What Now?

We departed somewhat from the schedule of clinical foci this week, since 3/4ths of my cohort took the second clinical day off this week, we skipped right to the last clinical focus, which can be more or less summed up by the phrase "what now?".

The other student and myself were asked to summarize what we thought our strengths and weaknesses are, something I found it difficult to do on-the-spot, even going second and having some time to prepare. We talked some about our plans after school, shared some ideas, and got some advice.

My goals this was to feel like I've gotten back to the comfort and awareness level that I felt I had in previous semesters. This week included one day with a four-patient+meds assignment, a challenge I had been looking forward to despite some of the missteps in earlier weeks. My morning routine has been getting more streamlined, a process that has taken much longer than I would have liked. Establishing effective routines is very challenging for me, and now that I feel like I'm getting the hang of it, it's almost time to leave! Still, my organizational routine has improved from one semester to the other, so positive gains have been made. My plan was to use this improved familiarity to quickly target and collect the data I needed to plan my care, get report from all of the RNs (four of them in the case of the second day!) and take some time to reflect on what my priorities would be.

Patient X was in for a perforated colon, a colonoscopy had resulted in a lower GI bleed so severe that pressors were necessary to control the bleeding. As I assessed her at the beginning of the shift, I noticed decreased, ronchorous breath sounds. She reported a little shortness of breath and unproductive coughing, Incentive Spirometry volume was a non-reassuring 500mls or so. After some fluids and some chest physio she started coughing up thick, sticky secretions and her breath sounds cleared up somewhat. She never got the Spirometer above 750, but she was satting well in to the 90's and remained eupnic. She was reported to have anasarca (generalized edema), although when I assessed her, only pedal and ankle edema was evident to me. She received diuretics over the past two days to get rid of some of that extra nine liters of fluid she had in her, from what I could tell from the I/O balance sheets she was still up about 3L or so. She had a history of heart failure, so the IV fluids were running at a leisurely 60ml/hr or so.

When Patient X's assistant and I transfered her back into the bed, we noticed black stains on the linen-saver, so we set about getting her cleaned up. The stool looked pretty dark, so I grabbed one of the heme-test kits from the bathroom, which turned up positive. Probably not surprising, considering her last bowel movement yesterday contained a good amount of blood and clots, and on the RN's advice I placed a note on the front of the chart for the MD to see next time they were in. During hygine, I noted a superficial disruption of the skin in the perianal area. The redness around it was blanchable, but I thought I'd have the RN come in and take a look anyway to suggest a dressing. The RN decided that it was a stage II pressure ulcer and instructed me to apply an allevyn dressing. Something seemed off about this to me, since the redness was blanchable, but the RN assured me that it should be documented as a new stage II pressure ulcer. Eager to get some more wound documentation under my belt, I set about gathering the forms. Two other RNs (one of which was referred to as the resident "wound expert") decided to see for themselves before I submitted a nosocomial pressure ulcer report, and declared that since the wound was not over a bony prominence, it could not be a pressure ulcer. THIS seemed off to me as well, since capillary pressure is around 32mmHg, sacral pressures on a hospital mattress can easily exceed 100mmHg, and this was a relatively massive patient...it didn't seem far-fetched for me to imagine pressures in the medial gluteal folds exceeding 32mmHg.. but the blanchable erythemia was the key, I think. We reclassified the wound as a skin-tear, after the dressing I had applied had been removed and then reapplied.

