Susie Clabots

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					Susie Clabots
Journal #5
July 22,2008
NURS 499
Preceptorship done at St. Clare Hospital ICU

1. New learning: My first two examples of new learning occurred in the ED because
there was a code announced overhead in that department. I always follow the ICU nurse
to any of the codes announced and today it was some woman who actually came in
dsypneic and then all of a sudden after arriving in the ED became pulseless. So, this was
the first time that I got to perform CPR and really watch all that goes on during a code
such as this one. (All of the other codes I had been to were a little bit less emergent). I
also was trying to pay close attention to what everyone was doing during this time. I
watched two attempts at IV placements, the second one made it in, but then was blown
when they tried to use it. So, the last resort was an intraosseous IV placement, with a
piece of equipment that was basically a drill with a needle in the end. The physician who
placed had never inserted an IO using this tool and so I wasn’t the only first-timer there
. I am not saying that I am anywhere near that physician’s knowledge level (because
I’m not) but the situation just reminds me of what people tend to say about learning. You
know what everyone always says, “we learn best by doing.” As I see it, you really should
just jump in and do it because you will remember it best that way. It was just a good
example of how, in the healthcare field there is always something new coming out that
can quickly put someone in that novice position for at least a little while.
         My other new learning was my chance to watch one of my patients go and get a
lumbar puncture done. She came in with altered mental status, hypotension, and was
intubated upon arrival (The husband told me that he had just gotten home and could not
wake her up and so called 911. She has a caregiver who takes care of her while the
husband is at work and the caregiver had been gone for about 40 minutes...so basically
we don’t know how long she could have been in an anoxic state). She is blind and deaf
(she does have a cochlear implant), both of these conditions are quite recent, being thrust
upon her only within the past 3 years. She is only 53 years old. She also has severe
scoliosis and while looking at her CT report it was noted that she had severe disk
degeneration on her cervical spine area which was also causing anterolisthesis and
creating her spinal canal to be narrowed at that point. Just by looking at her head
placement, it is constantly pushed to the left and down a little bit so that he head almost
rests on her left shoulder. When questioned about it, I was told by her husband that she
thinks her head is upright. She also has a pacemaker that was put in not too long ago,
after an attempted ablation that was unsuccessful. She has CHF issues, and neuropathy
(which I wonder if it could be attributed to her spinal condition because she also has
many compressed disks in her lower back). So, they were sort of trying to get a better
glimpse of her situation, rule out meningitis (although she had no fever and her WBC was
not extremely elevated and I don’t know if they assessed for nuchal rigidity because of
her deafness), test for syphilis, culture and sensitivity, also looking for hints of an
autoimmune issue going on in her body. This poor woman was apparently without major
health issues until 3 years ago, and has just been through the ringer ever since. It appears
to be some type of autoimmune disorder but nobody has been able to come to any
conclusions about what exactly is going on with her. Her husband even mentioned that
recently she has been having hallucinations of which the psychologists/psychiatrists think
are not mental (psychological) but are medical (or organic) in nature since she has not
history of prior mental illness. (Although she has been through a huge amount of stress
and trauma these past few years and I wonder if it could be some form of PTSD
emerging).
        The EEG was done two days in a row with encephalopathies showing on both
days. Her behavior even after extubation and later in the evening on the second day after
admit was still not baseline, according to the husband.
        So, back to the lumbar puncture. Her situation was unique in that, although she
was lateral recumbent, her spine was quite deformed and due to the discomfort of that
position, she could not stay with her legs curled up (to spread the disks apart a bit more
for easier access to the CSF). She was also on the ventilator and had her dobhoff in, so
postioning and monitoring her was very important. She also had to be sedated because
she would get to riled up once we took her off the propofol. What I learned other than
the important issues of patient monitoring during the procedure was that the CSF was
sampled 4 times in order to get the purest sample on the 4th sample. The first samples
could be contaminated by the procedure itself (blood cells that entered via the puncture
site). So, the CSF should ideally be totally clear by the 4th sample. Thus the testing can
be more accurate. She tested negative for VDRL (syphilis), as well as for the RA
(rheumatoid factor…which is indicative for autoimmune issues). I don’t know how the
C+S sample turned out though. The intensivist did say that she was negative for
meningitis though.

