve. I thought back to my first semester at the small private hospital in the northern part of the state, where one of my clients had a surgically induced ileus that lasted for two months. Two months on the med/surg unit, yikes. Patient Y needed to pass some flatus, and I was going to do whatever I could to make it happen. My first day with him was short, since he arrived on the surgical unit between 7 and 8pm. He was deliriously happy (maybe because his colon was attached to his anus once more!). He was also extremely disoriented. He thought it was 1987, and didn't know what hospital he was in. He did, however, know his name. He was fading in and out of consciousness, my priority assessments for him were respiration rate, breath sounds and NG tube. Because of his disorientation, he was a high fall risk as well as being at risk for pulling out his NG tube, IV access or JP drain. He was extremely lethargic but cooperative, and didn't try to get out of bed while I was around.

When I came back to check on Patient Y on day number two, however, I was told that he had been trying to pull his tubes and climb out of bed. Apparently when he saw his eldest daughter he figured it was time to leave and started to make a break for it. In other settings I've been in I've seen vest-restraints used for this kind of confusion caused by the confluence of age, narcotics and metabolic stress caused by surgery. The solution here was to put another layer of hospital gown on with tapered sleeves. In this configuration the patient was not as aware of the tubes in him in the first place. I wasn't sure if this was a good thing or not, but figured either way Patient Y should be oriented to the presence and purpose of the tubes sticking out of him.

I didn't have any of the problems other people described with Patient Y, this often seems to be the case when I take care of confused, elderly male patients that are described as "difficult", "moody" or "combative". His memory did not seem to be intact, but continuous reorientation to his surroundings and situation seemed helpful. I didn't make him feel bad when he couldn't figure out what day it was, I just reminded him what day it was ::shrug::.

I was determined to help Patient Y pass flatus, since that seemed to be what was holding him up in his clinical pathway. I didn't know what else to do for him but ambulate him as he could tolerate. His staff RN administered some carafate GI protectant syrup, since he had a strange reaction to the usual post-operative pepcid dose (it affected his level of consciousness, I've never heard of that kind of reaction). The syrup was instilled through the NG tube, which was then clamped before our ambulation adventure. Did I mention this guy used to play football? He got a craniotomy and everything (part of his skull was removed). He walked vigorously, I had to keep reminding him to slow down, and watch his habit of listing slightly to the left as we walked.

I picked a poor time to change the vacuum collection device attached to the NG tube, I didn't realize that the black marker line with "3p" written on it meant that someone had already recorded that amount of drainage at 3PM. Doh! I got some guidance from the staff nurse assigned to Patient Y at the end of the shift. I feel like that was obvious enough for me to pick up on, chalk it up to orienting to a new unit maybe. On my first day with Patient Y his JP drain put out 75mls of sanguinous drainage, the second day there was only about 8 or so while I was with him.

Patient Y was on PCA Morphine, but this was discontinued on the second day, because he was "using the PCA like the call button". Despite frequent reorientation to the PCA pump and the television remote, Patient Y was unable to effectively use either, so maybe he wasn't in the right mental state to self-administer analgesia (or use the call bell or operate the TV for that matter). I took note of this and made sure I kept an eye on him.

Looking over Patient Y's labs, I noticed a massive left-shift, and a pattern of CBC results I've come to associate with recovery from surgery (decreased H&H, RBC, Left-shift in the WBC, I'm told this combination of values represents reticuloendothelial blockade, a normal response to injury and infection). I monitored his temperature closely since he was also scheduled to receive a flu vaccine. His temp ran low throughout my time with him, I remember reading somewhere that low core temperatures are positively correlated with longevity. Another thing that jumped out at me was the Glomerular Filtration Rate in the 40's...ouch..renal impairment anyone? I didn't see anything in the history about renal disease or dysfunction, so I just made sure he was putting that 30ml/hr into his foley.

On the second day I had two additional playmates, Patient W and Patient Z. Patient W, who was by the window, came to the hospital for a colonoscopy. During the colonoscopy, a non-functional part of her bowl was perforated. She has a permanent colostomy that she cared for independently. She was due to be discharged "any time now", of course "any time" ended up meaning "four hours after she was told she was ready to leave". She was frustrated by this and attempted to wave off my initial assessments of her. I assured her that the brief assessment I was going to do was necessary to ensure her safety. I think the peach cobbler they brought up for her after dinner improved her mood dramatically. She slept most of my time with her, probably out of frustration. While she was awake I made sure she was comfortable, her biggest issue according to her was mustering the patience to wait quietly for the ambulance to take her back to her skilled nursing facility. Despite her admonitions, I made sure I checked for peritonitis with some light abdominal palpation, gave her the neuromuscular twice-over and checked for Homan's sign.

