I'm on my last clinical day...and I get an interesting case....
I get a 20 yr. old patient who has had tibia and fibula (both lower leg bones) fractures and a dislocated shoulder. Ouch!! He is in a full leg cast and has his upper right arm in a sling. It gets more interesting....Yesterday my patient was diagnosed with a pulmonary embolism. For those who don't know what this is, it is a very serious and life-threatening condition marked by a blood clot that has broken off somewhere in the venous system and lodged itself in the lungs. A blood clot in the lungs produces symptoms of shortness of breath, fever, and low oxygen saturation; basically my patient couldn't breath! They got him on oxygen 2L NC and raised the head of the bed up. He was placed on Coumadin and Lovenox (anticoagulants- blood thinners) to prevent coagulation of red blood cells to form yet another clot. My patient seemed stable and had no symptoms of the pulmonary embolism.
Now how do you get this?? Usually a clot forms at the site of injury, in his case, his leg. Due to in activity, poor circulation, lack of movement of the extremity, and/or poor wound healing, the clot could form and break off. The clot then breaks off and floats in the bloodstream where it will get lodged in the lungs. What amazes me is that he is so young. You rarely see this in patients under 40. Usually there is a history of vascular problems or a serious injury. This scared me.....
So monitoring my patient frequently was a must. He had tachycardia and became febrile a few times but his oxygen saturation was normal. I had to encourage fluids as well as the use of the Incentive Spirometer. It was very important to remind him to deep breath and move around.
The sad part to me was that his family and even the patient seemed to not understand that this was such a big deal. I mean, I'm glad no one was freaking out about it, but it seems like they don't know that this is life-threatening. Back then, like 50s and 60s, a diagnosis of a pulmonary embolism was a death sentence. Now, we know the symptoms and what to expect so we can have an immediate intervention. I know that when I'm in the hospital, I want the whole sha-bang....anti-embolism stockings, SCDs (sequential compression devices-helps with venous flow in the legs), assistance with active range of motion, exercise, fluid intake, IS use, deep breathing......I won't take any chances!
I left my patient in a stable condition. His family was educated on the medications he was to be given. His Hct and Hgb were low so he will be receiving a blood transfusion. My patient has well managed pain, and he is able to work with Physical Therapy about ambulation. He seemed in good spirits :) Though his symptoms are subsiding from the pulmonary embolism, he is now and forever will be at risk for another. So, if he has surgery again, he will have to be monitored very closely.
So I continue to learn with this experience; Life is so precious. Anything can happen at any age; whether you are physically fit or not. Health is important and knowing what is going on is important. That's why I am so glad I am going to be a nurse, because I can teach about the patient's condition and educate them on the severity as well as treatment and recovery. Like my instructor says.... "We aren't here to just take care of you.....we are here to teach you." :)
Thursday, October 28, 2010
Wednesday, October 27, 2010
Urinary Retention
Today I had a patient who was Post-Op day #1 from a Total Right Hip Arthroplasty. He was recovering well with clear lung sounds, adequate pain management, and good voluntary passive range of motion. The Day nurse D/C'd the foley catheter in the morning as well as the hemovac drain. He was on PO medications for pain and nausea medications as well.
Sadly, my patient still hadn't voided all day which concerned me because my patient could have urinary retention. My nurse asked me to perform a bladder scan on the patient to see if the patient had any urine in the bladder. The scan came out to be over 400mL of urine! eeeeek! So we needed to straight cath him right away (which means temporarily drain the bladder). The day nurse completed the task in the afternoon while I was at lunch. Around 1800 I bladder scanned him again with over 400mL of urine, again! So my nurse and I concluded that he needed his foley catheter replaced again.
So, me being all nerdy, I got excited because my nurse told me that I get to insert a foley catheter. Ohh my goodness!! All the instructors at school say, you will really feel like a nurse when you insert a foley catheter. So you know how I was feeling! Instead of explaining the procedure and grossing you out.....my nurse basically helped me step by step just to remind me of what to do. I completed the skill successfully and my patient's bladder was drained and continued to drain the bladder. YAY for new skills! :)
My patient was relieved because having a distended bladder can be painful and uncomfortable. I have the same patient tomorrow, so I hope that he will be able to void on his own :) Until then.....
Sadly, my patient still hadn't voided all day which concerned me because my patient could have urinary retention. My nurse asked me to perform a bladder scan on the patient to see if the patient had any urine in the bladder. The scan came out to be over 400mL of urine! eeeeek! So we needed to straight cath him right away (which means temporarily drain the bladder). The day nurse completed the task in the afternoon while I was at lunch. Around 1800 I bladder scanned him again with over 400mL of urine, again! So my nurse and I concluded that he needed his foley catheter replaced again.
