My official (late) Thank you to Mother Jones for including me in Change of shift: http://nurse-ratcheds.blogspot.com/2007/08/its-roundup-time-at-change-of-shift.html
and thank you to Susan Palwick at Rickety Contrivances of Doing Good for the add here: http://improbableoptimisms.blogspot.com/2007/08/grand-rounds-volume-3-number-49.html
I feel special! ♥
It just happened again: 3 in a row. This happened by switching with someone who needed the day off.
I am tired. 3 twelve hour shifts are never twelve hours. (at least not for most new nurses).
I get to work at 7am. I leave by 9 pm at the earliest (sometimes). I just have not found that key to organization to get me out on time.
Trying to get everything done is impossible. I learned to say no to the night nurse! My patient rolled onto the floor at 6 pm from the ED. I took vital signs, assessed for chest pain, called for admission orders, deemed the patient stable, and that was that. I was not going to stay even later, to … admit the patient, reconcile medications etc…I just said it is a 24 hour job. I said the policy says….”…………………..” Oh I got “b****ed out for that one! She said she is aware of what the policy says, she asked me if I was aware of “nurse courtesy” OK I felt like a jerk. What is a new nurse to do?
I am not super nurse.
Meet Jane of the hospital jungle.
I am not Zorrita Nurse.
I am not Zorro nurse girl. I can not make everything perfect for the next nurse! I am doing my best.
Some time ago in the not so distant past someone, somewhere, at some hospital was a patient with severe cardiac decompensation. A new nurse on some telemetry floor in some hospital was caring for this patient and she was in distress over this dropping, dropping blood pressure.
Some cardiologist (not Zorro MD) was in the hallway telling the family member: The prognosis is not good. The heart has failed. There is nothing we can do. Family member gets bewildered look, not really comprehending.
New Nurse is some feet away waiting to ask the cardiologist what nurse can do for this falling blood pressure and increasing heart rate, not realizing the clinical situation and not realizing what is being said to the family member. Cardio (calmly) goes back to the desk where nurse is standing and family member comes “reeling” into nurses arms in tears.
Cardio starts the patient on dopamine 5mcg/kg/min–which improves the pressure (observed fairly quickly to nurses surprise) and new nurse is so happy it is sickness in itself. (can not understand it yet). Patient is now hovering around 94 SBP.
But then…..of course at change of shift time the patient becomes symptomatic, of course the patient has become symptomatic. The patient was admitted with CHF and a BNP greater than 5000. Nurses have been holding diuretics IV for the really low pressure for the last 18 hours or so. (in fact most of the patients medications have been held for these pressures). All cardiology has left the building. So the new nurse calls. “umm….cardio I am calling because this patient is short of breath, has terrible lung sounds (increasing), and increasing tachycardia, although happy to say that pressure is improving, and complaining of chest pain.” cardio replies: what do you want? New nurse says: I am a new nurse, you tell me.
Adds dobutamine 5mcgs, continue the dopamine (cardio tries to give new nurse titration orders and new nurse politely tells cardio that she can transfer this patient to the unit but can not titrate on this floor so it is set at 5mcgs/kg/min) and cardio gives parameters for lasix so that the lasix can be given now. This is all given as a question.
New nurse says OK and reads everything back to be sure on the double, but what about this tachycardia?
Cardio is not to worried about the tachy at 117. New nurse thinks this is the price the heart will pay for better perfusion to the–kidneys and other pertinent organs. New nurse is ok with it too. For some reason new nurse feels that this may not be the end though.
One hour into the night shift and New nurse is sitting at the nurses station at her little computer….documenting still. When the monitor is dinging and alarming for that patient…and the tachy is getting more tachy. The patient is sweaty, cool, and complaining of chest pain (I guess so at 160 beats per minute). The whole family starts crying, they fill the hallway. New nurse watches night charge nurse roll in the cart. House Doc asks for Lopressor, given by night nurse, and heart rate decreases slowly to 110…with a pressure of 112/80. New nurse walks out the door.
Of course for days and days and ever more….New nurse will be wondering about the works of Adrenergics and how they mysteriously raised that patients blood pressure. New nurse is seriously amazed: it was a small dose these 5mcgs, but they worked! I wonder if any other nurse became so amused after this observation for the first time. ?
I am frustrated that I display a lack of confidence sometimes. There is just so much I need to learn and “re-learn”. Over and over again.
I want everything to be perfect and stable (all the time) and when 7pm comes around. I want all my patients in clean white sheets, relaxing comfortably in their rooms, clean, and tidy and in no distress. I am just so “hung” up on this. So I work and work like a busy bee all day for 12 hours and feel like I am going round and round trying to “fix” everything. When 7pm comes–it “looks” or seems that there is so much more–and that I did not do anything!
And it gets worse if the night nurse starts aggressively asking questions before you can finish (i am getting there!) I am trying to get all the information out in one sentence…but that is really not physically possible.
Anyway I will surely write that post when one day—one fine day– all my paitents are pretty clean in white sheets, all with stable pressures, all NSR on the monitor, none of whom are in pain, none of which are febrile, all smiling happily ready to meet the next nurse!
So patient is going to have steroid injection with lidocaine into the shoulder for torn rotator cuff pain. Ouch. That is the least of my worries though. The patient only has a blood pressure of 78/56. The orthopedic surgeon who is about to inject the steroids into the patients arm with a needle, thinks that the needle should raise the blood pressure.
The shoulder is the least of my worries.
The liver. I must admit does not excite me to much. Most likely because I am still trying to understand so many other things. It just so happened that one week (meaning 3 twelve hour shifts) which I will not admit when, I happened to be caring for two people at the same time with problems both related to cirrhosis of the liver.
During this time I observed: Mental deterioration. Ascites, and care after paracentesis. I was also informed by Zorro (one of the many Zorro’s I will not reveal which Zorro) that I was also observing: Low SVR syndrome and Hepatopulmonary syndrome. I am still trying to understand the latter, as for low SVR syndrome, I “get” it but still do not understand why it is happening with liver problems. For more info on these complications see the link: See Lesson 1 and Lesson 13 here:http://www.chestnet.org/education/online/pccu/vol14/index.php It helped me a bit.
I observed: fatigue, malaise, disorientations, distention, jaundice, itchy skin, shortness of breath.
I felt: sad and tired from repeating myself over and over with no verbalization of understanding. I was worried.
I felt: happy with decreasing ammonia levels and better understanding, better response and improved mental status.
Be nice to your liver it does alot! The liver is in the right upper quad of the abdominal cavity!(yeah!) It helps regulate blood glucose. It converts the toxin Ammonia to urea. Protein metabolism. Fat metabolism. Vitamin and Iron storage. Drug metabolism. Bile Formation. Bilirubin extretion(which seems cyclic).
And all this is the reason for this latest artwork above titled: your liver. Don’t forget to click on the liver to make it bigger!
Impression
(zorro MD)
See Jane Nurse 
