4.17.2008

three weeks to go...

This week's clinical focus was Management of Patient Care. This was timed nicely to coincide with my personal goals for this pair of shifts. I had a lot of good support and advice towards that goal this week, and some interesting semi-conflicts that tested my willingness to take control of the assignment, even if it means disagreeing with someone I'm working with.

Patient X (a man in his late 70s) was in for left-sided pneumothorax (his third!). The history was notable for chronic obstructive pulmonary disease with moderate activity limitations, asbestos exposure, hypertension and hypercholesterolemia. He was dependent on continuous 4-liters of oxygen via nasal cannulae. This was my first patient with a chest tube, something I had spent a lot of time studying for our critical care content last semester. This was also the first time I had palpated and auscultated crepitus. One of the major assessment points that I got from this hands-on experience is that firm palpation may be required to detect crepitus. His clinical course had been delayed somewhat due to air leaks in his chest-tube setup. The suction had been lessened from 20ccH20 to 10ccH20, ostensibly to allow the pneumothorax to resolve without further leaking.

His skin was extremely fragile, and he had a skin tear on one leg covered by Telfa, and a stage-one pressure ulcer on the thigh that was covered by an occlusive dressing. I've been focusing on my wound documentation lately, so changing the Telfa pad with RN-A gave me opportunities to fill out some fields in the computerized charting I don't always encounter. The occlusive dressing over the pressure sore was left in place, to spare his paper-like skin the repeated trauma of removing the adhesives.

My goal with him was to get him out of bed. He stated he had been laid up in bed for some time, and was skeptical that he could get very far. I encouraged him by saying just a few feet would be beneficial, and I set about gathering everything I needed to get him up and around. Now that I've been on this unit for a while, I'm finally starting to get the sense of where everything is, so I gathered up a walker and a portable O2 canister.

This is the setup for a lesson about O2 canisters I'll never forget. I found the only O2 canister in the storage room, opened the valve, and saw 4L of O2 come hissing out. Perfect, I thought. I dropped it in a hand-truck and brought it back to the room. We hooked up his chest-tube and foley collection device to the walker, and I stood next to him with the O2, still putting out the 4L. About ten steps down the hall, something starts to go wrong. His steps falter, he intensified his pursed-lip breathing (a technique that helps COPDers expel CO2), and he asked for a chair. I called out to one of my classmates, who hurried over with one. Fortunately, this attracted some attention, and the instructor came over and took charge of the situation, directing us to get a chair with wheels and get him back to his room ASAP. Due to what I believe was air hunger, he became irritable, demanding that we get more O2 instead of bringing him back to his room. It was explained to him that going back to the room was the quickest way to get him to the oxygen, but this wasn't very reassuring to him. We got him back on O2 in a matter of seconds, and I pensively watched the O2 sats go from in the 70s to the high 80s (his baseline). This could have been averted if I had noticed the -other- indicator attached to the tank, which shows the amount of O2 left in the tank. A hard lesson, thankfully no one got hurt. In trying to be more independent, I had made the mistake of thinking I could carry out a task I had no experience with, because it “looked simple enough”.

Down the hall was Patient Y, a pleasant elderly Austrian woman with the Flu (A-type). For some reason, I was tickled at the fact that she referred to Xanax by it's generic name, Alprazolam. It sounds nice in an Austrian accent. She had a history of congestive heart failure, atrial fibrilation, diabetes and arthritis. Oh, and she's another COPDer. Pulmonary assessments, obviously, were prioritized very highly, not only because of the flu, but the possibility of pulmonary edema secondary to her heart failure. I kept an eye on her jugular vein (for distention), pushed PO fluid intake, and praised her for ambulating with her husband and puffing on her incentive spirometer regularly.

During my initial assessment of her, her family was present (around 2 generations, from the looks of it), and I enjoyed answering their questions about what I was doing and why, it was a great way to think critically about my own assessment by having other people ask questions about it. This was my only patient with RN-B for this week, who was great about letting me “run the show”, while also offering advice and encouragement.