So, me being all nerdy, I got excited because my nurse told me that I get to insert a foley catheter. Ohh my goodness!! All the instructors at school say, you will really feel like a nurse when you insert a foley catheter. So you know how I was feeling! Instead of explaining the procedure and grossing you out.....my nurse basically helped me step by step just to remind me of what to do. I completed the skill successfully and my patient's bladder was drained and continued to drain the bladder. YAY for new skills! :)
My patient was relieved because having a distended bladder can be painful and uncomfortable. I have the same patient tomorrow, so I hope that he will be able to void on his own :) Until then.....
Thursday, October 21, 2010
Open Abdominal Wound
So today I had a patient who was admitted with a bowel obstruction. My patient currently has Diverticulitis as well which together can create serious problems. For those who don't know what Diverticulitis is; it is a condition involving the diverticula (pouches in the walls) in the intestines. These pouches can become inflamed or infected. For my patient, they became infected....So they opened him up from just above the navel all the way to just above his bladder (basically right down his abdominal muscle line). They removed some of his intestine and created an ostomy temporarily so the bowel could heal before they opened him up again to continue to repair his digestive system.
I was able to work with my patient who was in between the two surgeries. They decided to leave the wound semi-open because they were going to open up the same area in surgery in a few months. The wound was about 1 1/2 inches deep and you could see the stitches connecting the lowest layer of the tissue. So my wound; about 18 inches long, 1 1/2 inches deep and about 3 inches wide. Ohh my goodness! :)
My nurse came up to me and told me to do the wound care on this patient; basically replace the old bandages. She told me up front, you need to keep a straight face, show no emotion when you look at the wound. I did very well :)
So I put on sterile gloves and packed the wound with soaked sterile saline gauze. Then I placed two Abd bandages along with soft tape. The Patient had no pain or tenderness as I was bandaging the wound. I'm so grateful that I got to perform that skill!
Now my patient will go back into surgery in 3 months and reverse the colostomy and completely close the wound. Yay for recovery!
I was able to work with my patient who was in between the two surgeries. They decided to leave the wound semi-open because they were going to open up the same area in surgery in a few months. The wound was about 1 1/2 inches deep and you could see the stitches connecting the lowest layer of the tissue. So my wound; about 18 inches long, 1 1/2 inches deep and about 3 inches wide. Ohh my goodness! :)
My nurse came up to me and told me to do the wound care on this patient; basically replace the old bandages. She told me up front, you need to keep a straight face, show no emotion when you look at the wound. I did very well :)
So I put on sterile gloves and packed the wound with soaked sterile saline gauze. Then I placed two Abd bandages along with soft tape. The Patient had no pain or tenderness as I was bandaging the wound. I'm so grateful that I got to perform that skill!
Now my patient will go back into surgery in 3 months and reverse the colostomy and completely close the wound. Yay for recovery!
Wednesday, October 20, 2010
Cervical Vertebral Disc Repair
Today I had a patient who had surgery on a few of their cervical vertebral discs located in her neck. This wasn't her first surgery on that area which helped her know what to expect with her recovery. She came in to my unit during my shift and was able to relieve her pain with PO (oral) medications. That is not so common considering most patients Post-Anesthesia have to be given every thing through IV due to nausea. She was recovering fast!
One of the most important assessment tools that I had to use involved frequent Neuro Checks. These involved looking at pupil dilation and constriction, extremity strength, presence of numbness or tingling, and movement. So I began her assessment; I took my penlight and looked for equal reactivity of both pupils to determine brain function as pupil dilation involves cranial nerves. I then asked if she was having any numbness or tingling in her hands. She complained of numbness in her right hand which she said had prior to surgery. Then I had her squeeze both my hands to feel if their was equal strength in both her upper extremities. Both were fine. Now onto the lower extremities; I had her Dorsoflex her feet, which meant to lift up her toes, push down on my hands with her toes, and I had her wiggle all her digits so I could look for adequate movements. Along with the Neuro checks, I also checked for adequate circulation by checking pedal pulses, capillary refill in the nail beds, and feeling/observing for warmth, coloration, and movements.
It is important to assess these things especially for patients who have had any sort of spinal/vertebral surgery because of the risk for spinal cord injury. The spinal cord is a part of the central nervous system thereby contributing a major part in bodily functioning and voluntary movements.
