09:45: This is where it starts. I am admitting a patient, a young NICU nurse with Crohn's disease, being worked up for possible liver failure. She was A&Ox3 and scared as HELL. And in pain. With a PCA.
As much as I consider PCAs a wonderful invention, they always tend to exasperate me. The user interface kind of sucks. I think it's required to suck, so the patient can't figure out how to reprogram it. You also need a second RN to witness every change you make. It also involves heaps and heaps of documentation, including a computerized pain assessment form. Filling it out feels like trying to shove a square into the circle hole. Thanks, JCAHO.
This young patient tells me that her mother is flying in from another city, where her 30 year old brother has just had surgery to remove his jaw. He has throat and neck cancer. So at some point I need to intercept the Mom and make sure she's not hysterical. I am starting to tear up, myself. As a new nurse, I have not yet developed that hardened exterior which prevents me from with over-emoting on the job.
Back to the pain issue. I consider this a priority considering she's A&O and hemodynamically stable. She's also scheduled for a CT scan, so I want to get this issue wrapped up before she has to be transported. I had to negotiate with the resident 3 separate times to increase her dosage. He kept upping the demand dose by 0.1mg, which was ineffective. He was finally advised by the attending physician that it was okay to implement a basal rate of 1.0mg/hr.
So each time he rewrote the dose I had to reprogram it, and find an RN to witness. This whole process took an hour.
While I was admitting this patient, my other patient was being extubated after about 2 ½ weeks on the ventilator. A precarious situation at best, I wasn't sure if he would fly. So I had to leave my new patient several times to coax my other patient to take deep breaths and get his 02 sats out of the 80s.
So now the docs are rounding on my first patient. I really want to participate (and am expected to participate) so I can figure out where they are headed with her diagnosis and plan of care. Unfortunately I am busy re-programming the PCA, after having flagged down yet another nurse to witness my dose change).
And now she's off to CT. It's noon. The docs have just ordered about 20 labs on her. She has one peripheral IV with D10 running through it. I need to stick her and am horrible at phlebotomy. I will deal with this when she comes back.
I assess my other patient. He's fine so I sit down to work out this whole computerized pain flowsheet that I must document. I need to document every change I made, with an assessment to match, I need to document every aspect of her pain (quality? Duration? Onset? Who actually feels like answering these questions when you are, in fact, in pain?) I need to find the macros (tiny embeddied programs which add the pain assessments to my vital signs flowsheet) I am not sure which ones to use. I ask another nurse for help. She prints me out the official pain protocol. Nice of her to do so but it's really not helping me.
My nurse manager walks by asks how I am. I tell her I'm really frustrated at the moment with the PCA and all the documentation associated with it. She suggests that maybe it's because I'm new and inexperienced with PCAs. Thoughtful of her to point this out but it's not helping my current situation. Not one iota.
I look up at my monitor and realize that my extubated patient is not flying. His sats are down, pressure's up. I go in to find him very upset and agitated. He points downward. I lift up his sheet and see that he's lying in a massive pool of old bloody stool. His fecal incontinence bag has suddenly burst. He has had 3 massive GI bleeds in the past 3 weeks. The end-product was now in his bed.
I grab yet another nurse to help me clean him up. We lay him flat and start to roll him and his 02 sats go down even more. He has audible wheezing. We straighten him back up again. We tells the docs, who order a chest x-ray. We then decide that if we crank up his 02 and get two additional nurses to help us, we can get this poor guy cleaned up.
We were wrong. This time he desats AND bradys down to the 40s. One of the senior nurses tells me that if he has a choice between breathing and laying in bloody stool, he must choose breathing. Or else die.
By now it's almost 2PM. My other patient has been back for awhile and I am woefully behind in her care. The charge nurse is telling me I must go to lunch. I am supposed to report off to another new nurse who is on orientation. I tell her I don't feel comfortable with this, there are too many tasks that need to be done. She tells me, "Well, the orientee has to learn, and if she can't do it then you need to delegate to someone else."
Okay. So I find the orientee. Her patient has just returned from CT and his blood pressure is falling dangerous low. We collectively decide that I will delegate my tasks elsewhere.
