4.24.2008

Home Stretch

This week our clinical focus was Law and Ethics. Of particular interest was identifying situations that raise ethical issues, as well as resources that support nurses in executing their duties ethically.

My goal lately has been to continue to improve my care planning (at the bedside, rather than on paper). In collecting all of my information for the day, I'm not as prepared as I could be to describe what my plan of care is while giving report to the instructor. What I plan to do to improve this in these last few shifts of student nurse practice is to set aside some time at the beginning of the shift to come up with one or two nursing diagnoses for each patient. This will also better prepare me to answer questions about my patient's pathophysiologies, a couple of questions about these patients came up that I wasn't able to answer as well as I might have if I were answering test questions or just having a simple conversation with someone, so I think this provides a couple of good hints as to how I can better prepare during the beginning of my shift.

Patient X is a middle-aged woman who was admitted for rectal bleeding. She had a band-lap a year ago and a colectomy one week ago (also for GI-bleed). I found her busily making her bed and arranging her room when I walked in to introduce myself after report. She was being held for just one more day to ensure the rectal bleeding had subsided. She walked around the unit and puffed on her incentive spirometer without being prompted. She expressed some frustration at having to wait for someone to remove the sequential compression devices wrapped around her calves. Easy fix! I demonstrated how the device worked, and she demonstrated to me that she could apply and remove the SCDs. Problem solved! I stopped in to check on her after dinnertime, and found her SCDs detached and at the bedside. When I reminded her that she has to wear them whenever she's in bed, she said she was about to get back up anyway. Towards the end of the day, her call-bell went off, and I found her resting peacefully in bed with the SCDs in place. "There ya go. Aren't ya proud of me?" she quipped. We chatted for a bit about how her diet had changed since undergoing the lap-band procedure, she felt slightly guilty about having a tray of food out (since it took her about an hour to finish her meal), since her neighbor was wheeled in unable to consume solid foods. Her neighbor is Patient Y.

Patient Y was status-post "abdominoplasty and ventral hernia repair", due to "crease dermatitis". Her history included hypertension, shortness-of-breath on exertion, hypothyroidism, DVT and heart palpitations. RN1 called me over to take phone report on Patient Y, and I took down a complete set of notes from the RN in the post-anesthesia recovery unit, which was probably one of the most complete and concise reports on a patient I'd ever heard. Patient Y had three JP-drains, a flank-to-flank abdominal dressing, and some pretty severe abdominal pain. Even now, I'm not sure if she ever did, in fact, have a ventral hernia OR crease dermatitis, since it was explained to me that these indications were fabricated to benefit the surgeon's paycheck somehow, and that all that was really done was an abdominoplasty to remove excess skin from a gastric bypass surgery two years ago. A fellow student overheard me going over my plan with RN1 and said something like "Oh, another one of Dr. X's 'hernia repairs', eh?". In retrospect it would have been interesting to get one of the RNs to get me into the results viewer so I could read the dictated report of the surgery. I got the opportunity to conduct the admission assessment on Patient Y, and got some input from RN1 how to streamline the process and get it done efficiently. In retrospect I think I should have had the patient's chart with me at the bedside (on the COW) while I was going over the health history.

Patient Y's biggest challenges over the two days I was with her were pain control and ambulation. She was way behind the ambulation she needed to complete to progress through her clinical pathway, and I only succeeded in getting her out of bed once, after which she walked about 20-30 feet. She walked stooped-over, saying that standing straight worsened her incisional pain. I premedicated her with oral dilaudid AND had the RN push IV dilaudid in an attempt to control her pain well enough to get her to cough and walk. Her lung sounds were pretty rough and juicy both days, but particularly after surgery. After some incentive spirometry they cleared up somewhat, but she still hadn't gotten rid of all of that inspiratory wheeze and ronchi. She required a lot of assistance to ambulate (fortunately I could do it myself), and I kept reminding her not to look down. As her posture stooped more and more, rather than -telling- her to lift her head up, I -asked- her if she was dizzy. This effectively prompted her to look straight ahead, although with her stooped posture this meant extending the neck somewhat. Abdominal splinting didn't seem to help much.