My patient was discharged at the beginning of Post-Op day #2! Crazy good! :) It was an amazing recovery!
One of the most important assessment tools that I had to use involved frequent Neuro Checks. These involved looking at pupil dilation and constriction, extremity strength, presence of numbness or tingling, and movement. So I began her assessment; I took my penlight and looked for equal reactivity of both pupils to determine brain function as pupil dilation involves cranial nerves. I then asked if she was having any numbness or tingling in her hands. She complained of numbness in her right hand which she said had prior to surgery. Then I had her squeeze both my hands to feel if their was equal strength in both her upper extremities. Both were fine. Now onto the lower extremities; I had her Dorsoflex her feet, which meant to lift up her toes, push down on my hands with her toes, and I had her wiggle all her digits so I could look for adequate movements. Along with the Neuro checks, I also checked for adequate circulation by checking pedal pulses, capillary refill in the nail beds, and feeling/observing for warmth, coloration, and movements.
It is important to assess these things especially for patients who have had any sort of spinal/vertebral surgery because of the risk for spinal cord injury. The spinal cord is a part of the central nervous system thereby contributing a major part in bodily functioning and voluntary movements.
My patient was discharged at the beginning of Post-Op day #2! Crazy good! :) It was an amazing recovery!
Wednesday, October 13, 2010
Low Oxygen Saturation
So today I was assigned a patient who was post-op day #2 from a Right Total Knee Replacement surgery. She was on her road to recovery. She is still struggling with ambulating and she has been getting assistance using a walker to get around. The previous nurse reported to me that my patient's oxygen levels have been in the 80s. She was given 2L oxygen through a nasal cannula to keep her oxygen saturation levels up.
So here is an experiment for you. . . try to breathe through a straw, plug your nose, and slowly take breaths for 2 min. First of all, that is how an a patient with Emphysema feels when they try to breathe. After breathing for 2 min, your oxygen saturation goes down to about 93%. That's when it's difficult to breathe. Can you imagine what it would feel like to be sating at 83%??? Talk about oxygen deprivation!
Well, I freak out about this sort of thing. I told her to take a few deep breaths and that got her oxygen level to the 90s. I gave her 2L of oxygen by nasal cannula again and she seemed to be doing a lot better. It worries me though. I don't like it when a patient has to be on oxygen after a surgery. I talked to my nurse about it and she said they might have to order a chest x-ray if she can't keep her oxygen levels up on room air.
I continued to assess her lungs and encouraged the use of her incentive spirometer. I left my clinical rotation while she was still on oxygen. I'm hoping, during report tomorrow, that she improved overnight.
Ohh the importance of oxygen. Every breathe we take supplies every living cell in our body with oxygen which is needed for cellular respiration to create energy for our body's tissues and organs. We can't live with out it. Every breath keeps us alive. . . "The Lord God formed man from the dust of the ground and breathed into his nostrils the breath of life, and the man became a living being," (Genesis 2:7).
You could imagine how I was feeling today! My poor patient breathing without oxygen getting to her body. I'm so grateful I could be there to help. I'm hoping for a change for the better :)
So here is an experiment for you. . . try to breathe through a straw, plug your nose, and slowly take breaths for 2 min. First of all, that is how an a patient with Emphysema feels when they try to breathe. After breathing for 2 min, your oxygen saturation goes down to about 93%. That's when it's difficult to breathe. Can you imagine what it would feel like to be sating at 83%??? Talk about oxygen deprivation!
Well, I freak out about this sort of thing. I told her to take a few deep breaths and that got her oxygen level to the 90s. I gave her 2L of oxygen by nasal cannula again and she seemed to be doing a lot better. It worries me though. I don't like it when a patient has to be on oxygen after a surgery. I talked to my nurse about it and she said they might have to order a chest x-ray if she can't keep her oxygen levels up on room air.
I continued to assess her lungs and encouraged the use of her incentive spirometer. I left my clinical rotation while she was still on oxygen. I'm hoping, during report tomorrow, that she improved overnight.
Ohh the importance of oxygen. Every breathe we take supplies every living cell in our body with oxygen which is needed for cellular respiration to create energy for our body's tissues and organs. We can't live with out it. Every breath keeps us alive. . . "The Lord God formed man from the dust of the ground and breathed into his nostrils the breath of life, and the man became a living being," (Genesis 2:7).