I find a nurse to help me and she agrees to draw all of my labs (yes!). While she is doing that I take the opportunity to catch up. I'm looking through all of my new orders. We use a computerized Physician Order Entry system (POE). When a patient gets transferred, the screen has a tendency to look very messy, with the current orders and the discontinued orders all culminating into one big cluster you-know-what. In the back of my mind I remember that my patient had a dangerously low blood sugar at 4:30AM. I am expecting the physicians to write an order to check blood sugars once an hour but I can't find this order. I did check her blood sugar at 11:00am (it was 150) and know the labs that were just drawn will give me another blood sugar, so I forget about this. I also have an order for vancomycin from 10AM. I seriously doubt that you can hang vancomycin and D10 so I'm wondering what to do. I investigate the matter and find out that it's an old order that should have been d/c'ed but never was.
Now it's 3PM. The charge nurse insists I get off the unit and go to lunch. On the way the intern stops me and says that if her labs look good, we could probably transfer this patient to the step-down unit!!!! Great!!!! That would mean that this young scared patient would have been tranferred to 3 different units (as well as the CT scan) in less than 24 hours!
How wonderfully efficient!
I head down to the cafeteria. On the way I realize that something is going on with another patient I have had many times in the past. She's status/post lung transplant and has been intubated/reintubated at least 3-4 times in the past year. I am sensing that she is going to die today, as I see many of her family members around. I've gotten somewhat close with them over the past couple months and it frustrates me that I don't even have a single minute to spend with them and maybe give some comfort.
That changes once I sit down to eat my cold pizza. The husband of this dying patient approaches the MICU lunch table and says tearfully, "I just want to thank you for all of your caring and support."
I jump up from my chair. "Has Beverly passed?"
"No," he says, "but she's going to."
I give him a great big hug and burst into tears myself.
Then I am back at the table and I've swallowed my tears. So much for emotional decompression.
By 4PM I am back on the unit with renewed courage and resolve. Unfortunately my day will tailspin into a complete and total mess.
My young patient? Her electrolyes are in the toilet. I need to replace them and I have no IV access. She has now begun continuously vomiting and has diarrhea, with no bathroom in her room, not even a commode.
My other patient? He is more and more agitated. Since he tolerated laying flat for the physician to pull one of his central lines, I decide I will risk cleaning him again. Boy, was I wrong. This time he bradys down to the 30's.
And all the other nurses are in the break room.
Eating cake.
For a baby shower.
(If you've read my earlier posts you will know that I've been trying to conceive for two years now.)
PART TWO....
I am now giving my report to the night nurse. I preface this by saying, "Look. I've had a really terrible day. I felt like I never quite got caught up. I'm sure there are some things that I've missed."
She shrugs this off and I continue on with report. We get to the part where we go over recent lab values. She says, "I don't care about her labs."
I reply, "Well at least let me tell you about her abnormal electrolytes," and proceed to do so.
Then we get to the part where we each review the orders of the day and sign off on them. She is already walking away from me. I ask, "Aren't you going to go over orders?"
She just dismisses me with a wave of her hand and says, "I don't do that."
It is our unit's nursing policy to review labs and orders. I am too tired to argue with her. Plus she has 10+ years seniority over me.
I go home for 10 hours and return in the morning. I have given myself many pep talks so I can face the new day. Despite this, I feel extremely low.
When I go to get report from the night nurse, she pulls me into an office and shuts the door.
"Listen," she says. "I had to report you to Patient Safety Net."
Apparently there WAS an order for 1 hour blood sugars. I had looked for it but I could not find it. Somehow it was there all along and I did not see it. Also, I left the potassium pills in the young patient's room. In the midst of her vomiting and diarrhea storm, I forgot to throw them away.
She then proceeds to lecture me on everything I did wrong.
She wants to know why my patient was admitted at 10AM and why my labs weren't drawn until 2:30PM. I guess she didn't realize that the labs were actually ORDERED AT NOON and that my patient was OFF THE UNIT FOR A CT SCAN.
I try to defend myself to her. She comes back with, "In a court of law it doesn't matter! You have to CYA! You have to protect your license."
Remember, folks. This is the same nurse who failed to follow nursing policy and review the orders and the lab values with me before I left for the night.
So I did what I absolutely did not want to do. I burst into tears. Night nurse leaves the room to go get someone else to handle my emotional outburst.
So after crying to the nurse educator for about an hour, I leave the unit. I am ill-equipped to handle patients that morning. I am thinking that no amount of pain is worth this. I am thinking that ICU nursing is probably not for me. There's a local psychiatric hospital that would hire me (if not admit me) on the spot.
And people wonder why there's a nursing shortage.