Next up is Patient Z, a woman in her late 80s with Hematuria of unknown etiology. History of rheumatoid arthritis, Skin cancer, Breast cancer (left-sided mastectomy) and diabetes. When I arrived on the unit, she was away for a cystoscopy, I was able to coordinate well with RN-A to make sure we were both close at hand when she arrived. This one had me mentally chewing on my nails, and questions posed to me by the instructor about this patient demonstrated to me that I had been too focused on the actual medical diagnoses in how I approach planning patient care. My primary concern with her (which I had to cajole RN-A into giving me a hint about) was that a blood clot might obstruct her bladder or ureters. I smacked my forehead, because I could have figured that out if I had just thought it through. Obviously I'm going to be watching her foley drainage closely, since she's putting out relatively small amounts of opaque red urine. I didn't put that together when asked, I think, because I was too hung up on the “unknowns”, which weren't really relevant to my plan of care anyway. The problem was that there was blood coming out of her foley. The “solution”, as far as I was concerned, was to carefully monitor the drainage for clots and volume of output. Blood pressure and level of consciousness were important assessments to me as well, because of the bleeding. One of her daughters is a clinical educator in oncology at our facility, I valued her input concerning what her expectations for her mother's care were (which were, you know, the things I'm supposed to be doing anyway, but I think giving her the opportunity to relate her expectations to me was helpful to both of us, as far as peace-of-mind is concerned).

New arrivals on day-two included Patients W and V. Another new addition was the opportunity to work with RN-C, an agency nurse who posed a particular set of challenges and rewards as far as my goal of becoming a manager of care are concerned. When we started off she...kind of treated me like I didn't know anything. This only bothered me momentarily, because rounding with her was very rewarding. She gave me some pro-tips from her experience as a Neuro nurse about how to conduct cognitive assessments, namely that asking about the year and the month is more constructive than asking for what day it was, since, she pointed out, neither of us could really remember what day it was half the time anyway. We also assessed an epidural together, something she's had a lot of experience with. In the past, in other environments (not in the hospital), I've had a tendency to be somewhat annoyed when someone explains to me something I already know. In this case, it took me a while throughout the shift to show her what I -do- know and what I can do. I won some praise from one of the nurses who was demonstrating the epidural infuser's operation to RN-C for rattling off the priority assessments for epidural anesthesia.

The epidural was running into Patient W, a woman in her late 70s who was one day status-post left-upper lung lobectomy, secondary to lung cancer. She had bilateral masectomies secondary to breast cancer, so blood pressures for her were obtained by wrapping the cuff around the calf, slightly above the ankle. She experienced 10/10 bladder pain that was preventing her from taking in any nutrition. After adjusting the position of the catheter and palpating the bladder, I decided to hunt down RN-C for her input. She decided the best course of action would be to replace the foley. She spun around to leave to grab a foley kit (she really is a whirlwind of activity!), before I stopped her and suggested that I could do this with my instructor. It would have been my first foley-insertion on a female! I asked the patient if she had a preference as to who did the procedure, and she said it didn't matter to her. RN-C then expressed that she would rather do it her self “because....” and then she trailed off. When I caught up with her later, she said “oh, it was really tricky anatomy anyway, you wouldn't have gotten it”. I was slightly miffed by this but I didn't show it. How am I supposed to “get it” without trying? I didn't let this get to me, though, since I'll have lots of opportunities to practice and perform -skills-, I just felt like I was being slightly excluded. I could have run the bladder scanner for her, I bet she didn't know I could operate one of those. Later she mentioned offhand that she forgot to put a thigh-strap on the patient to secure the foley, this time I just said “Don't worry about that, I'll take care of it” and dove into the clean-utility room to retrieve the strap.

Patient W also exhibited rising back-pain, which she rated as “12/10”. She said it felt the same as when she threw out her back. This started setting alarm bells off in my head, and after taking a peak at the epidural site and making sure sensation was present in the dermatome around the site, I tracked down RN-C again to see what she thought we should do. I saw there was an order that allowed us to slightly increase the epidural infusion rate, but RN-C figured administering Morphine IVPush and getting a toradol order would be the way to go. Thinking about this later, that makes sense, since the epidural is for the constant pain and the morphine is for breakthrough pain (in this case). The sudden extreme back-pain made me panic for a moment, I felt like there's something related to epidural anesthesia I should be worried about, but couldn't put my finger on it. CSF leak? No, that's headache. I don't know what exactly I was worried about, but that only contributed to how ominous the occurrence seemed to me.

Patient W also had a chest tube, except this one was hooked up to wall suction, with a pressure of 20ccHg. I confused cc's of Hg and H20 in the report. The level of drainage was 120ccs above the last marked volume on the collection device, so I charted that as output and kept an eye on it. It didn't increase again all shift, which makes me wonder if perhaps it just hadn't been marked in a while.