Patient Y had experienced cholelithiasis and pancreatitis secondary to an obstructive gallstone. He underwent endoscopic retrograde cholangiopancreatography (ERCP)to remove the offending stone. His diet was sips of clear liquids, which progressed to full clears on the second day. His chief complaint during my time with him was pain. Fortunately this pain didn't prevent him from walking around the unit. He was concerned about the fact that he wasn't able to produce stool. This wasn't surprising since he hadn't eaten anything in the five days or so before I met him. He reported feelings of lower GI fullness and discomfort which weren't relieved by colace or senna, so I suggested he walk some more and drink room-temperature fluids. He seemed very flat, withdrawn and depressed during my time with him. His ex-wife and brother came to visit him, and he was preoccupied with how he would obtain nursing care at home once he left the floor. This puzzled me, since he didn't seem to have anything wrong with him besides the constant "3/10" abdominal pain. In fact, I had difficulty figuring out what his clinical course was, since his amylase and lipase were back to normal (they weren't even measuring them anymore), his 'lytes were mostly normal (although we were supplementing his IV fluids with potassium), and his medical issue had been resolved. On further discussion and investigation, his RN mentioned that he could be discharged when his pain was well-controlled with oral analgesics, something the patient was fairly sure would happen the next day. The RN had the impression that he was somewhat drug-seeking (or at least requesting analgesia for the euphoric effect rather than pain-control) and "milking" his hospitalization for attention from his relatives (and ex-relatives). Looking back I see how she may have formed this impression, although "in the moment" I think I'm still at the stage where I take reports from patients more-or-less at face value. Either way in this case, the same conclusions are reached, the same steps taken, regardless of our impressions.

Patient Z was off the unit on the first day for a hepatobiliary iminodiacetic acid scan (HIDA), so I assessed her relatively late in the shift, when she returned from the scan. She was in good general health, although in the past she had experienced thoracic outlet syndrome. She spent most of her time talking on the phone and chatting with her visiting spouse, and in the meantime I got to go over the pre-operative checklist with her RN. The next day she returned from a lap-choly and got to do some discharge teaching with the instructor. I've had limited opportunities to "do" discharges, so it was interesting and novel.

Patient W was my abdominoplasty patient from the previous week. She was back for "wound ischemia", although her labs revealed psuedomonas infection. Her orders specified that she should remain in the "crunch" position at all times, to prevent stress on the abdominoplasty wound. We walked together a couple of times and her breath sounds were much clearer than the last time we met. Patient W had some lengthy wound-care orders, which I was excited about since I enjoy the hands-on, arts-and-crafts nature of wound care and I've hardly gotten to do any wound care in the past two semesters, although I got to do a fair amount in the first two. The wound-care could have gone more smoothly, It didn't occur to me to set up a sterile field, electing instead to use the sterile wrappers of the individual products. This would have worked fine for simple wound-care, but I had three JP drain sponges to change and a petroleum dressing to apply to the abdomen, so I could have simplified things greatly by setting the field up. My awareness of the sterile field needs more practice, dealing with those pesky paper packages is something I need more practice with. Something positive about the experience, though, was that I've gotten a lot better at applying sterile gloves than I was in the past. I plan to seek out more wound-care opportunities in the future, not only because there's plenty of room for improvement in my technique, but because I think it's something I could get good at doing simply because I think it's fun.

Patient V had gastric bypass surgery when I met him during the second clinical day. He was in a bariatric bed with padding on all of the siderails. This confused me for a moment and I went back to his chart to look for evidence of a seizure disorder. Apparently this is just how the bari-beds come. For a morbidly obese man who just had major abdominal surgery, Patient V was in great shape as far as recovery from surgery was concerned. He ambulated without difficulty and more than the minimum requirements of his clinical pathway, he was well educated about the stages of the gastric bypass diet, his pain was well controlled with patient-controlled analgesia, and had reassuring assessments all-around. It was difficult to auscultate his breath sounds, and I wasn't sure if this was because of his girth or not. He was able to max-out the incentive spirometer in one slow, deep breath, and used the IS independently while awake. His nasogastric tube didn't put much out in the way of drainage (another good sign), and his time with me was easy and uncomplicated.

I greatly enjoyed having a four-patient assignment for the first time. Some of the skills performed need some more work, and some of the success I did have was at least partially thanks to the supportive and helpful RNs and PCTs working alongside me, but I'm left with the overall impression of progress. Identifying areas of my routine that needed improvement was a long process that relied heavily on repetition, with minimal obvious gains at first, but there's a sense that something has "clicked" with the routine that's made more improvement possible. I find myself imagining giving report at the end of the day as I collect my information at the beginning of the day, systematically pulling out information from the charts and computers, instead of the "shotgun" approach I had employed earlier, where I just tried to mobilize as much data as possible and find a use for it later. Having four patients instead of three seemed easier, somehow (although I know things would have been much different if the patients I -did- have had heavy medication profiles), I think constant activity is somehow easier for me than activity punctuated by periods of time where I'm uncertain what to do.

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