Code

November 12, 2012

I had my first true patient emergency the other night. It was not something that I hope to repeat any time soon.

My patient had type I diabetes & their blood sugar was very difficult to control. They also had end stage renal disease requiring dialysis 3 times a week. When I got report from the off going nurse I was told the patient didn’t have IV access. Apparently they pulled their IV out the night before & despite multiple attempts, no one was able to establish a new line. Starting IV’s on dialysis patients always tends to be challenging. I was also told that they were a diabetic & we were to check blood sugars before meals & at night.

When the shift started their sugar was 500 (normal is 60 – 100). I looked back at the patient’s blood sugar readings for the past 24 hours. They had been running high all day, but nowhere near 500. The night before their sugar was around 400 at the beginning of the shift & dropped down to 89. It’s fairly typical for sugars to drop in the early hours of the morning.

I also looked at the amount of insulin they were given each time their sugar was high, & how it had affected their sugar the next time it was checked. It seemed fairly normal for the patient’s sugar to run high despite how much insulin was given.

I called the doctor to see what he wanted me to do. He gave me insulin orders that seemed very reasonable for the patient & the situation. I administered some fast acting insulin as well as some long acting insulin around 10:30pm. I rechecked the patient’s blood sugar around 11:30pm & it was 450. I checked it again at 1:30am & it was 91. At that point, the patient was alert & oriented. They were resting in the bed & did not want anything to eat or drink.

I didn’t think much of it since it’s typical for blood sugars to drop some during the night. Plus, I was taking into consideration how their sugar dropped to 89 the night before with similar insulin administration.

Around 2:15am I was checking on everyone during my hourly rounds. I immediately knew something was wrong when I looked in my patient’s room. Their once unruly hair was now matted down to their head & soaking wet. They were shaking & making a grunting noise. It was a sight I’ll never forget.

When you find one of your patients in distress, you brain goes back to the basics. I sprinted to the nurses station & grabbed a Glucometer, some oral glucose (sugar gel), & some IV supplies. I also yelled that I needed help & a set of vital signs for the patient. Another nurse & a patient assistant came running.

I attempted to check their sugar but the Glucometer just read “LO” which means it was less than 40. The patient wasn’t responding to their name but they would withdraw & moan in response to pain. The other nurse started to squeeze the sugar gel into the patient’s mouth, but they wouldn’t swallow it. As I picked up the phone to dial the code my fellow nurse attempted to start an IV…unsuccessfully.

As the alarm started blaring overhead, I remembered the patient was a dialysis patient. They had a perm-cath that they got dialysis through which meant I had a possible line going directly into their blood vessels. Floor nurses aren’t supposed to access dialysis lines, but all I saw was a way that we could get some sugar into the patient – fast.

Again, I sprinted to the nurse’s station & grabbed an amp of D50 (pretty much a thick sugar-water). As I started to push it through the dialysis catheter the doctors, nurses, & respiratory therapists started to arrive in response to the code that was called.

The doctor who gave me the insulin orders arrived just as the patient started coming to. After examining the patient he said, “Well, I guess we gave her too much insulin.” I looked at him & said, “Ya think?!?”

Before I pushed the amp of D50 the patient assistant had been able to draw a vial of blood to send to the lab. The patient’s blood sugar was 10 when I found them. TEN. Who knows what I would have found if I had done rounds 15 minutes later…

I am thankful that I found them when I did. I am also thankful for my fellow nurse & assistant who helped me out. They kept me cool, calm & collected…at least as much as humanly possible.

Advertisements

Solo

September 8, 2012

I’ve been on my own for about four months now & every night is an adventure. I will never forget the events that unfolded the very first night I flew solo…

I had six patients. #1 was in for a GI bleed & he was receiving 2 units PRBC’s (packed red blood cells – aka a blood transfusion). He was losing blood faster than we could put it in & his blood pressure kept dropping. At the most stressful point in the night, his blood pressure was 84/40.

#2 had a complex history. He was in pre-op for a fractured humerus consult when his oxygen levels plummeted into the 60’s (normally 95-100). He was admitted to my floor for his respiratory issues, but he had a GI consult for some nausea & vomiting. On a side note, he had a working colostomy from surgery years ago…this becomes an important tidbit later in the story.