One of the PCTs got a blood pressure of 207/78 on her, which I suppose isn't all that surprising considering she's on medication for hypertension, didn't receive her AM dose due to hypotension, and just had an episode of excruciating pain. The orders included a parameter to call the MD if the systolic blood pressure was higher than 190. I started to track down RN-C once again and thought to myself “She's in with a patient, I'll just have the HUC page the MD for me, I have all the info I need”. I had the MD paged and then caught up with RN-C to tell her what the situation was. Just then, the HUC shouted down the hall for me, the MD had answered the page almost immediately. I headed over to the phone, not even thinking to check to see if RN-C was following me or not. I sat down and answered the phone, and gave a nice, concise SBAR report to the MD. When he asked “you administered IV Morphine in addition to the epidural?” I said “well, I can't give IV push morphine because I'm a student, the RN administered it.” “Let me talk to the RN”, he said. “Just one second..”, I hit the Hold button and retrieved RN-C, who was still down the hall. The mistake I made here was letting my enthusiasm for doing something on my own prevent me from following through to the next logical thought in the sequence I had just initiated. Ok, I had just reported something to an MD...but what if he has an order in response? I can't take a phone order on my own, I need to have an RN with me. I was able to do this whole sequence of events on my own at the last facility, because MD's ordered purely electronically there, no phone orders at the last facility (or at least they were very rare). This is a poor excuse, I know.

Last but not least was Patient V, a man in his early 80s who was with us for a perforated bladder. Apparently, he was here the previous day for cytoscopy related to a bladder tumor. At home, he was unable to urinate and his bladder swelled to epic proportions. In a way, Patient Z from the day before had prepared me a little better to care for patient V, and I monitored his foley output closely for clots and volume. He put out a reassuring 750ccs or so for me. I saw his MD come and visit, he heard good bowel sounds and noticed decreased abdominal distention (back to baseline, according to patient V), so he said they would just observe him for another day and that surgery wouldn't be necessary. Patient V slept for a lot of the shift, but I got him out of bed to weigh him for his admission assessment (which still wasn't complete when I arrived, it was only missing that weight), checked his abdomen for warmth and firmness, and even did that fun little fluid-wave test for ascites (it was negative). I hung a bag of maintenance fluid for him, which I flubbed. I feel like I've demonstrated progress in how I've been hanging IV piggyback infusions, but for some reason doing something similar but slightly different caused me to be clumsier than I should have been. All I need to do is remember not to try to hold so much in my hands at once. I get so worried about keeping the tips sterile that I'm afraid to let go of anything, lest something bump into something else out of my control. What I need to remember is that I don't need to hold on to the tip when it's covered, it doesn't matter if it rests on the bed or even the floor. I clearly need to practice more with the cartridge-based volumetric infusion sets, having three different types of infusion sets in three clinical sites (gravity, peristaltic, volumetric) has made me not only “master of none” but “barely competent with any”. I spent some time in the lab today going through the steps with the cartridge, I think as long as I remember to invert the cartridge first I'll get it right next time.

There was some question as to whether patient V was aphasic, the previous shift thought he seemed somewhat confused, and reported occasionally having difficulty coming up with the words he wants to say. This piqued RN-C's interest, and when I followed her into patient V's room I got a front-row seat to the previously mentioned pro-neuro assessment. He was easily aroused, knew what year and month it was, but struggled with the name of the president. A good tip I picked up on from her was if someone's struggling with an answer, to give three choices rather than just sitting there and letting them flounder or cutting their train of thought off. She didn't detect any obvious neuro deficit, so we chalked up the non-aphasia to the fact that he's..well, in his 80s.

This week provided some interesting challenges, some hard lessons, and some clues as to how to get to where I'm going. It's a little frustrating that I've made what I feel are substantial gains in hanging IV piggyback infusions, only to screw up something even more basic. The point is, though, that the practicing I did with the piggybacks paid off, and so it's clear what I need to do to smooth out the primaries. I feel like I kept it together pretty well, too, staying relatively positive and goal-oriented in the face of setbacks.

I'm not sure how much progress I've made in being a better manager of care, this week. I'm staying aware of the documentation more conscientiously and communicating better with the rest of the team, but I feel like there's still too much I defer to the staff RN's in terms of decision-making. I don't think its a bad thing for me to keep them up-to-date with the goings-on, but I think in the future I need to include my own recommendations for what I plan to do instead of phrasing it in a way that prompts them to give me instructions.

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