Critical Thinking Journal Cardiac unit Day 5

So I think I don’t like the unit. I told Pat that today. That’s all nice ‘n all, but I think she took it the wrong way. She said that what she heard me say is, “You think that older people don’t have the right to good nursing care and to get better.” Doh…that’s not what I said or meant. My arguement: I just think that I’m not that nurse who is going to take care of these patients. I think that my argument was too heavily on the side of “I want to see big returns…I don’t think I’m making a difference in these patients. I think that I want to see a return in these patients.” Truth is, this argument is too, um selfish and really only thinks about me me me. It has no focus on the patient. The same principles I learn with these patients will be used on the population I think I want to serve…Everyone needs oxygen exchange, perfusion and blood circulation. In this regard, the only return I get from the unit is I get enough patients for case studies. I need to be able to recognize abnormals in all these systems so as to nurse all populations. It’s just too bad I don’t like to do it with the elderly, CHF and COPD patients. To sum it up in lay terms, they’re so big and they are in the hospital, virtually suffocating to death because they can’t breath properly (either caused from respiratory problems or a form of heart failure). A fully grown adult is disoriented and can’t hold in their bodily functions – sometimes so disoriented, they can’t even recognize their own spouse of 60+ years. They’re at the side of life that the body is tired and has a longer recovery time. They sometimes don’t even get better. They come back again and we send them home with replacement or adjustments to their meds. We can try to replace oxygen through oxygen therapy, but sometimes they can’t even breath deep enough to make a good enough effort. I am just thinking that I don’t want to work with these patients. Am I wrong to say it’s more hopeless for these patients than it is with cancer patients? I think that cancer patients have a hard battle to fight, and they have something to hold on to. They hope for a cure. A hope that the chemo or radiation to buy them more time on earth. They have hope that the surgery or radiation will get rid of it. With CHF and COPD patients, their chances seem so bleak. They only have to wait it out until one day the deterioration gets so bad, they die – slowly and inhumanely. OK – you get my drift? I am drifting off to sleep writing this, so I think you should know that while I have these feelings, I also know and recognize that cancer patients have irreversible damage. They too may not make it. They too may need to wait out the storm until it can’t get better and they just die. I think that cancer has a fighter kind of psyche to it, and that CHF and COPDers have a wait around to die thought and I can’t do much about it but to endure these symptoms. I’m probably wrong about this view, but those are some of the things I’ve seen with patients. They’re old, weak and don’t want to fight an illness that seems too debilitating and hopeless to really make an effort at. It’s as if they say, “Take care of me, cause I am frustrated with the lot that’s been dealt me, and I don’t want to deal with caring for myself – it’s not worth fighting for, cause the illness will eventually overtake me.” Cancer patients I’ve encountered have a different outlook. They say, “I’m gonna fight this thing, and I will win! If I can’t win, then I will do the best I can.” As I read my thoughts, I see generalities and a me-centered attitude. I can’t ignore the feelings of hopelessness I feel when I work with these patients. Maybe I will have these same feelings when working with other ill populations. I just don’t seem to have these feelings when working with others yet. The bottom line is: ALL patients need proper care. I need to learn all I can about serving these patients, because other patients will need care I give this population. These patients need my constant, vigilant and skilled care. I need to focus on them and learn at every turn.

I was assigned 2 patients for this day. One had a recent MI with a history of hypertension, and the other was a MESS. She had c-diff (isolation and contact precautions, meant all who enter wear mask, gloves, gown – everything stays in that goes in, nothing comes out), abdominal aneurism, abdominal abscess, 2 drains, renal failure, 1 assist mobility, TPN (total parenteral nutrition – food directly in blood stream), hypertension, diabetes, depression, and the list went on. I started to prepare for my patients last night. I wanted to make sure that I understood the TPN feeding, so I called Pat and she said to look up multi-med line in Lewis. I wanted to make sure that they called it that, because so many times, it’s called something else in the book, but the rest of the nursing world calls it another. Indeed, when I looked it up in Perry, all they divided parenteral nutrition into was central parenteral nutrition and peripheral parenteral nutrition. They had nothing on TPN or multimed lines. It wasn’t until I got into Lewis where they really explained it in detail. They had nothing on multi-med lines, but they did have things on central lines for parenteral nutrition (which could be the same for peripheral or central). Anyways, Lewis did a better job at explainations, but I still didn’t get what a multi-med line was (hehe). OK the real information I needed anyways, was the nutrition itself and the solutions. Now I know where to find the information and nursing implications in caring for these things. Then I called Pat back about the (um, I can’t remember why), then she asked me what my patient’s diagnoses were. I told her and she said that I should only have one patient. I worked it out with her that I should probably focus on the cardiac patient because that is after all what my rotation is all about. Phew! That was good that I was going to get the cardiac patient because the other one was very complex. I want to learn about the cardiac stuff. I prepared to work with that patient and learned some wonderful things (including NSTEMI). I was excited to go in an work with that patient. When I got there, I found out that that patient was no longer on the floor. Ugh. Ugh mostly because I really didn’t prepare for the patient or the drug. I did prepare a little, but not for the drugs. When I told that to Pat, she said to go ahead and take this patient and don’t pass the meds. Hmmmm. OK – so I go to prepare for the day by doing a bit more reading in the chart and talk things over with Pat. Well, then I found the co-assigned nurse who told me (instead of report) that I shouldn’t have this patient. She’s terribly complex and the family will have a meeting to decide surgery or not surgery. OK, so on to find another patient. Pat assigned a CHF patient. Below is the DARP note I will turn in to Pat:

64 y.o. ♂ admitted 1 day ago. Family states pt. was “agitated, confused and short of breath.” Pt. was admitted for CHF exacerbation. Today, at beginning of shift, pt. was lethargic with periods of O2 sats down to 82% while awake and during sleep up to 90% on 6L O2 NC. Sats come up when pt. asked to breathe deep through nose. Breathing pattern regular, but shallow at 20 BPM. LS bilat crackles in bases, all other lobes CTA. Patient is a mouth breather. 1+ Pitting Edema to ankles, – Homan’s sign, cap refill &lt3sec, skin turgor elastic. Apical pulse regular & strong, 90 BPM. Pt. Alert and Oriented x 4, Pupils PERLA @ 2mm, GCS 15. Pt. moans with breathing, but this was with complaints of lower back pain of 10/10 dull (directly over spine). Pt. states this pain comes and goes at different times in his life. This is not a new onset. Abd soft, non-tender, round with bowel sounds present in all 4 quadrants. RUQ hyperactive, all other quadrants are normoactive. Foley catheter draining clear yellow urine. 24° I&O reveals 2000 out and 800 in. Oxycodone administered, changed O2 route to Venturi Mask 15L O2, FiO2 50%. HOB &gt 30% and patient repositioned to upright on back. Educated patient with I.S. which he was able to get to 1,000 1,250 and then to 1,000 CC, slow and labored. Reinforced C&DB methods. Patient refused breakfast and drank 250 CC water during shift. Pt. sats now 85-88% at sleep, 90-92% awake. Very lethargic and wanted to sleep all morning. Patient no longer moaning, but when he wakes, C/O back pain and then falls back to sleep. Spouse came and visited, but pt. only had short periods of waking to speak with the spouse. Reported new findings to physician. Continue to monitor O2 Sats, reinforce cough and deep breath and I.S.. Patient resting.

[[end of DARP note]]

At the beginning of the shift, when the O2 sats were 82% @ rest, the Dr. was called and she said she would be in shortly. In the meantime, they ordered a nebulizer treatment to be performed by respiratory therapy. They physician arrived and asked where the nurse was and demanded that the patient be put on a mask. She stated that the nurse should know that we can change the mask if the patient sats are this low. She proceeded to change the patient over to a Venturi mask at FiO2 50%, flowing at 15 L. The patient immediately satted at around 90%, still lethargic. I asked Pat what I could do differently, because it seems like there was trouble. What I learned was the following: sit the patient up, increase O2 to all available ordered. Find out what the standing orders are about changing the O2 delivery changes a nurse can make. Call the Dr.. Those are the things I can do. What had happened, was that the patient was finally resting and asked to lay on his side because his back didn’t hurt anymore – and he needed some sleep. Apright or on his side, his O2 sats were the same – however, siting him up in bed has scientific backing that shows it helps people breath better by using gravity with us – it allows for better lung expansion. The venturi mask ensures that there’s a certain percentage of oxygen being delivered – normally I think it’s 23%, but he was getting 50%. Also, it’s important to note that nursing can’t change the way O2 is delivered unless there’s a physician order or some kind of standard orders on the floor – O2 is a drug. His pain seemed to be decreased, but the physician seemed to think that he was overdosed on oxycodone and therefore in respiratory depression. After my shift, the physician ordered narcan and it was administered. WOW what a punch that has on a person. It reversed the effects of the oxycodone – he was in pain. I can see that thinking like a nurse would have directed some different actions, then changing the delivery of oxygen could help this patient – this is a collaborative nursing action and would have taken some knowledge and initiative on my part. I should have read the standing orders and be familiar with the policy and procedure of the institution. Paying attention to these details would be the ideal. I hope that tomorrow is better and that I have two patients to be challenged and not think so much about myself…think about the patient.

~ by Mike on November 15, 2007.