#3 was in with altered mental status and kidney issues. Her electrolytes were all out of whack. Her potassium was sky-high so day shift gave her a dose of Kayexalate…a medication that lowers potassium by emptying out the bowels faster than you can get to the toilet. The day shift nurse was smart (or evil) & gave the medicine right before shift change. The patient wasn’t real steady on her feet. I tried to reinforce the importance of pushing the call light so someone could come help her to the bedside commode. Needless to say, every time I walked by her room she was out of bed, attempting to get out of bed, or already on the bedside commode…by herself.

#4 had an extensive history of diabetes & respiratory failure. She had an insulin pump that controlled her blood sugar. She was on supplemental oxygen & receiving breathing treatments to aid with her breathing issues. She also suffered from an existing back injury which she took narcotic pain medication for.

#5 had an especially painful issue with his intestines. He could receive IV Dilaudid (heavy-duty pain-killer) every 2 hours PRN (meaning he had to ask for it). He also had uncontrollable diarrhea related to his intestinal issues.

#6 was in with kidney issues, nausea & vomiting. The kidney issues were likely related to the vomiting, which by the way, the poor man couldn’t stop doing. All the anti-nausea medication in the world wouldn’t have done him any good. I’d give him some Zofran or Phenergan & he’d be ok…for about an hour.

The evening started out fairly routinely. I completed all my assessments & was just about to sit down & chart when 1’s first unit of blood was done. So I rushed down to the room, flushed the IV with normal saline, took his vital signs & started setting up for the 2nd unit of blood. I heard my name being paged so I hit the call light to call the desk. 5 was ready for his pain medication, & 6 was throwing up again.

I sent a CNA to get the blood for me while I drew up the appropriate pain medication for 5, & nausea medication for 6. By the time I was done in both rooms the blood was ready for 1. Blood is a time sensitive product. We have 30 minutes from the time it’s picked up from the lab to the time we have to start running it into the patient. And you must have two nurses verify & sign off. Then the primary nurse (me) has to stay in the room with the patient for the first 20 minutes to make sure they don’t have an allergic reaction.

I had just started the 2nd unit of blood when I heard my name being paged again. 4 was ready for her pain medication & 2 was having difficulty breathing. I had to stay with my patient receiving the blood…especially since his blood pressure had just plummeted…but it’s never a good thing when someone says they’re having difficulty breathing. I called the charge nurse & asked her to check on 2 for me. 4 was going to have to wait about 15 minutes for her pain medication.

Once I felt comfortable leaving 1, I went to check on 2 & the respiratory therapist was in there giving him a breathing treatment. I got the pain medication for 4 & was on my way there when I spot a naked bum flying from the bed to the bedside commode, leaking poop the whole way there… I called for reinforcements (and housekeeping). 30 minutes later I was finally on my way to 4 when I got paged again. 2 was breathing easier but was nauseous & 1’s blood pressure was lower than low.

I paged the doctor about the blood pressure & pulled up the nausea medication for 2 while I was waiting. On my way to give 2 the medicine the doctor returned my call & gave me new orders for 1. So I entered in the orders, went to 2, gave him the meds & was paged again. 5 needed more pain medication & something to slow his diarrhea, & 6 needed something for nausea.

The entire night played out like that…over & over being paged & pulled from here to there; trying to fix one crisis after another…it was exhausting! I believe I STARTED my charting that night around 3am which is about when everyone finally settled down.

When it was time for me to do my final round that morning I started with 1. He was looking much better after the blood transfusion & his vital signs were stable, but he was still pooping a decent amount of blood. 2 was finally sleeping well so I decided not to wake him just yet. 3 was worn out from the night of pooping, but her potassium was back down to normal. 4 wanted her pain medication. 5 wanted his pain medication. 6 needed another bath, new linens, & more nausea medication. I was almost finished in 6 when I heard my name paged…I was needed immediately in 2.