2. Most challenging: This week my biggest challenge was definitely working with
my patient who was deaf and blind (I’ll call her Bee). Every time we took her off the
propofol and right after we extubated her, she was just in such distress and it was so
difficult to figure out how to help her. It was emotionally frustrating and physically
draining because she continually tried to stand up but had been intubate for 3 days and so
did not have the strength yet, plus the environment was so strange and she had IV lines
that she would attempt to grab at. She did have a cochlear implant and a device that you
hook on her ear and then the magnetic piece goes on her head behind her ear (it sticks to
the implant via magnetic force, really neat device). The problem was that she just
seemed to not listen to what we were saying and even her husband was speaking to her,
she still did not respond most of the time. Her husband said that she did not seem to be at
her baseline (and at that point the EEG was still saying that there was encephalopathy).
Stroke, and/or cerebral hemorrhage had been ruled out. She did have a rising CPK
however, as well as a CKMB, which could have very well been rhabdomylosis from
laying in bed for almost 3 days.

3. Critical thinking: I kind of had two moments. The first was with a patient who
had become septic (she was hypothermic when I came on shift) and had a huge
diverticuli abscess, she went to surgery about 8 hours after admission. I actually got to be
involved with and see her intubation about an hour prior to her surgery (I suppose that
could have been included on my new learning as well). **I am going to answer my
leadership question #5 (leadership question) right here because it fits.
So, we were infusing a lot of fluids to maintain her BP and within about 2 hours she
appeared to have to work a little harder to breath. Eventually she could not breath except
sitting up and we were helping her tripod because she was too weak to do so on her own.
I listened and you could definitely hear that her lungs were actually becoming clogged
with so much fluid being pushed.
         By this time my nurse was getting things ready to get her intubated. An ER doctor
came into the ICU and when he saw her he said, oh she looks fine, she is breathing pretty
well while sitting up. I thought to myself, well she can’t even hold herself up to do so,
me and another nurse were holding her up to tripod. Even I knew that she needed to be
intubated, merely a student nurse. My nurse was upset that he underestimated the gravity
of her patient’s current status and spoke to the physician and then he came back in to do
the intubation about two minutes later.
         That was a great example of how the nurse needs to be persistent about issues like
this, and be a strong patient advocate, especially in emergent situations. The physician
also said that the patient shouldn’t be on a propofol drip and that she could just be given
boluses of versed to avoid the hypotensive effects of the propofol. This issue was another
issue of the ER doc not really taking into consideration that she was going into surgery
and the anesthesiologist probably would not have time to worry about doing versed
boluses, nor did the ICU nurse have the time to do that either. So, needless to say the
propofol was hung and she ended up doing fine on it. And she actually held her own, in
terms of vital signs, during surgery, which was a surprise to most of us considering that
the outlook was not the greatest during those septic hours.
         Ok, so this example of leadership was also one of the critical thinking examples
because me and my nurse were observing this patient’s patterns and as soon as she started
to have that difficulty breathing and we listened to her lungs we knew what the next step
needed to be.

