3.12.2008

All Thumbs



This week our focus was Delegation, we discussed our experiences so far in delegating tasks to the PCTs on the unit, what's been working, what can use some improvement, and how to deal with problems as they arise. Just like last week, issues surrounding our clinical focus popped up throughout the day. I think I jinxed myself during our pre-clinical conference, by reflecting on the fact that I've had the same PCT assigned to my rooms during the last two weeks, and how we had a great working relationship.

Wouldn't you know it, I worked with a new PCT today, and problems arose I could have sidestepped by communicating with her better. I have to endeavor to come prepared for -positive- manifestations of our clinical foci, instead of looking back at the end of the week and saying "oh yeah, that's what went wrong!"

My main goal was still to get my meds in efficiently and on-time. Until I get this sorted out it doesn't seem reasonable or desirable to set additional goals (well, aside from making better use of the clinical foci).

Patient X is an elderly Italian woman who lives in an assisted living community. She was status-post open cholecystectomy. She had a T-Tube, which was placed in the bile duct. This allows for bile drainage as well as a means of introducing dye for diagnostic imaging. The T-Tube was clamped, and the JP drain was filling up with bile rather than the sero-sanguinous drainage I'm accustomed to seeing. I asked around about this, since I thought it was odd, all I could find out was that one doctor thought it was a Bad Thing and ordered the T-Tube unclamped, then the Surgeon informed the RNs that it was a Good Thing and ordered it clamped again. I asked if this meant that the bile duct was leaking into the wound (since that's where the JP drain is applying suction), but all I got were shrugs in response. She was extremely anxious, she attributed this to the death of her husband of 60 years. I saw many members of the team stop in to provide reassurance, hugs&kisses and orientation frequently. Since one of my patients was discontinued early in the shift, I spent a lot of time in this room doing the same. The RN told me it was a big help. Controlling her back pain was extremely challenging. Due to a near-fatal reaction to an analgesic administered elsewhere in the hospital, her pain coverage consisted of Tylanol and nothing else. She had some irritated skin on her spine, and after seeing how much pain removing the adhesive dressings caused her, I replaced them with non-stick telfa pads and tegaderms. That and application of warmth seemed to help. The RN described her as "the princess and the pea", but I still felt it important to take her reports of pain seriously. Near the end of the shift, she cried out in distress, and I found her making uncoordinated movements in bed, with the bedclothes strewn about. When I asked her what was wrong, she said that something was "very wrong with" her, she seemed to have the whole "impending doom" thing going on. History includes A-fib, palpitations and pulmonary fibrosis (and she was only drawing 100cc on the incentive spirometer), so my immediate concern was respiratory failure or cardiac abnormality. After a rapid assessment, I sat with her and held her hand until she went back to sleep. The reassuring findings were absence of cyanosis, baseline vital signs, good breath sounds and regular heart sounds that matched my last assessment of her. I really feel like I did a good job with this, stuck to my ABCs and was ready to get help if I noticed respiratory distress or abnormal assessment findings. Later I was told "impending doom" is an every night thing for her, and that she panics when prematurely roused. I would have done exactly the same thing every night, then. I think it might also have something to do with her nighttime Xanex (which was not administered by me), a combination of taking it before bed and being roused right while it should have been kicking in might have resulted in some confusion and dysphoria. She was discharged on the second day.

Patient Y was her neighbor, brought in for back pain and 3/6 pneumonia. This was my first "floridly" kyphotic patient, and controlling her back pain was also a challenge. She was also extremely depressed and withdrawn, and kept stating that my assessments were not necessary. I joked about it and got her to crack a smile a couple of times. Ambulating her was extremely difficult, watching the PCT helping her was instructive. What I learned about this was that it was necessary to actually provide forward momentum by gripping the clothing and pushing from behind, and then allowing the shuffling steps to catch up. Even after a solid span of time on an Ortho unit, I hadn't seen this technique. She stayed both days of my shifts, she should have left earlier, we felt, but she was waiting for an MRI and the machine was down. Like one of my patients last week, she was perturbed by the presence of multiple family members of her neighbor in the room. I reduced sensory stimulation by drawing the curtain, although she never expressed a preference for nearly everything I offered, except the warm compresses (which she liked). I asked her if the commode or the bedpan was easier on her (since I remember reading that the bedpan is generally harder on the patient), but she said it was about the same either way. On the second day with her, I walked in to find the day PCT assisting her to the commode. The PCT explained that she was a high fall risk and asked if I could stay with her until the patient was finished eliminating (it was past the end of her shift and I'm sure she was anxious to get moving). I explained that I still had to get report on two more patients and prepare to administer medications, and that I'd return soon. I made sure to let her know this in a friendly, non-confrontational manner.