On my second day with Patient Y, she received reiki from a volunteer at the hospital, which was interrupted somewhat by the other occupant of the room, who was somewhat hard of hearing and didn't understand what was going on. I think if I were there during that previous shift, I would have tried to temporarily relocate the other occupant of the room. There were plenty of empty rooms, since the census was low, and if that wasn't appropriate she could always lounge in a recliner near the nurses' station for however long a reiki session is. In any event, when I came on shift I noticed Patient Y hadn't received her ordered muscle-relaxant, so RN1 and myself split up to track down the RN from the previous shift and ask her about it (along with an uncharted dose of heparin for patient Z, which I'll get to in a minute). Before finding her I found the med at the bedside, still sealed in it's envelope. Apparently the previous shift's RN left it there because reiki was being performed at the time she had intended to administer it. I think I would have put it in my pocket (or some kind of utility belt if I ever get one).

Patient Z is in his early 80s and was admitted for a UTI and kidney infection. It wasn't clear to me if the UTI came first or the kidney infection, but either way, assessing for changes in flank pain, ureter pain and urinary output were key priorities. I feel like I should have came up with this on my own without being lead so much to those conclusions, all I would have needed to do was take a moment after collecting all my data to reflect on the pathophysiology. The weak start I got off to this semester made it difficult to take in the "big picture", but I think this is improving (albeit late).

I got an opportunity to sit in on Patient Z''s doctor coming in to explain his clinical course to the patient and his family. He explained that the plan is to attempt to resolve the infection with antibiotics and fluid support, and if that fails, to surgically place a nephrostomy which would later be converted to an internal shunt to the bladder. This was not the preferred option due to the patient's age and history, which included unilateral renal failure and rectal cancer. He was on NPO at the time, but the doctor indicated while he was in the room that he could eat a regular diet as tolerated until midnight the next day. This was good news, since the normal saline infusion wasn't giving him any of the nutrition he would need to fight off the infection. The diet order wasn't entered into the chart, however, so I caught up with RN2, who took a phone order from Patient Z's doctor. At this point, all I could offer him was one of the boxed lunches kept around for late admissions, but the cold-cut sandwitch and banana were better than nothing!

What concerned me the most about Patient Z was his insufficient urinary output. He was found to have a low glomerular filtration rate, but I took the opportunity to palpate and ultra-sound the bladder anyway to confirm that he was not, in fact, producing any urine. He only produced 100ccs during the 8 hour shift, and the bladder scanner came up triple-zeroes (I tried several times). He consumed a couple cans of ginger ale, but still nothing. Figuring all that fluid was going -somewhere- I kept an eye on his breath sounds (for fine crackles) and blood pressure, but didn't detect those or any other signs of fluid overload (no edema, dyspnea, etc). His history included depression, and although he seemed in high spirits when the doctor and his family were around, this quickly changed after visiting hours. Thinking back to some of my NCLEX prep questions, I figured the best thing to do would be to allow for time to hang out in the room for short periods of time, being clear on how long I had and when I'd be back (when I could, I wasn't always successful at this, something else for me to work on). Patient Z was rockin' the highest white blood cell count I had ever seen..about 41x10^3!! At least his immune response wasn't diminished by age...or was it? The differential WBC looked like what I usually see in inflammatory processes, I wasn't quite sure what to make of this high number, I did notice that it had practically tripled in the past day or so. Another thing I intend to remind myself to do (so other people don't have to remind me) more often is put the laboratory data in context by examining trends instead of just values.

Patient W was one of the more difficult and rewarding assignments I've had this semester. Her admitting complaint was altered mental status, and on examination was found to have a UTI, renal insufficiency and dehydration. Her history had a term I hadn't encountered before, "undersocialized conduct disorder". Sounds pretty self-explanitory. She also had a history of ETOH dependency, ETOH psychosis, severe aggressive behavior and encephalopathy. The encephalopathy had me scouring the chart, since it didn't specify "hepatic encephalopathy", which I would expect with an ETOH history, and there were no hepatic issues in the chart that I could find (I was expecting at least cirrhosis, if not failure). She's in her mid-80s, and in conversation with her husband I learned she was able to work before the mental status change that brought her to the hospital (her work consisted of sweeping and cooking, from what I could tell).