You could imagine how I was feeling today! My poor patient breathing without oxygen getting to her body. I'm so grateful I could be there to help. I'm hoping for a change for the better :)
Saturday, October 9, 2010
Total Bilateral Hip Arthroplasty
One of my patients I had during the last two clinical days was recovering from a Total Bilateral Hip Arthroplasty, in other words he had both his hips replaced. I asked the nurse about this procedure and they said that they rarely do both hips at once because the recovery time is lengthened too long which could lead to other health problems. Because my patient was 52yrs old, he was young enough to handle the recovery period.
We will call him "G" for short. G is an athlete who developed arthritis in his hips. He had no significant medical history except for a tonsilectomy. My focus of care was to make sure my patient had a good recovery which required movements, breathing exercises and assisting with activities of daily living. All during the shift I was able to encourage deep breathing and the use of the incentive spirometer which helped expand his lungs and increase oxygen and waste product exchange in the body. It is important to stress these activities because when under anesthesia, mechanical ventilation is used and fluid can accumulate making it difficult to breathe. A goal for a nurse with a post-op patient is to keep those lungs free of fluid and to make sure the patient is getting an adequate oxygen supply. I assessed my patient at 82% oxygen saturation, my first response was..."G can you take a few deep breaths for me?" He did so and brought his oxygen level to 96%. That's how easy it was. We just have to keep making sure they breathe!! Other times coughing will help.
The most exciting thing that happened with my patient was getting him up to a walker and walking him all the way down the hallway which is about 150'+ feet. The day before I walked him about 20.' What an improvement! I was so impressed with someone who was post-op only 2 days with BOTH hips replaced to have such an incredible improvement! I was so happy! I told him I would go get him a butterfinger for walking that much (I had caught him eating one earlier) and he said, "Where are your angel wings? Are you hiding them from me?" haha! He was such a sweetie!
It's great to see that patients who have such a huge surgery improve that much! It warms my heart to hear that G is actually going home today, walking, with pain free movements, with a smile! So glad I could be a part of his recovery! :)
We will call him "G" for short. G is an athlete who developed arthritis in his hips. He had no significant medical history except for a tonsilectomy. My focus of care was to make sure my patient had a good recovery which required movements, breathing exercises and assisting with activities of daily living. All during the shift I was able to encourage deep breathing and the use of the incentive spirometer which helped expand his lungs and increase oxygen and waste product exchange in the body. It is important to stress these activities because when under anesthesia, mechanical ventilation is used and fluid can accumulate making it difficult to breathe. A goal for a nurse with a post-op patient is to keep those lungs free of fluid and to make sure the patient is getting an adequate oxygen supply. I assessed my patient at 82% oxygen saturation, my first response was..."G can you take a few deep breaths for me?" He did so and brought his oxygen level to 96%. That's how easy it was. We just have to keep making sure they breathe!! Other times coughing will help.
The most exciting thing that happened with my patient was getting him up to a walker and walking him all the way down the hallway which is about 150'+ feet. The day before I walked him about 20.' What an improvement! I was so impressed with someone who was post-op only 2 days with BOTH hips replaced to have such an incredible improvement! I was so happy! I told him I would go get him a butterfinger for walking that much (I had caught him eating one earlier) and he said, "Where are your angel wings? Are you hiding them from me?" haha! He was such a sweetie!
It's great to see that patients who have such a huge surgery improve that much! It warms my heart to hear that G is actually going home today, walking, with pain free movements, with a smile! So glad I could be a part of his recovery! :)
Friday, October 8, 2010
Confidence?
This week was hectic; work, school, more work, clinical day #3, clinical day #4, all day class friday, ECG class....eeeeesccch...Let's just say I was ready to go home today...
I had an interesting day on Thursday, clinical day #4. It's amazing how one little thing can effect your whole entire day; the way you think, your confidence, your reflexes, your attitude, even your spirit. Right before my clinical rotation, I checked my grades online for one of my assignments. I didn't do so well, but that itself isn't a complete turn around for me. I had comments from my teacher saying, "You missed the mark," "This is sloppy," "This worries me," "If I was your supervisor, I would report you for writing this," "I want you to talk to the class about this assignment," "You need to explain to the class about what you wrote." ..........
So, I wasn't feeling to good after this. My confidence level just plummeted. I didn't understand what I did wrong. I also didn't appreciate him telling me to display my work in front of the class like.. "this is what not to do." So I emailed him and told him how I felt about it. But, I had no time to talk to the instructor personally because of clinical.
