Last night was one of those nights where I was split between two hospitals. From 7-11 I worked at the acute psyche facility. This particular hospital happens to be located in a rather bad part of town. For example, we had a patient needing medical treatment and transfer to the ER for physical assessment. As security and I waited at the rear doors for the ambulance we noted two people across the street shouting at one another. About a minute later shots were fired, two shots to be exact, and I decided that perhaps I would wait inside the facility. My co-workers were kind enough to let me leave at 10:30 and with security at my side I bolted to my car and headed across town to my next assignment.
I arrived and received report at which time I was told "the admission is done" Now, I have noted over the past many years that people have varying degrees of the definition 'done'. If I tell someone an admission is done then I mean that all the orders are checked, noted and initiated. Apparently the person I followed meant only that the orders had been checked because I soon discovered that my admission still need tube feeding started, IV started, wound vac applied and his HS meds. Whew! Glad the admission was 'done'.
Moving right along, I soon discover that it is 12:50 and I have 10 minutes to hang an IV antibiotic or be out of compliance. Patient has a IV lock which I try to flush only to discover that it is infiltrated. Oh yea! The patient with a critical INR of 10 needs a new IV. I run to get supplies and hurry back to his room. Although he received Vit K today there is still ample amounts of bleeding as I pull one IV and insert another. Got it on the first stick (go me), scanned the drug, got it hung and all with 3 minutes to spare. I'm pretty sure that's some kind of personal record. Of course while I was inserting the IV my phone rang with the news that my patient in room 21 had resps of 44 and so this is my next stop.
I enter with the understanding that the family has not totally committed to comfort cares even though my patient is in multi-system failure with critical labs in multiple values. And of course, no bi pap to ease her breathing and statements like "she really doesn't seem to be in pain." I review with the family (again-as previous shifts documented) that her labored respirations is an indication that she is struggling for air and that we can give her something to help relax. Family agrees and I am dismayed to realize that she has only low dose Ativan 0.5mg IV q6 hours. I page and get it changed to q2 but doc is not interested in increasing the dose or giving Morphine. I give the Ativan and of course it really doesn't help. Her respirations remain labored throughout the night. At six am I get the call that now her K+ is critical at 6.2. MD orders Kayexelate orally or enema if she can't swallow. I am torn and so I page the palliative care doc. Although I understand it is not supposed to be my job, under the direction of this doc, I approach the family about the Kayexelate. I explain how it will pull out her K+ by giving her diarrhea no matter if we give it orally or rectally. I continue that even just one hour ago when we lowered the head of her bed ever so slightly her lips and nail beds turned blue and that even if we were to to get her potassium down today, it would be back up again tomorrow because of her renal failure. I also explain that if we do nothing, her elevated potassium could cause her heart to go into an arrythmia, an abnormal rhythm, and explain that this would be a very gentle death. I ask them again do they want us to focus on comfort and dignity or continue to persevere. Mercifully, the daughter spoke up, "I don't want her to have it. She would just be miserable and I don't want her to spend her last days getting on and off a bedpan." I hold the daughter's hand and commend her for the strength of her decision and let her know that the palliative care doctor will be in soon. She hugs me and thanks me for the care I have provided. A very rough ending to a very rough night but at least on this day I don't have to torture a patient with medications as they die. I also managed to get that Morphine order from palliative care and give a dose before I leave. It is the least I can do.
As a nurse for over 20 years I have worked with CNAs, Techs, LPNs/LVNs, and RNs of every caliber. What I have discovered is that each has value beyond measure. Currently I am blessed to work in a staffing pool for a major hospital system that allows me to use all my experience in various fields at six different hospitals to keep me challenged. My goal at Life As A Nurse is to share the experience, good and bad, with all of my nursing peers, those in school to become a nurse and those who are curious and thinking of nursing. May my journey and those of others who share their stories here guide, refresh and most of all, let you know you are not alone. God Bless all nurses at every level. Lord only knows, we deserve it.