Saturday, February 23, 2008

Clincal Journal Entry #5: 2/20/2008

Today, our clinical goals were to chart vitals (my patient was q4h so I had to get 2 sets in the computer), and to actually complete and fully document a head-to-toe assessment with the co-signature of my instructor.

Kinda boring, right? But one thing I've learned is that there are no boring days as a nurse. The reasons vary, but the statement remains the same.

This week, my patient was especially exiting for me. He was in with a renal hemorrhage and failure to void. It was an obvious problem because he was on strict I&Os;, and they consistently asserted that he was receiving literally liters of fluid and only voiding a few hundred mL a day. I was extremely excited to solve this mystery. I worked with my instructor to think of where all of the fluid could be. Was it presenting as edema? Nope, he had no edema anywhere on his body. Was it lying around somewhere in his lungs? Nope, they were entirely CTA (clear to auscultation). Perhaps it was sitting in his bladder? The doctor ordered a bladder scan which my instructor observed me perform, and it showed only 197mL of fluid in his bladder - a far cry of a couple liters. Unfortunately, my 6 hour clinical wasn't long enough to see the mystery solve, but I'm so curious as to where they found that fluid! My best guess now is that it's somehow hidden in one of the intricacies of kidney physiology. The nephrologists were definitely called in, and I'd love to know what they had to say...

But back to nursing, today was a huge experience for me because I got to try and learn a bunch of new things. For one, my patient was legally blind due to macular degeneration, and he was very hard of hearing. It's amazing how much we take for granted. I consciously tried to speak slower and clearer and use more descriptive words and just remember that he couldn't see anything I assumed he could. This is definitely a skill we as nurses need to master. Especially when a patient is both blind and (to an extent) deaf, communication is severely hindered. A normal deaf person would be extra-competent in lip reading, but what about if he was blind, as well? A normal blind person would have an extra acute sense of hearing, but what if he was deaf, too? See the issues here? By the end of the day I was doing really well remembering to talk slowly, loudly, clearly, and explain things in great detail. Let the patient touch, feel, sense things. "Patient, can you feel this? This is what I'm going to put on your legs to help the blood flow better." Take the patient's hand and put it on the edge of the bed, "Here is the edge of your bed, okay?" "Here is your cup." "Here is your call button." Pointing won't get you anywhere, so you better make sure the patient can feel where it is. It's amazing how strong these patients' sense of tactility is. Early in the morning, I recall looking at the picture of an adorable baby on his bulletin board. "Who is this cute baby on your wall, Patient?" I asked. As soon as he made the strangest look on his face, I realized what I had done. He has no idea what I'm talking about! "Oh, I'm sorry, there is a picture of a cute little baby hanging on your wall." And then he realized it must be his new great-great-great granddaughter, and I asked him to tell me about his family. So it's a work in progress, but I learned a ton from this patient who was so patient with me as I worked on my blind-deaf communication skills. (I can't even imagine how hard it would be if a patient were blind and completely deaf!)

One of the first things I noticed in the morning was that Patient didn't have any leg compressors on. He had been in bed for a few days and was not very ambulatory (his nurse told me that even getting him up into the chair was a feat in itself), so I would definitely consider him at risk for pressure ulcers, DVTs, etc. Sure enough, there was an order in the computer for them. I told his RN that I couldn't find any pneumonic compressors in his room, and I thought he should definitely be on them, so she came into the room almost as if she didn't believe I couldn't find any. Sure enough, not in there. I was kind of upset that it took her probably 2-3 hours to feel like calling down for them (why don't they even keep those things on the floor?), and I was also upset that she, being his RN, did not notice that. Now I know you can play the "overworked, too many patients, etc etc" card, but still. That's too big of a risk to take. But I watched it, and I made sure I had those on his legs by the time I left.

Just did a bunch of little things during the day that added up to consist of a bunch of hours... Beds, baths, position changes, charting, assessments, vitals, I&Os;, the crazy computer system, ya knowwww.... :) I really did have fun with my patient though. He was such a sweet guy, definitely a joy to be with.

Right before we left for lunch and post-conference, Patient's IV kept beeping, claiming there was an occlusion. This went on for almost an hour, so RN finally decided we should pull it and put it in his forearm instead of in the bend of his arm where the tiniest movement would set it off. Of course I wasn't going to leave at the opportunity of a very competent nurse willing to teach me how to perform an IV insertion, so I bet you'll never guess whether I stayed to observe or left to meet for lunch.

Nurse inserted the IV very systematically, telling me what each step was and why she did it the way she did it. She taught me the trick of using alcohol pads to loosen tough tape adhesive and save Patient lots of discomfort from the tape ripping off his arm hair. She taught me what a good vein feels like and how you know when you're in. She even taught me why a Heplock is called a Heplock! (No, it's not because it's for heparin... it just used to be for heparin) Once the new IV was in and we had the tubing connected, she let me remove the old IV using the alcohol pad method and carefully just pulling the tubing straight out while applying pressure to prevent unnecessary bleeding. Very cool.

Then one of the best parts, Patient told me what a great nurse I was and how I'd made his day just by being there for him. Goal accomplished.

Then of course, post-conference was fun - it's always cool to hear how everyone's day went and what everyone else learned. It's so amazing how different, yet similar, our learning experiences all are. I really love this thing called nursing and honestly, when it comes all down to it, it's my patients that keep me going. Sometimes the going gets so rough but then I just picture them and how they told me I made a difference in their lives, and suddenly I'm centered again. Our instructor made a big point in post-conference about how one's life experiences impact who they are as a nurse and I can't agree more. It's the reason I'm here, while it's the reason I have to fight much harder than others to stay here. It's the reason empathizing is easy and I think it also might just be the reason I don't mind my alarm clock only on Wednesdays

Amazing. All this stuff... Life stuff... Good stuff... Kinda like a crazy miracle, don't you agree?