So clinical comes fast, and I get there a little early to receive report on my patient that I had the previous day. CW was stable, but had low Hct and low Hgb (lab values that show the amount of hemoglobin in the blood) These values were low which led to the decision to transfuse blood. His blood pressure was low the previous day too so Diuretics (water pills) were held as well as the Atenolol (High blood pressure medication). It was important for my to monitor his blood pressure, pulse, temp, and oxygen levels as blood was being transfused. CW had improved Hct, Hgb, and BP after an hour after the transfusion. So my day began with the transfusion, I couldn't do much because I wasn't checked off for those skills yet except for vitals. I was grateful though because my mind was elsewhere. I felt like I couldn't do anything at this point......
So my nurse, Mayra, was a 6 month new grad so she was learning as well. I had to do a lot! The pressure was on me to take care of this patient basically by myself because Mayra was new. So here I am after the transfusion with lots to do. Medications, Lovenox injection (blood thinner), teach about Lovenox (because CW will be doing this at home), VS every 4hr, encourage deep breathing and use of incentive spirometer, help to bathroom, ambulate in hallways, encourage physical therapy exercises, IV therapy and fluids, pain management, shift assessment, reassessments every 4hr, and making sure CW is okay checking every hr.
This didn't include helping Mayra with her other patients. I can't believe I will have at least 4 patients every shift. Thank God for nursing assistants! :)
Though I was losing it and my confidence was low, I knew I was going to make it through the day. God got me through and in a great way. I was so busy, I forgot about my assignment and my feedback. I actually now feel like I can have a second patient. Slowly but surely add a patient every clinical day....
Then to make my day better...Mayra said she was quitting next summer and I asked her if I could have her job....she was like "Ya! Take it, it's yours!" I would cry if I got a job there.....my goodness.....
So what to get out of today......I will get hit with situations like this, but it's in God's hands. If you ask, he will provide. God is my confidence.....
Aaaaamen...and now off to week 4!
I had an interesting day on Thursday, clinical day #4. It's amazing how one little thing can effect your whole entire day; the way you think, your confidence, your reflexes, your attitude, even your spirit. Right before my clinical rotation, I checked my grades online for one of my assignments. I didn't do so well, but that itself isn't a complete turn around for me. I had comments from my teacher saying, "You missed the mark," "This is sloppy," "This worries me," "If I was your supervisor, I would report you for writing this," "I want you to talk to the class about this assignment," "You need to explain to the class about what you wrote." ..........
So, I wasn't feeling to good after this. My confidence level just plummeted. I didn't understand what I did wrong. I also didn't appreciate him telling me to display my work in front of the class like.. "this is what not to do." So I emailed him and told him how I felt about it. But, I had no time to talk to the instructor personally because of clinical.
So clinical comes fast, and I get there a little early to receive report on my patient that I had the previous day. CW was stable, but had low Hct and low Hgb (lab values that show the amount of hemoglobin in the blood) These values were low which led to the decision to transfuse blood. His blood pressure was low the previous day too so Diuretics (water pills) were held as well as the Atenolol (High blood pressure medication). It was important for my to monitor his blood pressure, pulse, temp, and oxygen levels as blood was being transfused. CW had improved Hct, Hgb, and BP after an hour after the transfusion. So my day began with the transfusion, I couldn't do much because I wasn't checked off for those skills yet except for vitals. I was grateful though because my mind was elsewhere. I felt like I couldn't do anything at this point......
So my nurse, Mayra, was a 6 month new grad so she was learning as well. I had to do a lot! The pressure was on me to take care of this patient basically by myself because Mayra was new. So here I am after the transfusion with lots to do. Medications, Lovenox injection (blood thinner), teach about Lovenox (because CW will be doing this at home), VS every 4hr, encourage deep breathing and use of incentive spirometer, help to bathroom, ambulate in hallways, encourage physical therapy exercises, IV therapy and fluids, pain management, shift assessment, reassessments every 4hr, and making sure CW is okay checking every hr.
This didn't include helping Mayra with her other patients. I can't believe I will have at least 4 patients every shift. Thank God for nursing assistants! :)
Though I was losing it and my confidence was low, I knew I was going to make it through the day. God got me through and in a great way. I was so busy, I forgot about my assignment and my feedback. I actually now feel like I can have a second patient. Slowly but surely add a patient every clinical day....
Then to make my day better...Mayra said she was quitting next summer and I asked her if I could have her job....she was like "Ya! Take it, it's yours!" I would cry if I got a job there.....my goodness.....
So what to get out of today......I will get hit with situations like this, but it's in God's hands. If you ask, he will provide. God is my confidence.....
Aaaaamen...and now off to week 4!
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