Critical Thinking Continued: The other critical thinking example was not the most
giant of all but it was me attempting to comfort my patient. Going back to Bee, the deaf
and blind pt with scoliosis, among many other issues, she was so worked up and began
crying. I thought, part of this distress could be pain (from the neuropathy and or the
scoliosis with lost of disk degeneration). So, I just started rubbing her back in an attempt
to relax the muscles on her upper back and shoulder area (it almost looked like she had a
little hunchback). She actually stopped crying and let me massage her for a while and it
really seemed to help her.
         Later on that evening, she was getting really worked up again and I had put her
hearing device on so we could try to communicate with her again and after her struggling
for about 30 minutes, and I was in the room by myself with her at that point, I decided to
take off the hearing device and leave her be for a while. Immediately after I took it off,
she said “Thank you”. She had never said that before, not once.
         So, I was wondering if maybe the cochlear implant was malfunctioning and
hurting her head when people were trying to speak to her. I don’t know, but I did get that
message loud and clear from her, and that was basically the only time that happened. It
also could have been that she was just so frustrated because she couldn’t make out what
we were trying to say to hear via that implant (although I tried to make my phrases slow,
simple, and well annunciated). Just goes to show me that even though you have the
technology, it won’t always make things easier…it sure didn’t in the case of this patient.
        UPDATE on the cochlear implant incident. I phoned my sister about this
because she is an audiologist and works with cochlear implants frequently. So, I asked
what could have been happening and she told me that the patient may have said thank
you because the device was receiving to much background noise to be able to decifer any
voice sounds clearly. When I thought about it, the ICU rooms usually have many little
noises, oxygen, IV timed pumps, any other machines in the room, not to mention sounds
of people walking into the room or even just by the room, etc. So, the patient could very
well have been overwhelmed by all of the different sounds and so because she couldn’t
understand us well enough, due to all the background noises interfering, she just wanted
to keep the device off. I would probably have done the same thing if I were in her shoes.

4. Written evidence: Well, my written evidence came in the form of me attempting
to teach myself a bit about cochlear implants. I read through a couple of articles
discussing how exactly they work, giving the person the sensation of hearing by directly
stimulating the auditory nerve (bypassing the tiny hair cells) via the electrical signal that
began in the form of a sound wave from outside the ear and was basically conducted from
soundwave to electrical impulse on the inside. In one article there was mention of a
woman who had a stroke and forgot how to use her hearing aid (not a cochlear implant)
and so that in itself was probably traumatic because the nurses may not have known how
to work it either. So, just realizing how to work with devices that are used by people with
deficits like hearing loss and/or vision loss. It is one thing to at least be able to show the
pt what you are doing or talking about, but what happens when they can’t see either? So,
that really opened my eyes to being aware of all of the pt’s senses as well as my own.
         Something else I noticed was that much of the research regarding cochlear
implants was focused on children and infants born deaf. Not much research on when
deafness occurs later on in life. The big thing I took away from the article on issues in the
management of infants and young children who are deaf-blind was that of interparent
consistency and the idea of synchrony between child and parent. I definitely tried to use
a sense of consistency with my patient the second day, by also squeezing the same hand
gently before I was going to speak to her using the device, just to try and attempt at
making a pattern so that she would begin to know who I was (at least a little bit) so to
allow her some comfort in knowing. This article also mentioned something about how
the circadian rhythm is thrown off in those with blindness and although this was in
children, I saw it happen in my patient. Her husband told me that she now sleeps during
the day and is up during the night.
         In all, this patient Bee just gave me a little piece of the frustration she must go
through every day, or at least, any time she wants to go outside or to an unfamiliar place.
Without being able to see your surroundings, it can be quite scary just going outside to
the grocery store. So, I can only imagine what she was feeling the first time she woke up
in the hospital (when we turned off the propofol to assess her neuro status) with a tube in
her mouth, nose, bladder, a PICC in her arm. Then she became anxious and was trying to
pull at things and so we had to restrain her (which of course would just create even more
fright) because even with her husband trying to explain to her, she wouldn’t calm down.
McAleer M. (2006). Communicating effectively with deaf patients. Nursing Standard
20,19,51-54.

Holte, Lenore PhD et al. (2006). Issues in the Management of Infants and Young
Children who are Deaf-Blind. Infants and Young Children. Volume 19. No. 4 pg 323-
337.