Patient Z was in the process of being discharged when I arrived. He had a peritoneal abscess in his scrotum, and was also experiencing dementia and depression. He was just waiting for his ride when I met him. His RN was late getting to the unit due to the parking problems, so I focused my attention on Patients X and Y until I got report. When I did finally touch base with her I got the necessary info and carried out my assessments. I think she was perturbed that I hadn't found her sooner, but I didn't want to compromise the care of the two patients I did get report on, and Patient Z was still being cared for by the Day RN in the evening RN's absence.

Patient W was in for a Lap Choly, her big issue was nausea and dyspepsia. She didn't consume much nutrition, not because it was aggravating her stomach, but rather because the taste of the foods was too stimulating for her. She walked frequently and was mobilizing pulmonary secretions encouragingly. I noticed her breath sounds were diminished on the left but not the right, which makes sense since her JP drain and most of her abdominal pain were on the right side, and so she's been sleeping on the left.

Patient V had an open choly and a colostomy closure. She had a left-upper-lobectomy, so that was another interesting respiratory assessment for me. There was some confusion between me and her RN over whether or not we had to do a wet-to-dry dressing change, she had originally thought the dressing changes were ordered every shift, but when we examined the orders we saw that it was every day, and her dressing had been changed already in the ICU. There might have been a good argument for changing it again anyway, given the nature of the microbial profile of most ICUs but the RN and I decided to stick with the schedule in the orders. She had a caregiver with her, a nursing student, and she wanted to jump in for much of her care. I redirected her when she wanted to empty and record urinary output, but included her in appropriate aspects of Patient V's care, like helping her get changed and assisting with nutrition.

I'm still not meeting my goals. On the first day, I felt like I did really well, and got a lot of positive feedback from the RN. I passed a classmate in the hall and asked her why she was looking so down. She said she made a small mistake early on, and it snowballed into bigger mistakes due to anxiety and second-guessing. I had the same experience the next day, where it was my turn for meds. I started off early on gathering all of the things I would need for the day, and filled my pockets with NaCl flushes after noting the scheduled IV access flushes. When it came time to use them, I found that the plungers had all been depressed, and my leg was wet with saline. As funny as this seems to me after the fact, it threw me off for the rest of the day, even though it didn't directly impact anything else I did. Another thing I did poorly was, in adjusting to delegating vital signs to the PCTs, I didn't get the nessisary assessment data I needed for administering blood-pressure medications. To my credit, I realized this before attempting to make a serious medication error, but it added to the train wreck that was my second pass/pour at this facility. A combination of these things raised my anxiety to the point where I felt clumsy and stupid for most of the day.

Another factor continues to be my nutrition. I met with my cohabitants and worked out some solutions for arriving well-fed, and bringing food with me so I'm not dependent on the cafeteria or whatever stray carbs I can scavenge from the break room. My plan to deal with mistakes without allowing them to snowball into bigger ones is to cut down on the caffine. I drink coffee compulsively when I'm on the unit, and it's making me anxious and clumsy. I'm bringing tea next time. I do feel like I'm making progress with how I approach my organization for the day, and I think the Third time will be the charm. I'm going to make it a priority to track down the PCT and organize myself with them the same way I do with the staff RNs. I have changes to make to my organization sheet now, as well. My strategy so far has been to try a sheet that works for someone else, and then modify it based on my experience of using it for next week. I think I'm honing in on something that meshes with my thought process and penmanship.

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