Monday, March 5, 2012

Manager's should leave well enough alone!

I'm an RPN (LVN/LPN for those US ppl) and at my hospital we get to practice to FULL scope - which means that we can do ANYTHING an RN can, minus take care of unstable patients.

So on one of my evening shifts I had the privlege of carrying 5 pt's - one where the family is over bearing and there looks like there's going to be legal action taken against the hospital as the family feels that the hospital has caused their mother's stroke (for another post); one pt that is a total care, but she turns really well, and she's a diabetic which means glucose testing and insulin; another pt is independent and only requires 1800 meds. Then I was supposed to get TWO admissions! Now one is enough but two REALLY sucks! And this I knew was going to be the case as soon as I started my shift. CRAP, CRAP, CRAP!!! At least that's what I said in my head.

The ONLY saving grace was that one of the new grad RPN's was going to be shadowing me for 4 hrs. GREAT! And good thing I had her or else I would have been screwed!!! Before the newest patient came up, I took report on the second patient. This is the report for patient number one...

Female in with confusion NYD (not yet diagnosed) and diarrhea. But she was in FOUR POINT RESTRAINT!!! Ok flag number one! Ok, on with report.... aggressive with staff and that's why she has the restraints on. She's on 40% oxygen by mask.... flag number two!! Then I get given her VS - temp normal, pulse in the 90's (okies... sorta), BP normal, O2 of 96% on said oxygen.... but flag number three and probably most worrisome was that her respirations were 40!!!! Yeah this doesn't sound normal... I was told that pt was stable and that there was a referral for a Dr - one that I've mentioned before I had to call in the middle of the night (refer back to my post about my pt with seizures and a back compression fracture). Another issue I had while I took report was that this pt was a diabetic, NPO but only on NS (normal saline) TKVO (to keep vein open)... which didn't make ANY sense because you would think that critically thinking that this pt would become dehydrated since she had diarrhea, was NPO and was a diabetic... ok whatever, I'll bring it up with our MRP (most responsible physician) who would be responsible for this pt - and get her started on D5W at 50cc/hr or something like that. At least that way you are addressing the dehydration possibility AND the diabetic sugar levels.

WELL, when this lady came to our unit, she looked and more importantly SOUNDED terrible!!! I don't know if any of you have ever heard of the "death rattle"... the sound that the chest makes when a person is close to death and aren't swallowing their saliva and these secretions go into the chest and make it sound all congested.... well that's what this lady sounded like. It was crazy - and all of us nurses were like, "why is this patient even coming to our unit, she should be going to ICU"....

The porter, RPN shadow girl and I transferred this patient onto our unit bed and away we went with our assessments. I had the other RPN take the respirations and I would get her BP, pulse and O2 sats.... Again BP was fine, pulse was elevated and O2 sat was 80%!!!!!!!!!!!!! And that was on 40% Oxygen - 8L per minute... MRP was on the unit and I went and grabbed her and had our unit clerk page support (part of our code blue team - which in essense is like me calling a silent code blue) - put the patient in high fowlers and went to grab ventolin and atrovent as well as suctioning equipment. RPN gave us a 40 resp rate and I gave her the suctioning equipment while I set up the breathing treatment. While she was on 100% O2 - during the breathing treatment - her level stayed above 92% - but once we put her back on the 40% she would bounce between 67%-94% sats... the 67% happened often because she was also having periods of apnea and would only breath once you verbally stimulated her.

Once she was stabilized a bit - where she was sitting above 80% sats for more than 5 minutes - I spoke with my UL (unit leader) about what this patient looked like clinically. She asked me whether I wanted someone else to take over. I told her no - that although she was unstable, she was stably unstable and that I felt that I was supported by many people on the unit. I had the MRP there, that if things changed that I have SEVERAL RN's on the unit that could take over, and that support was already paged and I knew what threshold to initiate calling a code. I also indicated that since I had the other RPN, I could stay with this stable patient in a closer fashion than is normal, for our unit.

Therefore I kept this patient... Thankfully I had the other nurse, who then took the initiative to take the blood sugars on the other people, as well as this new pt... and give meds, while I was caring for this new patient pretty much on a 1:1 basis.

About an hour later support came and assessed the patient and then got the other referring doctor to come see the patient and made the decision to put this patient in the ICU - all the while we are ALL in agreement that this patient should NEVER have come to our unit! The support nurse thankfully found a spot in the ICU and put that stuff all in place - without having to go through many hoops that would generally have had to occur and instead it was going to be a trade off. When this patient went to ICU, that I in turn would get an ICU patient back to me (one that was ready to be D/C'd from ICU though). By the time that that happened, I had this patient for almost 3 hours... it was craziness!!!! My lady patient was so unstable that we sent her, not by stretcher, by left her in our bed and wheeled her down the hallway to ICU. With me in tow, ensuring that she breathed.

It was funny bringing her to the ICU because when I gave the nurse taking over, report, she asked me if I would ever consider working in ICU... when I told her yes, she told me to apply for a job. I had to tell her I had to wait another year and a half until I finish my RN, and then maybe I would. I think that this shocked her. LOL

Thankfully I didn't end up getting ICU guy, even though I took report, because I was told that he was quite a handful (had him my next shift and yes he was!!!). Just as I transferred my lady to the ICU, I got my second admit, who although not unstable, was still pretty sick. She was septic and the poor lady had chronic liver cirrhosis and her belly was BIGGER than a lady at 9 mos pregnant - and anyone who reads this and has been to that point - you can totally empathize with her.... sooooooo uncomfortable!!! And her poor legs looked like tree trunks they were sooooo edematous.

Much to my surprise, half way through my shift, when my RPN pal went home, another nurse on my unit helped me by unloading one of my patients - which was UNBELIEVABLY helpful!!! When she did that, she lightened up my load tremendously and allowed me to focus on the unstable patient, but still touch base with my other patients since they were all in the same area and the patient she took was in a TOTALLY different part of unit. Bless her heart!!!

Such a crazy shift! Hope I don't have one of those for a long, long, long time to come! I guess it serves me right since I've had such quiet, easy going shifts before this... I just had a feeling that it was the calm before the storm, and WHAT a storm it was! But I guess it made for a fast and interesting shift and an interesting story for here.

Also - this is being investigated because if the nurse had done her assessments thoroughly, she would have noticed the respiratory distress, should have realized that this patient was NOT suitable for my medical unit, and SHOULD have contacted the physician to indicate this. ALSO, IF the manager of the ER hadn't gotten involved and MADE the nurse call my unit to send this patient to MY unit, the patient could have been given enough time to be assessed by the referred doctor and wouldn't have been sent to my unit in the first place (IMO!). Interesting all the way around!

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