Question #10. Healthy People. My little sweet old woman who was septic and had
an emergency colectomy done and colostomy placed was actually a good example of the
access to healthcare indicator of healthy people. She is a Christian scientist and thus, had
never been to a doctor and had no prior medical history. She had no allergies because she
had basically taken no medications. So, after arriving in the ER and being rude to all the
nurses, her granddaughter gave her a good talking to and then after that she was as sweet
as could be to all the hospital staff. She was totally accepting of and grateful for all the
care provided by my nurse and myself and she understood that she could very well die if
she refused intervention. So, apparently she did want to live. And after that I did a bit of
teaching about her colostomy bag and discussed the importance of not working her
tummy muscles too much because we didn’t want any evisceration or things of that
nature (her incision was not closed yet). Also, she was not eating (her clear liquid diet)
and it could have been due to a little bit of depression and just being a little out of it (I
think being in the hospital for more than a few days can do that to people…not much
sleep during the days or even during the nights sometimes). So, in terms of healthy
people goals and indicators…I think we did a pretty good job of offering her complete
access to healthcare which she accepted and then she actually initiated the request to
learn about her colostomy more and so we set up the ostomy nurse consultation for her as
well.

7. Describe a situation where you worked with family or community
systems: I had a patient who had aspirated a lot of her own emesis and thus was
definitely an ARDS patient. She was on a couple of pain meds and also had a high
alcohol blood level. So, the physician gave her about an 80% chance of mortality and so
I was really trying to explain to the family members to give them the best picture of what
was really going on inside of this patient. So, I was just trying to do a lot of teaching
about what vomit can do to the lung tissue, what the ventilator is doing for her, what
some of the medications are doing for her, what the SvO2 tells me about oxygen delivery
to the tissue, and discussing her vital signs with them when they had concerns. I just
wanted to allow them to get the real picture so they could have a little less fear of the
unknown.

8. Ethical conflict: There was an 87 yr old woman who had CHF and was definitely
just struggling to breathe at many times, with an oxy mask on at all times. She had an EF
of about 25 % (I think) and she was just going to aspirate anything that was a thin liquid.
So, my nurse was discussing with the nurse who had been on shift prior and they were on
agreement that a morphine drip would probably be a good idea for her. The patient was
have lots of tachy episodes and the only thing that would help was morphine (and at least
2 if not 4 mg). And that was about every 2.5 hours this would happen. So, the patient
eventually got her morphine drip, although it was started at 1mg (and my nurse even had
it down to 0.5 mg for the later half of our shift) and she seemed to be doing alright. So,
hopefully by the time I hand this journal in hospice will be discussed for her. It is
sometimes feared that we are playing dr. Kevorkian, but in reality, I believe that everyone
deserves the least painful, and most comfortable and peaceful way of death possible. The
patient understood that she was dying and she understood why we were only allowed to
give her thickened water because of her high aspiration risk. Her family was always with
her and she was good spirited about the situation. I think the best role the nurse can play
in these situations is to understand the best you can about what the patient truly wants and
work to get them just that.

9. Comments, frustrations or emotions: The thing that I would like to
comment on is that my patient with ARDS actually passed before I could work with her
the next day. I knew the 80% chance of her to die from what happened, but I was a little
shocked when she had passed during the night. Apparently she had coded 4 times and
the last time she did so, she died. I guess I just wish that I could have seen it all happen so
that I could see what went was going on during those 4 times. I guess I truly just felt
sorry for her husband and two teenage sons because it was so hard for them to even
come to the hospital when she was admitted. They came once in the afternoon but only
stayed for about 20 minutes and then went back home. I know that some people just
can’t deal with the whole hospital thing very well, but I felt sorry for them that they could
have missed their last moments with her alive because of their fear of hospitals. So, now
I know, that when a pt is that critical, I will try to encourage (but never force) the family
to stay as close as possible because you really never know what can happen.

				
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