Two in One Night...Oh Come On!!!!

There are bad nights in the hospital, and then there are really bad nights.  Last night was a really bad night.  As I walked into the hospital and made it to the floor I work on, I heard over the loud speaker “Code Blue, Code Blue”.  This is not a good thing at all.  In fact it means that a patient is coding somewhere.  As I rounded the corner I found the excitement.  I jumped in with chest compressions and helping out wherever I could.  Unfortunately, the patient was too far gone and was not able to be saved.  Not a great way to start a shift.  This was going to be a very long night. 

As I was making my rounds, one of the nurses informed me of one of her patients that was not doing very well.  In the few minutes we had been there she had started to take a turn for the worse.  Her oxygen requirement had increased and she had to be placed on supplemental oxygen.  Her breathing had also increased and she was having trouble catching her breath.  We paged the doctor who ordered a chest X-ray and some medication, Lasix, to help pull any fluid off of her lungs.  However, he was not extremely worried about the patient’s condition. 

However as the night progressed, the patient respiratory status continued to decrease.  Her oxygen was increased again and again until she was requiring the highest amount of oxygen therapy we were able to provide on the floor.  She was still having trouble catching her breath, and after every breath she was having a weak cough.  In fact just by looking at the patient it was obvious she was exhausted and her energy to even take a breath was wearing out quickly. 

We re-paged the doctor, who came to the bedside to assess the patient.  He continued in his assumption that there was nothing wrong with the patient and he did not want to do anything at this time.  We paged Rapid Response and they came to access the patient and immediately knew something was wrong.  They managed to push the order through to get the patient moved to progressive care, however as our luck would have it there was no beds available at the time and it would be awhile before the patient could be transferred.  This turned out to be a very dangerous situation, because the patient was quickly approaching a point where she was not going to be able to breath at all on her own, which means we would have to call a code and the likelihood of reviving the patient would be slim.  However, if we could find a progressive bed for her they could move her and intubate her before it reached the point of a code.  Two hours later, a bed finally became available.  As Rapid Response began to move the bed to transfer the patient, she stopped breathing and they ended up taking her to the progressive floor doing chest compressions.  When they reached the new bed, they intubated the patient and she was able to get the oxygen her body demanded.  This was one work night I wished I would have called in for. 

What in the World is Going on With This Patient?

Sometimes one of the hardest things about nursing is knowing what is actually going on with a patient…especially in the middle of a patient decline.  During a decline, it is the responsibility of the nurse to inform other members of the healthcare team (doctors, rapid response, and respiratory therapists, etc.) what is happening with the patient.  The information obtained from the nurse helps set the treatment plan. 

However, many times when a patient is declining, there are a million reasons why the patient may not be doing well.  In fact many times, it is impossible to tell right away because so many different declines may have similar signs and symptoms, which may prolong diagnosis and treatment.

 
The other night was a regular, ordinary night with not much action occurring.  In fact we had all gotten into the mindset that this was going to be a good night, and this was our mistake number 1 (Never ever as a nurse or healthcare professional even entertain this idea, because as soon as you do, you will have jinxed yourself 
every time).

 As we were basking in our quiet night, one of the nursing techs came and informed us that one of the patients was acting a “little funny”.  She was definitely more confused and more agitated then she had been for the last few nights we had been there.  We went and checked on her, but found nothing to be alarmed about, our mistake number 2 (Never assume just because some patients get confused over night in the hospital, that this is normal for all patients).

 Twenty minutes after checking on this patient, I was giving some medications to another patient, when I heard patient number 1, start yelling at the top of her lungs.  “Help!!! Help me!!! I need you to help me right now!!!”  I went running into the room with the other nurse and we found the patient laying in the bed with a crazed look in her eyes and tossing herself all over the bed while still screaming at the top of her lungs.  Her next words got us springing into action.  “I think I am having another stroke!!! Help, Help me please.  I don’t want to die!!!”

 We quickly asked the tech to get a set of vital signs (temperature, heart rate, blood pressure, respiration and oxygen saturation).  While he was doing this, I quickly did a stroke assessment trying to ascertain whether she really was having a stroke.  My assessment came up inconclusive because there were some signs and symptoms of a stroke, but not enough to warrant a stroke alert.  The tech informed me he was not able to get a temperature on the patient.  I asked him if he would mind getting a blood glucose level.  Sometimes when a patient’s glucose level is low they tend to have signs and symptoms of a stroke.  As soon as the tech informed me of the glucose level of 15, I knew we had found the reason the patient was declining.

