Monday, March 5, 2012

CPNE Day 2: Patient Care Scenario Chaos

The info and/or pictures below contain copyrighted content from Excelsior College that may be confidential in nature. No identifying patient data is included and this information is meant for demonstrative purposes. No replication of this information is permitted. This is part of my post series on Excelsior College's ADN nursing program and the CPNE experience. See all related posts over here. 

After the mandatory 20 minute break I tried to regroup my thoughts but this became very awkward and only got worse as the day and next day went on. I was excited to have passed one, still on edge, and then come down to wait for my next PCS and the other students are sitting there. You're trying to gauge what happened by their expression, did you pass, did you fail?? Tears of joy or tears of sadness... awkward. I tried to encourage as best as I could to those who were wavering and tried to keep myself grounded and stay focused on ME.

Up the elevator we go for PCS #2. New floor and orientation. Walk into an empty room and notice this crazy metal contraption on the bed "this is an ortho floor so this is a trapeze thing" oh boy... I started thinking I better NOT have some patient in traction oiy. Get the Kardex and listen to her explanation, trying to gauge my 2 diagnoses while she's talking as I scope out the AOC's and it is a little more vague than PCS 1. She was post op hernia surgery and otherwise healthy. Ended up going with Acute Pain although I was nervous about this one because she'd been reporting pain 3-4 which was manageable but I knew the moment they took away her PCA and epidural it'd shoot up so I chose to run with it, and I had pain management assigned. Next was Activity Intolerance. There were some discrepancies with her status just like with PCS 1 which made things a little confusing and stressful. I was told she was off bedrest and now ambulatory so I was assigned to transfer OOB to chair, fine. I was also told the foley cath was d/c'd  but it was actually put back in after she couldn't void. I got nervous about this because I wasn't sure whether I should address it or not, technically the study guide states that we don't mess with foleys but I second guessed whether we should include it in output... 

This CE was also very "business" and I was concerned that it was going to be a repeat of my morning PCS. But this one at least allowed me to browse the computer chart freely and seemed a little less old/rigid if you know what I mean. I took a lot longer to plan this one out than I wanted to because I second guessed my diagnoses, initially was going to go with impaired phys mobility and then changed to activity intolerance when I got report from the CE because she used the exact words "she's had a problem tolerating activity, very short of breath"... ding ding, duh I thought, why was I trying to do mobility?! I also had a small freak out trying to plan the order of care because of how many AOC's I was given! This one was going to be down to the wire for sure! I had abdominal assessment, pain management, respiratory management with ISx10, intake & output, drainage for JP's, and out of bed to chair, and I knew my 20 minute check was going to be crazy because of all the stuff she had going on.

Passed planning and off to implementation, go to the room and CE goes "oh no, she's back on fall?" I notice a sign on the door "Fall Risk" and yellow magnets on something next to the door, and I looked at her like what does that mean for my assignment here? She kind of mumbles that we'll go in and see what the story is and I said that if we weren't going to transfer to chair I'd need to revise 3 interventions! She acted like "don't worry about it" and in we went. Turns out we were able to transfer her to chair so thankfully no revision there but oh boy did things get interesting...

So this lady had 800 tubes coming out of her/attached to her. This meant an absolute nightmare trying to assess anything and oh my word getting the poor lady out to her chair was ridiculous! She had 2 IV's running a variety of things each with a different main fluid bag and then each with a different minibag (meaning LOTS of checking IV type rate amount, tubing and pump settings on them all!), she had a PCA pump AND an epidural on it's own pump (there were 5 pumps to check folks!!!!), she had oxygen and was alternating between that and the end tital C02 monitor which has a pump and a weird tubing similar to oxygen. She also had 2 JP drains, telemetry, a foley cath, AND SCD's on either leg. I called her bionic woman. Somehow managed to get the 20 minute check done, thank god there were no interruptions, I did address the foley and wrote down the amount in the bag, I addressed ALL tubing from each pump, I addressed ALL pumps and settings, I wrote down all amounts in each of the 4 IV bags, I assessed both IV sites... whoa.