As I run down the hall I immediately started to worry: what if he’s not breathing? What if he can’t breathe? What if he’s thrown up & he’s choking on it? What if? What if? What if? By the time I got there & found out that his colostomy bag had exploded all over the place, I couldn’t have been happier. I was just thrilled that the man was breathing! Who cares that we were up to our elbows in shit!

Talk about a memorable night…


Always the student

April 29, 2012

I am 5 more night shifts away from being on my own at work. May 14th will be my 1st night at work without my preceptor. When I first started, a 12 week preceptorship seemed like a really long time…now it’s only 60 hours away from being over. I must admit, I’ve learned more over the past 10 weeks than I have in the past 2 years combined.

I don’t claim to know it all. Yeah, I got good grades in school, but that really doesn’t mean a thing. I truly believe that what you learn in nursing school is a generalized overview…just enough about everything to get you through state boards. No one told me that the real learning would begin once I started working.

Sometimes I get frustrated when I don’t know the answer to a patients question. Or when I tell my preceptor what’s going on with my patient & she asks me what I should do. I feel like because I did well in nursing school I should know everything. I’m beginning to realize that it’s ok to tell a patient, “You know, I’m not sure. But I’ll do everything I can to find out & get back to you.” when they ask me a question that I don’t know the answer to.

I learned in school that the abnormal lung sounds referred to as crackles make explosive, “popping” sounds when you listen to a patient breathe. We were taught that crackles can be heard when there’s an accumulation of fluid or when there are some areas of collapsed lung tissue.

Since I started working I’ve learned how to predict which patients will probably have crackles based on their disease process. I’m not always right; in fact, I’m usually surprised at least once per shift. It just goes to show that as a nurse, I’ll continue to learn throughout my career. Whether it’s in the classroom or the hospital room, I am Always the Patient, Always the Nurse, Always the Student.


Addendum

March 30, 2012

I had every intention of mentioning this in yesterday’s post, but it somehow got omitted in my sleep deprived stupor. Somewhere in between complaining about not being able to sleep & dreading what may become my near future, I wanted to mention the fact that regardless of how bad I make things seem, I still LOVE being a nurse.

I’m honored to be a part of the nursing profession. Whether I’m writing about wiping butts, my pathetic attempts to stifle my gags while suctioning a trach, or how little sleep I’m running on, I wouldn’t trade it for the world. We will all spend a substantial amount of our lives at work – considering that, I truly feel blessed to be able to do something that I love. Besides, I can sleep when I’m dead, right?


Up all day

March 29, 2012

On any given day I can sleep for hours on end…unless of course I’ve worked the night before & have to go back in that night. Take today for example: I worked 7pm – 7am, got home around 7:30am & have to be back again at 7pm. It’s almost 1pm & I’m still wide awake.

I came home this morning, put my pj’s on, washed my face, drank a glass of warm milk, took a rapid release 5mg melatonin & was in bed by 8:45am. I used some relaxation techniques & visualized every muscle in my body relaxing, starting with my head & going all the way down to my toes. I was completely relaxed.

It was then when a bird that must have been perched on my bedroom window sill let out the loudest mating cry I’ve ever heard. There went my relaxation…

I looked at the clock & it was 10:21am. I got up, fixed myself another glass of warm milk, took a Benadryl & headed back to bed. Again I started with my relaxation techniques while practicing deep breathing. I laid there for an hour but I could not get comfortable.

I moved to the couch. At any point & time I can lie down on my couch with a House or NCIS marathon on in the background & fall right to sleep. Not today though! So here I am, updating you all on how my journey as a night shift nurse is going.

I have cut out caffeine completely, except for one cup of coffee or can of soda at the beginning of my shift. I’ve still got my black out blinds & my white noise machine in my bedroom to help with the light & sound. I’ve considered that perhaps it’s all in my head, hence the relaxation techniques.

The one thing that I haven’t tried (and I’m still reluctant to do so) is to fully commit to living at night & sleeping during the day – regardless of my work schedule. The world just isn’t night shift friendly, at least the city I live in isn’t. Not to mention the fact that if I’m ever going to find a man I’ll have two dating pools to choose from: my patient’s (HIGHLY frowned upon) or Wal-mart’s finest…you know…the ones who come out after dark.