She was severely incapacitated when I met her. She had a vest restraint on, because she kept trying to get out of bed. My first impulse in situations like this is to try to improve the level of consciousness to the point where the restraints could be removed, but this was infeasible in this case, at least during my time with her. She had an extremely limited ability to communicate, the previous shift said she was completely non-verbal. Her speech was heavily slurred and confused, but I was able to piece together word here and there. Throughout the day her ability to express herself improved, she turned to me at one point and forlornly said "I'm not a party girl anymore". On the first day she was incontinent of black-green, liquid stool that oozed more or less constantly through the day. PCT1 and I had a great working relationship, and we got her cleaned up several times throughout the day. Good thing, too, given her condition the last thing she needed was a foley covered in stool. The whole situation was tickling my "efficiency" itch in my brain, I found it somewhat frustrating that there was no better way to manage her incontinence than to let her soil herself and then clean it up after the fact. Since the catheter was somewhat movable, I was worried about the possibility of even more microbes colonizing that short female urethra. I've heard there are specialized "continence care nurses", maybe one of them can give me some ideas. Maybe some kind of "cuff" near the proximal end of the catheter? A rectal tube, a device with a foam end that molds to the rectum, seems to be something reserved for the critically ill in The Unit, and I'm guessing would have been inappropriate for this patient due to the potentially short length of time that she would be incontinent (this ended up being true, as I got her to the commode the next day). A rectal pouch wouldn't have worked either, due to the level of consciousness and relative immobility of the patient. My secondary concern besides the foley catheter was a scabbed-over wound that was open-to-air over her coccyx. The erythema around the wound was reassuringly blanchable, but still, there was a wound with a movable scab on it that was covered with stool periodically. We gently cleansed the area and put barrier cream on it, I learned that placing an occlusive dressing wouldn't have been a good idea because it would rip the scab off later, and telfa+tape would have just slid off and gotten saturated. Thinking back, maybe I could have sealed the edges of the telfa with a tegaderm, but the same shear effect probably would have rolled the edges up anyway, like I saw with an abrasion over the spine with a previous patient.

On the second day, her alertness seemed to have been improved, and I was able to decipher more of her speech. I repeated much of what she said, so she could answer "yes" or "no", to confirm what she was saying, I noticed at times she contradicted herself, and sometimes I misunderstood what she said. She got a long overdue visit from a speech therapist for a swallowing evaluation today, after which she was placed on aspiration precautions. Attempts to feed her a ground diet the night before were unsuccessful, she spit that and the protein shake out during feeding. After the swallowing eval she was also ordered to be spoon-fed one-to-one.

Her nutrition was involved in one of a few small conflicts with PCT2 on that second day. At the beginning of the day, during my head-to-toe assessment, she expressed a need to use the toilet. Once I had confirmed she needed to produce stool, I got her out of bed and on the commode. I still had a lot I needed to do to prepare my care, so I hit the call-bell and asked the PCT to stay with her (or find someone to stay with her) while I carried out the rest of my assessments and prepared to administer medications. She rolled her eyes at me, I apologized, and left to continue my assessments. After the last of my three assessments (of patient Z, to give you an idea of how I prioritized them..the post-op day 1 was prioritized higher), the PCT came up to me and said "you're doing everyone's vitals, right?". I apologized again and explained that I had to prepare medications and wouldn't have time. She seemed surprised. The third and final issue came when Patient W's ground diet arrived from the nutrition cart. As I passed the room, PCT2 walked out and said "hey, maybe you can try feeding her". I walked in and woke patient W up by placing a hand on her shoulder and repeating her name. She awoke, and I got about half of the entree into her without any coughing or pocketing. When PCT2 came back, she said "oh, so she wakes up for -you-". I handed the spoon back to her and told her where I would be, preparing to hang an IV bag. When I walked by a few minutes later, the dinner tray was gone. "No more food?" I asked PCT2 in passing. "Nah, she's done", she said. I didn't review what she charted of her nutritional intake, but I think Patient W could have benefited from more attention in feeding her, and I don't feel like I had time to manage it myself. I considered raising a concern about this to RN2 (who was my co-assigned nurse for patients X, Y and W), but decided my priority should be to focus on the continued demands of patient W's care, figuring I could try to get her protein shake into her later (I couldn't).

