Source of Conflict

This week was another one-day week, due to the stresses of travel and my jealous guarding of my precarious status. The clinical focus this week was Conflict. Given how all of the previous clinical foci had a way of turning up in unexpected ways throughout the day, I was a little apprehensive about what kind of situations would turn up. I'm a conflict-avoider. That may surprise some people, but it's true. At least, according to some test they made me take when I worked at the group-home indicates as much. There was a time when I liked nothing better than to argue with people on the internet, through discussion forums and the like, but now just the thought of that sort of thing fills me with a sort of nameless dread.

The goal for this week was to have a smooth med-pass. That's it!

Client A was in for removal of the hardware in her left knee. There was concern of an infection, so a spacer was placed, and IV antibiotics were administered empirically. There was also a question about MRSA colonization of the nares, so this patient was on contact precautions. She had a long history of knee and abdominal surgeries, history was also notable for osteoarthritis, heart palpitations, depression and sleep apnea. She ambulated to the bathroom on her own, at which point I saw what's probably the worst example of incontinence dermatitis I've ever seen. Apparently, the foley catheter she had before I arrived was found to only be inserted a couple of inches when it was removed, and leakage had resulted in a large, red rash that was darkest in the perianal area but involved the back as well. I applied barrier cream, it took a LOT to cover all of the involved area. Neurovascular assessment took priority for this patient, particularly that of the left leg. My other chief concern for this client was skin integrity. That contact dermatitis, although blanchable throughout, had the potential to become one nasty sore. The client reported that she'd been spending all her time on her back, and that she couldn't rest comfortably on her side because of her knee pain. Fortunately, she was able to reposition herself pretty independently, so we worked together to find a good body position she could maintain restfully for an hour here and there. I could have -sworn- I saw an order in the chart for the use of an abductor pillow, and I mentioned this to the RN. She had one sent up from sterile service and we tried it out while she was in bed. She said it was comfortable at first, but then later elected to switch to a regular pillow between the legs. She had extensive pharmacotherapy, including a huge dose of seroquel, lexapro, lamictal, mirapex (for restless leg) and restoril (for sleeping). Her chart indicated that she is -not- med-naive by any means, but since the exact combination of medications is somewhat different for her in the hospital, I made follow up pain, neuro and respiratory assessments a high priority. A potential conflict with the RN arose over her assertions that this patient "Asks for her PRNs like clockwork", and suggested that I tell her that her pain meds were q3h instead of q2h. I thought this was an odd suggestion, and chalked it up to that RN's personal style. In my pain assessments I found that the client knew full well what her PRN schedule was, but at the end of the shift, the RN was suprised to discover that she had not requested every dose of her medication, which was the RN's goal for her. The client DID request her nighttime toredol IV-push, which was administered by the RN. I think the client and I worked well together to find strategies to minimize her discomfort, and that's why her PRN use was less than the RN expected.

Client X was a gastric bypass patient on post-operative day number one. She was behind on her clinical pathway, I think her history of multiple spinal fusions, status as a chronic pain patient and arthritis all contributed to a difficult recovery from surgery for her. My initial assessment found positive bowel sounds in all quadrants, a pleasant surprise for me since her last assessment by an RN was recorded as absent bowel sounds in all quadrants. She was on clear sips of liquid, 30ml an hour, which she recorded herself at the bedside. Our main priority with her was getting her up and walking. The anti-nausea medication she received made her sleepy, so she required some redirecting to get her out of bed for her second 3-laps of the unit for the shift. I made sure to walk with her to ensure stability, once she got herself moving she was stable and completed all of her expected ambulation easily. The care of this patient resulted in a conflict. At this facility, only staff RNs can collect blood sugar samples, and as the time to administer insulin came and went, the client's RN hadn't collected the sample yet. I made the mistake of telling her that the Insulin was overdue while she was eating, and she was extremely hostile to me afterwards. I apologized and spread my hands in acquiescence, and the rest of my interactions with her for the evening went on like the event hadn't occurred.

Finally, we have Client Z, another part of the previously mentioned RN's caseload. She was held in the emergency department for an "unknown" length of time, until enough time had passed and enough medications had been administered and enough treatments had been performed to "justify" admitting the patient to our unit. The RN explained that this was the "Game they play" with the insurance companies. After the fact, I was informed that the patient arrived -before- I went down to the meal. I don't have any memory of this now, but the sequence of events was somewhat jumbled in my mind. The RN conducted the assessment without me, I should have stuck around for longer until the client was situated and assessed to be stable. This client was PSTP from a laproscopic ventral hernia repair. What concerned me most about this patient was her sommnolence. After the RN pushed dilauded through the IV site, the client started nodding off in the middle of eating her juice-pop. I stayed with her a while to help her stay awake long enough to finish the pop (and not smear herself with the juice), and spent some time listening long and hard to her breathing. What concerned me most was the periods of apnea. I didn't see sleep apnea in her history, but she would have a good 12 resps per minute, but interrupted by 10-20 second periods of apnea that would end with her waking up, slightly startled. She was well oxygenated on 2L of O2 via nasal cannula, and exhibited brisk pupil responses and round, open, non-pinpoint pupils, so I was somewhat reassured by my assessments of her.

My plan to have a better pair of shifts next week is to ALWAYS CHECK THE NAME BAND FIRST before I do anything. Everyone I've talked to, be they nurses, paramedics or doctors, stress this as the most vital step in preventing medication errors. I also need to improve my communication with some of the RNs, the co-assigned RN for two of my patients in particular. Being a conflict avoider, I usually react to coldness or distance in-kind, I have to make sure I don't let someone else's stand-offishness control how -I- communicate.

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