MS wk 5 Journal

MS wk 5 Journal—Williams

This past Friday was a unique day at the hospital. The overall census at the hospital was down due to the holidays therefore they were consolidating patients in order to shut down a portion of the hospital to save money. 7A, the stroke, neuro unit was the unit to go dark until needed again. The last mother of the last family that I lived with worked as a nurse at a very small hospital (25 bed) up in Northern California. She was a night shift nurse and it was common during different times of the years for her to be called and either placed on call, or given the whole night off. The fluctuations in census made sense to me due to the small tourism town, however I didn’t really expect to see it at such a large hospital.

The day provided us with a unique opportunity to see multiple discharges and transfers. I was able listen in on the phone conversations from one nurse to another that had to be done prior to the new unit receiving the patient. I was also able to see some of the difficulties that come with either transfer or discharge. The patient, the nurse, and the family could be ready to leave, however they could be stuck waiting on the doctor to enter the discharge orders into the computer. Or perhaps the orders for transfer to a new unit have been made, the patient is ready, yet the nurse assume that they are waiting on a call from the new unit before the patient moves, when in fact the new room is open, and they are waiting to hear from the nurse with the patient. I believe that double-checking, and making reminder calls is better than doing nothing, even at the risk of getting on someone’s nerves. If problems can be avoided simply by better communication then it is worth taking a bit more time to clarify instruction, or lack thereof.

I believe that I had written one of the previous weeks regarding the potential for medication errors, and this week I had the opportunity to see the effects of one first hand. The order for TPN was not re-entered by the doctor, and neither the pharmacy nor the night shift nurse caught the mistake, or questioned why a new bag was not going to be sent up. Through this mistake the patient was without food for a period of time, somehow placed on a mechanical soft diet, and then placed back on the TPN without an alteration to the PO diet. It was interesting to watch the circle of blame, go from the nurses blaming the doctor, then blaming the pharmacy when the doctor was in the room, and the doctor blaming both the nurses and the pharmacy. I can see how it was perhaps the initial fault of the doctor for not reordering the medication, however the checks and balances in place (nurses and pharmacy) failed to catch the mistake, and the error was carried out to the patient’s detriment. Fortunately it was not a mistake of a greater magnitude.

I was a little frustrated with the seriousness with which the nurses were taking my concerns. I originally pointed out the rise of WBC from 14 to 26.9 in a period of two days while in the presence of antibiotics, which were discontinued that day. I understand now that the rise in WBC is not likely due to an acute infection, however neither nurse one, or nurse 2 could give me a straight answer for the WBC increase or the d/c of the antibiotics. Perhaps they were playing devils advocate, and making me think critically about it, but I don’t think so. I understand that I am very very new at nursing, so perhaps a level of 26.9 when the range roughly 4-10 is not that bad, but some indication as to why would have been helpful.

I also found that my concern over the growing abdominal ascites was not taken seriously. I mentioned it more than once, and the greatest response I received was, “Go get me a set of vitals, and we’ll see what that tells us.” The vitals were within the patient’s normal, however that does not change the fact that the pt stomach had gown much larger in the course of the day. I wish I had measured the pt’s abdomen somehow so that I could have given some concrete evidence. The best evidence that I had was that his respiration rate had bumped up 5 breath/min since the morning, even though he had received a narcotic for pain that afternoon which may cause slight respiratory depression. I had the opportunity to see a paracentisis while doing pt contact hours when I was getting my EMT license, and I watched 3L of fluid get pulled out of an alcoholic’s abdomen. Every person is different, yet his abdomen was not as large as the pt on Friday. I don’t know what more to say about this, in my opinion his stomach had doubled its volume in the course of 8hrs.

            The last thing that is related to assessments was the level of thoroughness that I have seen with physical assessments on the unit. I was impressed to see that the new nurse, nurse one did things like asses grip strength, muscle ROM and strength, took the socks off to find pedal pulses, and inspect the feet, as well as listen to the heart in two different places, and correlate that with a radial pulse. It was the most in-depth assessment that I have seen by a nurse in the hospital yet. However as I did my own assessment alongside him, I noticed that he did not mention an irregular heartbeat. The admission history as well as the patient hand off sheet said that the patient had normal S₁ and S₂ sounds with a normal rate and rhythm, however the patients heart rhythm was clearly not regular. I went back and checked three times over the next 30min to make sure I was not making things up, I would check apical pulse along with a different peripheral pulses at the same time. It was likely nothing more than A-fib, which is fairly common, and frequently presents with no symptoms or adverse effects for the patient, however a-fib is correlated quite strongly with cerebral ischemic events. (5 times more likely according to AHA, and National Stroke Association). Maybe it is of no big concern at the end of the day, however I think it is of greater concern that two individuals got two different results. If it was a scientific study both sets of data would be tossed until consistent, and independent results could be presented. Here again I probably should have said something but it is difficult to come up with the courage to contradict both the previous paper work as well as another more experienced nurse’s assessment.

One of my biggest struggles right now regarding clinicals is not knowing the level at which I should be involved. This past Friday I sought to function slightly more like a nurse on the unit. I organized a blank paper in the same manner that one of the other nurses did in order to keep track of 4 patients at once. I would take notes at each beside report in the morning, and I attended the 9am meeting with the case manager, other nurses, PT, and the doctor. I sought to fill my role as a student and understand the role of a floor nurse with multiple patients. I think I may have gotten in the way a little bit.

I honestly think I did a fairly good job this last Friday, I don’t think that I would change much, except for perhaps taking to the clincal instructor regarding conflicting assessments, or patient concerns that I feel are not being appropriately addressed.