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Almost

Posted Jan 27 2009 7:13pm

This week's clinical focus was time management. This has been my albatross in the past few weeks, a lot of different variables have been coming together to challenge my time management abilities. I feel like I've made some headway in getting the information and materials together to improve my organization, shedding the clipboard was a step in the right direction for this, I think.

Unfortunately, this was not the med pass I should have executed, failing to check an ID bracelet spoiled what would have been, to me, a significant improvement in my process. I completed a tutor referral that was helpful, the tutor is really good at drilling skills and thought processes in a way that doesn't seem repetitive. It took 40 minutes (the same amount of time as my last aberrant med-pass), and I walked out of it feeling much more confident about some of the neuromuscular tasks that trip me up. She suggested I come back and continue practicing and I intend to do so.

On to the patients. When I first gathered the data on my charges, I was intimidated by the lengthy histories and home medication regimens I found in the charts, but I feel that I was able to apply that information towards focused assessments and interventions.

Patient X was experiencing a small bowel obstruction. I learned in report that this problem could have been avoided by continuing her prescribed bowl regimen medications. She was an interesting person to have met. Although her history cited paranoia, hallucinations, depression, basically every psych diagnosis you could imagine, I found her a friendly person who advocates passionately for herself and other disabled people. She's a quadriplegic due to a C5-C7 spinal injury. Even still, she had enough control over her right hand to grasp and pull enough to reposition her body during my respiratory assessment. The placement of her supra-pubic urinary catheter was novel to me, it protruded from her umbilicus. This placement was optimal for her mobility in regards to urinary self-care. Her chemotherapy included two medications for muscle spasm I usually associate with Multiple Sclerosis, Neurontin and Baclofen. She exhibited generalized edema and a pronounced foot-drop. She was in an isolation room due to a MRSA infection of her bladder. Because of this, her supra-pubic catheter was clamped, and a foley was inserted to fully empty the bladder. My main concerns for her were multi fold: She needed to produce stool, which our administrations of laxatives seemed to be helping. Her bladder infection needed to be taken care of, which we addressed with IV antibiotics. Her immobility and edema placed her at heightened risk for skin breakdown, which we addressed by repositioning her body and transferring her from chair to bed via hoyer lift. She was much more modest than I'm used to seeing, and insisted that males were not present during her toileting. I supported her in this and enlisted the aid of the nearby PCTs, who were extremely helpful in walking me through the operation of the hoyer lift, which I've had few experiences with (although it seems pretty self-explanatory, working with them was extremely instructive in how to operate it gracefully). She is a nurse, I feel like I'm caring for more and more of them (us!) the longer I do this.

Patient Y was status-post thyroid lobectomy, performed earlier that day. She's in her mid 40's, and recovered nicely from the anesthesia. Early on in our time together I supplied her with some crackers (she was on a regular diet), which she promptly emitted. The RN administered IV Push Phenegran, which made her pleasantly (to her) sleepy. I encouraged the use of the incentive spirometer, she had a pretty decent respiratory effort at 1750ml. At first I was focused on assessing for hypocalcemia as an adverse effect of her procedure, mostly because I think assessing for chvostek and trousseau's sign is "really neat". What I failed to identify before reporting to the instructor was the importance of assessing for laryngeal edema. Key thing to know!! Mindful of the dressed wound on her neck, I did pay close attention to her respirations as she dozed from the effects of the antiemetic, and I'm confident that if I heard stridor, I would have immediately connected what the problem was. Still, it's vital that I remain aware of these things even when they aren't actively going wrong. The antiemetic enabled her to take in some nutrition, but not as much as I would have liked. She ambulated to the bathroom without noticeable weakness or dizziness. She had a JP drain that collected 20mls of sanguineous drainage.

Patient Z had two embolectomies in the femoral artery of the right leg. Her dressings were clean and intact, without drainage. Her history cited dementia and a long list of cardiac abnormalities, so I took care to listen carefully to her heart sounds, which I was simultaneously relieved and disappointed to find completely normal. She didn't seem like the typical "demented" elderly patient while interacting with her. When I gave her time to talk to me, she reminisced at length about her children, her dead husband, and happy memories of their family vacations. She did seem to exhibit some of the memory problems cited in the history, but no more so than "neurologically typical" people I normally encounter outside the hospital. I sat and listened to her so long that I lost track of time, she recounted her experiences in an extremely lucid and articulate way, and yet couldn't reproduce some of the basic information I asked for during my neuro assessments. My care for her included my most grievous error during this med-pass, maybe ever. She recently had a GI-bleed, her PTT was over 100, and her coumadin was discontinued in favor of a heparin drip. I replaced this bag without checking her ID bag. I spent a lot of time talking to her about her concerns about the retirement community she was accepted into after three years of waiting, and her fears that she may now be too sick to live there.

Things are coming together. Much slower than they should be, and with ridiculously stupid errors in the meantime, but I feel like I'm making progress. Abstaining from coffee and bringing a protein shake and frozen dinner made a positive impact. Despite the error, I feel like I've made a positive gain in not letting a mistake ruin my game later on, not letting my disappointment in myself distract me from continuing the job. I can do this.

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