Patient Z was in the same room by the door, and she was a riot. She had been in the hospital for about three days, and had a polyp removed from her left arm as well as a left-sided colectomy. She had progressed to a clear liquid diet by the time I saw her, and was sporting 5 fashionable laporotomy sites, the left-most of which was much larger than the others. She was also in her 80s, and had comorbidities that included hypertension, supra-ventricular tachycardia, osteoporosis, arthritis and a left-sided mastectomy. When I came in for my initial assessment, the first thing I noticed was a sign hanging over her bed that said "NO BP ON LEFT ARM", because of the mastectomy. She said the "other girls" had been taking the BPs on the left side because they haven't been getting readings on the right. I told her I would try the right anyway, and got an extremely low reading. This was important because she was due to get blood pressure medication a few hours from now. I mis-prioritized getting a more accurate BP with the manual sphygmomanometer, but got a more accurate reading well in advance of the coreg and lopressor administration. In the future I'll make that a higher priority. I also made the mistake of stopping the IV infusion running in to that side, this caused a cartrige self-test error when I started the volumetric pump back up. Back in the nursing lab today, one of the lab tutors told me stopping the pump wasn't necessary, and the self-test failure was caused by the cuff squeezing a bubble back up into the cartridge. I wasn't around to see the staff RN correct this problem, but after going back to the mock-up in the lab I think I'll know what to do next time around.

Patient Z also hadn't passed any flatus since the operation, so we went on a stroll through the unit together as well. We took it slow, in case orthostatic hypotension reared it's ugly head. When she started moving with the walker, I was struck by how short she was. I didn't notice while she was lying in bed, but between the progressive bone demineralization and being "a little on the short and stumpy side" in her words, her head didn't even come up to my axilla. She visited another patient down the hall that lives in the same retirement community as her. She seemed to derive some of her self worth by encouraging her friend to keep a positive attitude, and to try to get out of bed like she was. Her friend had just received a permanent colostomy, and it was psychologically difficult to her, especially since she perceived that she would not be able to return to her retirement community as a result. She wasn't part of my assignment, so I didn't get to find out much more about this person.

All in all, it was a great two days back in med/surg. I think I provided great bedside care by focusing on the core interventions for elderly post-operative patients for integumentary integrity, pulmonary toilet, early ambulation and wound surveillance. I got right back into the flow of introducing myself to, joking around with, reorienting and assessing the surgical patient, interacting with the patients is, like many people I'm sure, my favorite part of the job, and its a point of pride for me to keep them laughing, even if it means they have to splint their abdominal incision. Laughing is good for the lungs! I'm sure there's some kind of positive psychoneuroimmune/neuroendocrine influence there as well.

These two days also reminded me that I have some serious obstacles to overcome in providing competent care, especially my organization and documentation skills. I feel like this will come through practice and attention, neuromuscular conditioning like riding a bike or waiting tables. Not giving medications this first week threw me off at first mentally, but looking back on the shifts, not having to worry about medication administration paved the way to a smooth orientation to an unfamiliar environment. I just have to remind myself, when I feel like I don't have "enough to do", I need to concentrate less on what I -can't- do and more on what I -can-.

I like this place. I like how it's designed, I like the people I've worked with so far, I like the computerized charting, and I like my cohort. I appreciate good industrial psychology in building design, it's a welcome change from the linear hallways and institutional angles of the busy urban hospital from the past two semesters. I learned a lot there, but it's nice to have a basis for comparison. The computerized charting is fun and extremely handy, but not as simple as I had initially assumed it would be. The system isn't used in a vacuum, like in the training, but instead has to stand up to chaotic and changing conditions. The ability to dynamically add, remove and rearrange elements helps, but the big confounding variable is the expectations and standards of the rest of the people utilizing the charting system that make mastering it's use a non-trivial task.

I can't wait to go back. I'd do this every day, if I could. For a while, anyway.

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