 I quickly ran out of the room to grab some D50, which is a concentrated form of sugar that is pushed into a patient’s IV to raise the glucose level in the blood.  However, as I ran back into the room with the D50, the other nurse, the patient’s nurse, informed me, “Oh shoot she doesn’t even have an IV.”

 Because of the no IV access, the treatment options had become very limited.  I quickly grabbed a glucose gel tube and some glucagon.  As the other nurse put the glucose gel under the patient’s tongue, hoping the sugar would absorb into her blood, I quickly mixed up the glucagon and administered it as a shot in her leg.  When we rechecked her glucose level again, it was 14.  Our mistake number 3.  (When you arrive for your shift and you learn that one of your patients does not have an IV, it may be a good idea to ensure an IV is placed BEFORE the patient actually begins to decline and every minute counts).

 While we were starting the IV and administering meds to help the patient, the patient was yelling the whole time.  She was saying she was dying, she knew it.  She was having a stroke and we needed to help her.  Finally I grabbed her hand and was able to calm her down with a quiet voice.  Within seconds of placing an IV we were able to administer the D50, and within minutes she was more responsive and aware of her surroundings.  Thankfully all the pieces of the puzzle fell into piece relatively easily for this particular patient decline and we were able to quickly provide treatment with no harm to the patient.  

I HATE these caps!!!!!

Many times the supplies or equipments we use in the hospital may change based on availability or cost.  The newest change to hit us has been our IV connectors and IV caps.  Now usually I don't notice a difference in most things, however, I am going to be completely honest and say I HATE these new connectors and caps.
I was in the middle of starting a ridiculously hard IV when I attached the cap (we didn't have any connectors at this time).  The IV was drawing blood beautifully, however when I went to flush it, it would not flush at all.  No matter what I did, I was not able to flush the IV, which meant that I had to take the IV out.  It frustrated me a little since I knew the IV was good since it was returning blood.  Anyway I found a new spot and put in a new IV.  This time when I placed the cap on it flushed and drew beautifully.  YAY!!!  I taped it all down and hooked up the fluids.  Of course as soon as the fluids were attached and turned on, it decided it didn't want to work (I was not happy about this, thinking I was going to have to change the whole IV yet again).  I retaped the IV and did everything I could think of to make the IV work, with no success.  I finally went to a different unit and found an IV connector.  After connecting the connector and starting the fluid, it again did not want to flush.  At this point I was beyond frustrated.  A task that should have taken 15 minutes was turning into a 45 minute job.  Finally I got the bright idea to replace the cap on the end of the connector.  As soon as this was done, the IV worked like it should have.  I was so happy that I did not have to change out the IV again, especially since the patient was needing some blood pressure meds for her BP of 220/113.  

I Kill You!!!!

Since I work in a big hospital, there are occasions when the patients we care for are prisoners from the surrounding areas.  Many times, people are scared to enter their rooms because they are afraid they will get hurt, however, I always think these are the safest patients because there are always at least one guard stationed in the room.  The patients that always make me a little paranoid are the patients who have a mental health issue.  There are no guards in their room, and many times, it is impossible to tell what they are thinking or about to do. 
One patient in particular this week has managed to make most of the staff members wish we did not have to enter his room at all.  He was admitted for osteomylitis in his spine secondary to a past gunshot wound.  From the minute he was admitted he was telling stories of his time in prison.  While making conversation he would expand that it was because he had killed his first man when he was 10 years old.  As he continued to talk his stories became more and more violent and graphic, until he reached the point he was threatening every person who entered into his room. 
Well of course I was the lucky person who got sent into draw some labs.  While I was doing this, he was screaming at me and threatening to throw me through the window.  It was quite fun.  Honestly, I got the impression he threatened everyone but would never really act on his threats.  He said he was going to bring a gun in and shoot everyone, he threatened to kill his doctors because they didn't know what they were doing, he threatened to kill the cleaning ladies because his room was never clean enough.  In fact I didn't really pay attention to most of the the threats.  However, that changed really fast. 
When I returned the next day, I was met with serious faces.  The day nurses informed me that the patient had physically threatened one of the staff members and was now a candidate for having a security officer stationed in the room with him.  However the patient could still go down to smoke unsupervised because of course we do not want to invade on his privacy (really! Honestly...how does this make any sense!!!!????).  During one of these trips down to smoke, we received a call from another security officer informing us that they were going to return the patient to us, and he was no longer allowed to leave the floor. Apparently this patient had physically grabbed a doctor in the hallway and was beating him when the officers showed up.  The reason "I don't like those foreign doctors."