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What to do? A real life scenario – Updates Complete!

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All right nurses, here is a scenario for you. You walk into the room. The patient seems a bit “off” but he’s sick, (DM, HTN, etc.) and a bit older at 74 y/o.  The second time you head into the room, his wife and adult daughter are there.  They tell you he’s NEVER like this.  What’s the first thing you do?

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Thanks for the responses!  Melzie said to check vitals, blood glucose, and neuro status.  I love that she included to do a neuro check. You don’t want to spend a long-time doing this. I’d stick to orientation questions only (who are you, where are you, what date it is). Maybe ask them the name of the family in the room with him.  You want to be sure to do this neuro check because you want objective data.  How confused is he?  How will we know when he’s better?  It’s important to listen to the family’s feeling about the patient, but it’s just as important to convert that information from a statement of opinion to objective medical data we can do something with.

Sheila also said to consider the possibility that the patient has a UTI.  This is a great point, especially since the patient is 74. The older the patient, the more confusion a UTI could cause, even without a fever present.  Of course, a root cause like this is a secondary concern for now.

So, I’d get the vitals and blood glucose and neuro check as quickly as possible.   The patient is oriented only to self.  He has no clue where he is, the date, or who is President.  His vital signs are within normal limits except for his blood pressure which is 74/50.  A quick glance at his charge reveals he is on blood pressure medicine and his BP is usually closer to 140/80, even when on meds.

You page the doc.

What do you do while you wait?

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Wow.  See TaraRRT’s comment below.  I’m guessing she’s a Rapid Response nurse (based on her username) and did an amazing job of saying what she’d do next!  Here’s what I did:

I put the patient in trendelenberg and started running saline at 150 ml/hr.  The docs called me back immediately and arrived immediately so I did not, in this instance, call the rapid response team.  However, a call to the Rapid Response Team was definitely warranted given the situation.

The patient’s vitals recovered quickly.  The family was really grateful for my help–they felt very listened to and cared for.  This situation was actually a really good one for me as it was really early in my career and I felt like I made some good, quick decisions.

Run, LuLu, Run!!

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Nicole is a particularly southern NA.  She would honestly say things like “My boyfriend and I work re-po on the weekends,” in as twangy a drawl as you can possibly imagine.  One day she yells to me from the other end of the hall, “LuLu, come!!”  First of all, my name is not LuLu. My nickname is not LuLu.  LuLu is just what Nicole called me because that’s how country she is.

I start down the long hall.

“LuLu!!  Run!!”  I hate running in the hospital.  Nothing freaks out patients (or other staff) quite like seeing a nurse run down the hall.  “LuLu!”

I kick it up a notch and start to jog.

Pamela, in room 17, is no longer in room 17. She’s in Bob’s room across the hall.  Thankfully, Bob is off getting an X-ray.  I look around and put the pieces together.  Pamela had to poo. She got up, wandered into the hall, went in Bob’s room, used the bathroom, and then got in Bob’s bed.  Unfortunately she left a, um, “trail” everywhere she went.  The discovery of the trail was the only reason we discovered quickly that something was amiss.

Now mind you, two hours ago Pamela was a normal, middle-aged lady who knew how to find the toilet and use it.   To you nurses, what would you do next?  Yep, get a blood glucose.  Her “sugar” was really low.  Four juice boxes later, she was back to her old self and had no memory of her exploits.  Too bad I’ll never forget it!

Nursing Nightmare

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Of all the horror stories that came out of Japan after the earthquake, tsunami, and nuclear crisis, this story on CNN hit me the hardest.  As nurses, we want to do anything and everything for our patients.  We skip lunch (and even potty breaks) to make sure our patients are safe and comfortable.  We would do almost anything to save them.  I could never imagine leaving a patient behind to die.  But that’s just what Fumiko Suzuki had to do.

As the tsunami hit Takata Hospital, Fumiko saved those she could.  As she watched the massive wave approach the hospital, she ran up the stairs to safety, leaving behind those she did not have time to save.  After the tsunami, she stayed and cared for those who survived.