Until the day comes when I decide to live upside down & backwards for good, I’ll keep you posted as I continue trying your home remedies to sleep during the day. So please, keep them coming!


The trials & tribulations of a night shift nurse

March 14, 2012

First & foremost – I am SO thankful that I have a job. Out of our graduating class of 38, a little less than half of us have found jobs (we graduated on December 12th). Having said that, I must admit I’m having a very difficult time adjusting to night shift. Working from 7pm until 7am just isn’t natural. My schedule for the next three months is work 3 nights in a row, have 4 days off. It’s a pretty nice schedule considering I have every weekend off & 4 days to recover. That will change once I’m done with my preceptorship.

For the most part the other night shift nurses have worked nights for years & they swear there’s no way they’d switch to days. Nights on a hospital floor are generally calmer, quieter, & less stressful than day shift. The doctors aren’t there, family usually goes home, & the patients don’t go off the floor for procedures. It’s a great setting to learn the ropes of being a hospital nurse…if you’re able to adjust to the schedule.

That’s where I’ve been unsuccessful so far. Quite frankly, I’m not sure what else I can do to fix it. I stay up late Monday night and sleep in late Tuesday to prepare for my first night. The first night is the easiest for me. Things start going downhill when I get home the next day.

I come home, eat a bowl of cereal, & turn on the news while I unwind. I like to be in bed by 9am. If I can fall asleep within an hour there’s a good chance I’ll get 6 – 7 hours of sleep. My bedroom windows have blankets over them to block the daytime sunlight & I use a white noise machine to drown out traffic.

As soon as I lay my head down I’m wide awake & my mind is racing. Before I know it, my alarm is going off & I’m lucky if I’ve gotten 2 – 3 hours of sleep. Do that two days in a row & it makes the third night pretty dreadful. I’m beginning to feel like I stay awake for three days & sleep for four. So I’m looking for suggestions & advice: how do you other night shifters do it?


Training wheels

March 5, 2012

Last week was my first full week of my 3 month preceptorship. I worked 7pm – 7am Tuesday, Wednesday & Thursday. Of course I was sick with a sinus infection the entire time, but what else is new. Regardless, I am officially a “nocturnal nurse”.

My preceptor is a fantastic nurse who has a lot of experience in several different areas of nursing. She’s the charge nurse which has its pros & cons.

  • Pros: She knows just about everything & she gives me great advice on how to work more efficiently. I also have more freedom because sometimes she gets pulled away to admit patients or help the other nurses.
  • Cons: Sometimes she gets pulled away to admit patients or help the other nurses.

I am confident in my abilities & I know what my limitations are. But after having an instructor watch my every move for the past two years it’s hard to take those training wheels off.

I was in charge of 3 patient’s last week & one of them was complaining of nausea. After checking his orders, finding an order for a PRN dose of Zofran for nausea, pulling it from the pyxis (a magical machine full of medications), & gathering all my supplies, my preceptor said, “Ok. Go ahead & give that IV push & meet me back here. We’ve got a new admit coming to room 5.” I looked at her, said “Ok” and wheeled my workstation to the patients room while thinking “Oh my gosh! They’re really gonna let me do an IV push without watching me!”

Standing outside of the patients room I realized there was no “they”…this was all me. I was pushing a drug under MY license number, not someone else’s like in school. Even though this is a task that I am perfectly comfortable doing (and one that my preceptor had watched me do several times) I was still nervous. I checked the 7 rights at least three times:

  1. Right patient
  2. Right medication
  3. Right dose
  4. Right time
  5. Right route
  6. Right to refuse
  7. Right documentation

After telling the patient that he had the right to refuse for the 3rd time he looked at me and said, “Are you trying to hint to me that I should refuse this medication?” Thankfully, I played it off & blamed the fact that although I had done this before, I was a new nurse so I wanted to cross all my T’s & dot all my I’s. He smiled & politely said, “Consider ‘em crossed & dotted. Now give me the damn medicine before I puke on you.”

I love being a nurse. I can’t wait to experience more firsts. In a couple of weeks, I know I’ll be ready to take those training wheels off…until then, I plan on soaking up all the knowledge I can from my preceptor while taking care of those in need.