RN2 was proactive about helping me "do everything" that our patients required, but with two, slightly troubling exceptions. While I was performing Patient Y's admission assessment, she hung a bag of IV antibiotics for me, telling me that when one RN is stuck with an admission assessment, another helps them out by hanging the IV med. I explained to her that this might get me into some hot water with my instructor, and she verbalized understanding. Later, while I was ambulating patient Y, a newly ordered unit of whole blood arrived on the unit, destined for Patient W's circulatory system. While I was ambulating the patient, RN2 ran in another bag of IV antibiotics and initiated the blood infusion. This made me panic for a moment, because I felt like this was something I should have been doing (I've only assisted in a blood infusion once in the ED at the inner-city hospital I served at last semester). When I saw the difference it made in patient W's condition, however, I could understand why RN2 felt it was more important to get it done immediately than wait for me to be free to initiate the infusion. As the blood infused into her, patient W's level of consciousness improved dramatically. It improved so much, she hit me with a couple of gems like "when are you taking me home, you stupid guy?!" and "if you don't let me out, I'll sue you. My husband will sue." I spent a lot of time comforting her while she cried, the episodes would usually start with a long vocal tone that was probably meant on some level of the brain to be a string of words, and then ended in sobs. Reviewing her labs, I saw that her BUN to Creatinine ratio was such that she was not legally competent to make decisions regarding her care (a previous instructor introduced me to this concept, I think it's anything higher than 1:40). The high BUN (well in excess of 80) was an expected finding considering she was dehydrated. The half-normal saline and free water intake probably resulted in some dilutional anemia, her MD believed she had chronic anemia as well. I kept reminding her that it was too late to go anywhere tonight, and that when she woke up in the morning, she would see her husband, who had been spending pretty much all of the available visiting hours with her (something she had no memory of).

A couple of mistakes I made with Patient W was heme testing the stool on day one, when there was no order, and then not testing it on day two, when there was. I scanned through the chart at the beginning of the shift, I need to schedule regular intervals to re-review the orders in search of changes, since the computerized charting system isn't updated reliably. Another near-disaster involved that name-band again..I had prepared her crushed PO medications ahead of time, determined that she had a preference for peach-sauce instead of apple-sauce, and knelt by her recliner (parked just outside the nursing station) to reorient and comfort her while I was waiting for the opportunity to administer the meds. After a few minutes of telling her "your name is patient W, you're in Hospital-A, you'll see your husband tomorrow", I still needed a gentle reminder to finger the ID bracelet (which was clearly visible from where I was sitting). This time, unlike previous med-admin encounters, she was able to repeat her name and birthday with prompting, a definite sign of improvement. I think my strategy of anchoring the idea of "check the ID band as soon as you enter the room" needs to be modified to handle med-admin "outside the room". I managed to postpone the worry and pensiveness over that occurrence until I got in my car at the end of the shift. What I think I learned from that sequence of events is that pretending the instructor "isn't there" and trying to just "act natural" is a denial of the facts and reality of the situation. I'm there to do a job, but also to demonstrate for someone else that I can do the job correctly. I should conceptualize what I'm doing as having an audience of two people instead of one.

I left, as usual, with mixed feelings about my week. I ended on a good note with PCT2, although we didn't discuss directly the sublimated conflicts we had been having, we spent some time engaging in mutually supportive conversation in the break-room, so I was glad we parted company in that fashion, and I think this will make it easier for us to communicate better in the future. I won some mild praise from RNs 1 and 2, and got some feedback on how to better convey confidence (by suggesting things for me to NOT do rather than to do) and maintain client confidentiality while talking in the nurse's station. It seems like I don't catch on to the fact that some of the things people clue me into are things I shouldn't discuss openly, like the questionable nature of patient Y's "crease dermatitis and ventral hernia repair" and the lack of an infusion pump in that same patient's room. I half-jokingly refer to this as "tourist syndrome", since some of my slowness in picking up the cultural landscape of my surroundings reminds me somewhat of a tourist. I make light of it but also recognize it as an important deficit to monitor, since so much of this job seems to rely on linguistic and cultural savvy (for staff as well as patient interactions).

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