Then to vitals, apical heart rate which was a pain because she had a giant velcro abdominal binder (fyi- NOT easy to get off unless you rip it off and piss off the patient), I thought about trying to do her abdominal assessment at the same time so I didn't have to mess with the binder again but was worried about 'emotional jeopardy' for leaving her exposed too long if I couldn't hear the pulse again or something, so I opted to undo the top of the binder as best as I could to get to the apical. And what do you know THIS patient actually had a heartbeat! Go figure! Only took one set of vitals on her because I was sure, I stated them outloud at the time and looked for feedback from the CE, nothing... so oh well. Oral temp, there was a lot of back and forth to get more gloves with this lady because they only have them right at the door and I kept needing them for various things (moving the drains, moving the foley, etc).

Decided after vitals to do the abdominal assessment, problem #1 the lady couldn't lay completely flat. I told her to tell me how far I could lower the bed until she was uncomfortable and proceeded from there (maybe 35 degrees or so?). Got the binder completely off. Huge midline incision about 16" long, 2 JP's. Went to listen to bowel sounds, started RL- RU good but hypoactive, move to LU and sat there forever, nothing going on... not one sound. I thought OMG here we go again, start to look at my watch and time it, after 6 minutes I figured I was screwed. I had moved the stetho around a bit to see if I could get anything but nope. Moved on to the next quadrant and surprise NOTHING there either. I spent a total of 9-10 minutes listening to both and didn't hear anything.... again I tried to look at the CE for feedback, stone-faced, I started thinking what the heck am I going to do. I knew that she had just been permitted to have clear fluids and started flipping out about a paralytic ileus and what I should do or report or if I was being crazy and just not hearing right. I knew she had to have the foley replaced since she was unable to void so I knew it wasn't too far fetched that there could be a problem... Thinking about it now I should've just asked the lady to take a sip of water and then listened but oh well! Just as I was getting ready to give up I heard some sort of a noise, no clue whether it was a bowel sound or just the rustle of a pillow or who knows but I looked up at the CE and said OH FINALLY ok, got ONE! Moved up to the next quad and heard another tiny sound and said whew! Would love to know what the CE was thinking that whole time...  (you can bet I documented all of this and notified the primary when I was done just incase) I got an inkling that I was RIGHT and not losing my mind when the primary nurse came in a few moments later and asked her if she'd been able to pass gas yet and she said NO! I palpated with gloves since she had the JP's and then off to respiratory management.

Patient was super nice but very quiet. Problem #2 she couldn't sit all the way up to do the respiratory management. So I had to roll her side to side to listen to lungs, not a problem usually except for all of her bazillion tubes. I had to unpin the JP's, shuffle everything, move tubes, move pillows, have her hold the side rails then shove pillow on her back to keep her in place while I listened. Then move everything back, sit her up a little more, do the I/S x10, and do it ALL over again!

Are you seeing what is happening to my time here??? Yah.

Finally we're off to move to the chair, again quite the process moving ALL those damn tubes, I mean seriously! Back and forth to get gloves to get the foley to move it to the other side of the bed, unpin the drains again and readjust them. Switch C02 tubing thing over to 02 tubing. Roll all of the pumps around.... it was a circus show. Thankfully the CE at this point was being helpful, she wasn't giving me any feedback or being 'friendly-ish' but she was helping me to hold things and shuffle things about. After she was situated I drained the JP. I had already asked about where we put the drainage- toilet was fine, I opened the drain and capped it to go dump it out and noted the amount at which point she decided to tell me that they had a special cup in the bathroom I was supposed to use to measure it instead of using the drain hash marks...... ummm good info to have!! So I dance around to get that done and rinse it out and then rinse the measurement cup. I decided that I'd replace the papertowel that they had sitting there for the measurement cups but washed my hands first and then thought crap now I have to grab them and I'll have to wash again. At that point the CE held the cups up so I could get a papertowel (helpful like I was saying).