I cannot even imagine the pain she must go through reliving that moment.  I hope she knows she made the only decision she could have at the time and that she can “forgive” herself for having done what she had to. I’ll be praying for her.

The Thirteenth Hour

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A twelve hour shift as a nurse really lasts 13 hours.  I get there at 6:45AM and usually finish up at 7:45 PM.  Today I didn’t get done until about 8:30.  Boooh! My feet are killing me! Usually after a really long day my very sweet husband fixes me some food and even brings me a glass of water.  He knows my exhaustion will win out over the need to eat a healthy meal and I’ll go to bed hungry or I’ll eat something horrendously bad for me. He’s not home yet tonight so I’m tempted to go for ice cream or cookie dough!

However, after today’s shift, I may have earned the cookie dough.  It was a long shift and sooo busy that I barely got to breathe.  It was frustrating because I let my patients and co-workers down when I can’t accomplish everything I want to.  Then, to top the shift off, I got a mixture of tube feed (read: baby formula) and gastric contents (read: vomit) on my arm when d/cing an NG tube (read: pulling an 18 inch long tube out of someone’s nose).  Yuck!

By the end of the day I had to refuse to take report on a patient coming up from the Emergency Department because there just wasn’t any time for it.  I was struggling to keep up as it was!  Thankfully I get two glorious days of sleeping in before I go back Sunday.

And, breathe!

Drug Seeker – Part 2

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Megan was a “drug seeking” patient who sticks out in my memory.  Drug seekers are patients who use the health care system to acquire more medication, usually to feed their addiction to mind and mood altering drugs.  Of the many drug seeking patients I’ve taken care of, Megan sticks out for her sheer audacity.

Complaining of back pain, Megan and her boyfriend came to the hospital immediately after being discharged from a hospital 4 hours away.  She said she works in health care but that she was mistreated at an outside hospital; they would not address her pain.

Megan was admitted to our Hospitalist service.   After assessing her and reviewing her records, the physician could find nothing wrong with her back.  He knew that her long distance travel, request for specific narcotics, experience in the health care industry, and benign assessment all meant one thing: she may be a drug seeker.

He went to our state’s Prescription Drug Monitoring Program database. He pulled her up and saw that she had been prescribed 360 Percocet 2 weeks ago and 30 Vicodin 1 week ago.  Interesting. She told the physician and me that she had never tried Vicidon.  Assuming she had none left, she had burned through 2 months’ worth of narcotics in 3 weeks. Red flag much?  She was sent home with a taper of narcotics to help her wean off the drug. My guess is that after taking the taper drugs at a much higher frequency than recommended, she crossed state lines and went to a neighboring state.  Unfortunately, states maintain separate databases.  For all I know, she may have already been pulling her scam in multiple states.

The “Accommodations”

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I thought it was nice of the hospital to provide accommodations for nurses who wanted to stay at the hospital during this weekend of bad weather.  Personally, I was not going to take them up on their offer–the hospital is a noisy, stressful place, but I was intrigued to see what rooms they were offering nurses.  I figured it must be either extra space in doctor “call rooms” which have bunk beds in them or empty patient rooms.  Turns out it was neither.  Instead, they were offering us these little cots, that are about two feet wide, lined up one after the other in a conference room off of a high traffic area.  Seriously?  As far as my unit goes, not a single nurse stayed in the conference room.   Can you blame them?

The joy of being essential staff…

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An email from my manager regarding this weekend:

“Please be aware there is a snow storm for the weekend beginning Friday, Jan 29th.  You are considered essential staff and we look for you to be here.  If you think you will have a problem travelling here for your scheduled shift, please let me know, as we will have measures in place for staff to stay over the night before.  If you are scheduled for Friday night, it is a good idea to bring a change of clothes and toiletries just in case.  NOTE: If you are working Saturday and need to stay the night before, please let me know ASAP.”

Perhaps I should just move in to the hospital.  I’d save on gas at least.