Homestretch I just needed one more pain intervention, I asked if I could fluff her pillows "oh no, I'm great", I can give you a backrub! "oh no really I'm just fine thanks" and I'm thinking crap come ON I just need one more!! Then she says is someone going to change my bed? And I piped up OH sure, I can do that for you!!! (there's my #3) and the CE looks up and says "you know what, we'll have someone do that for you, we'll go get someone" and points to the clock saying she wanted to be mindful of my time. At that point I look at the clock and see that I have 20 minutes left and haven't even left the patients room once HA! I looked at the CE thinking oh my god thank you and boogied out of the room. She could've said nothing, she didn't have to do that and could've watched me change the bed and fail when my time ran out but she didn't. It probably would've dawned on me as I went to get sheets that I didn't have time and I may have been able to grab someone and document such to finish in time... who knows but thank you to that CE for not setting me up for failure!

I started documenting quickly, I had a billion narrative notes to write and kept thinking WHY can't we type these, it'd be so much faster lol (I type about 115 wpm, writing... not so much!). I started scribbling barely legible by the end as I kept glancing at my watch. Lots of expletives going through my brain again.... Got to the end and realized I put the intake in the wrong place, realized I hadn't written down the amount in the IV bags upon leaving that I *could include in intake, AND realized I hadn't declared vitals yet!! Minor details....

I literally SPRINTED down the hall to find the CE with 2 minutes to go, I shouted to her that I needed to go back in the room to check the IV amounts and she said, no you don't have to do that since you didn't hang it, I said are you SURE?? And she said yep. So I threw my packet at her and said I need to declare my vitals!! Gave me the speech about turning in the paperwork meaning I have met the critical elements and I said YES YES YES. Literally down to the second on this one...omg.

I sat there waiting for her to come back realizing that I hadn't read over one single note to make sure it was good, I didn't re-read my evaluation, there just was no time so I continued to have a complete heart attack waiting.... and waiting... when all of a sudden it occurred to me "OH MY GOD! It doesn't matter whether I pass of fail this one, I have to go do the WOUND again right now and if I fail that I'm going HOME!!" My head popped straight off at that point. Migraine galore (no literally, I went through almost a whole bottle of Tylenol migraine & ibuprofen in those 48 hours to where my kidneys were literally aching that evening... no joke)

She pokes her head past my cubby and says "well you passed!" and I nearly collapsed onto the floor, oh thank god. I told her now I was off to repeat the wound.... aggghhh. I went to the lobby and I was the last one around, a couple were already sitting down there for a while which I knew wasn't a good sign. First report was that 2 were done and going home, 1 didn't even get in a room, 1 had to go 3 for 3 the next day... it was awful.

Waited forever for my turn to repeat the wound and thankfully passed so I was ecstatic, I was sitting in the best position for day 3, I only had to pass this last PCS and I was done. At that point I started really thinking that I just may do this thing.... all of this visualizing I'd done about walking out those hospital doors with my letter finally started to seem possible... I pretty much knew Saturday night that I was going to be fine once I realized who my CE was going to be. She was wonderful and kind, helpful, she was a "hand holder" the ideal CE that you wish you could have that gives you hints you maybe shouldn't get but she does it..... I knew this was my CE for the morning so unless I did something to screw up supremely I was walking out those doors at 10 am with my letter. So I spent Saturday night trying to console and encourage my fellow students, you just feel AWFUL and can see the defeat in their faces and keep trying to tell them to dig deep, that it's possible but you feel for them because the tension is still there. Even as relatively confident as I was that night about the next day I was still very anxious, you just never know.

I hit the hot tub, played damage control with some customers since my suppliers dropped the ball as I left town on Thursday (great timing you aholes!), and was getting ready to watch tv before bed when I realized my Spring semester classes (through my community college) started earlier that week and therefore I had assignments due! HAA, I had completely forgotten about those classes starting, hadn't even ordered books yet! So I spent the next few hours doing THAT (joy) then took a shower and then realized at 11 that I needed to pack.... duh... bed at midnight purely exhausted with a 5:30 wakeup call.

Day 3 here

 

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