I headed back to Medical this weekend. I prepped on Friday on a patient recommended to me, who had a lot of care issues. After prepping for many hours, I decided I better watch procedure videos and pull out the E.P.P. chapters on management of a tracheostomy and PEG tube feedings because we've some theory on tracheostomy care, however, no real practice.
The PEG management seemed relatively easy once I had my routine settled on pulling back residuals, flushing the line and making sure that the valve was open for each administered medication and closed between. That wasn't an issue at all and I felt comfortable for the most part, doing my full head to toe assessments and dressing changes on the stoma in the GI and evaluating the trach site in the neck. I valued this experience because it was about as close as I was going to get to the ICU, without actually being there just yet. Since Critical Care is coming up, I jumped at the chance of learning some new skills. The first day went fairly well. My patient seemed comfortable. I was able to render full care, manage pain, complete all the charting, manage the nutritional aspects of the PEG line and spend valuable bedside time with my patient. After reporting off, the care nurse thanked me for all my help and I went home feeling like it was a decent shift.
Today was a different story though. I was ready for report and took some notes on hand-off about what a great job the care nurse did during the day shift. However, when I went in to assess her, her room looked like a disaster struck. She was down in the bed, the room was in disarray and nothing looked like the day before. I went over to arouse my patient and she immediately whispered to me that she had to go to the bathroom, and she was very uncomfortable. I repositioned her in bed so that she could sit on the bedpan and while she was voiding, I did my neuro assessment. She was A & O X3 and clearly stated something was wrong. After I did the toileting and assessed pedal pulses, femoral pulses and her back & abdominal assessment, I listened to her lungs and heart and noted the diminished lung sounds and long rhonchi and crackles...Her lungs were very congested and she had visible mucous in her mouth. I suctioned her several times and tried to get her comfortable, but she kept complaining that something wasn't right. When I went to give her meds, I told the care team that I did my assessment and thought respiratory therapy needed to be contacted and asked if we could call the pulmonary specialist too. I got that "But, it's Sunday..look." Ok, and what does that mean if we have an on-call physician or a back up hospitalist? Another blank stare that basically asked me if I was daft, without saying it outright.
They didn't seem too alarmed because she was still SPO2ing above 90, but I thought her breathing was labored. The other care nurse disagreed and didn't think she was in distress. I decided to stay in her room for the duration of the shift and it appeared she was getting worse. Nursing has a term called "snowing" a patient. This is to relax a patient who is experiencing anxiety. In some cases, it helps. I think in this case, while it was perfectly appropriate to help manage a patient's pain and anxiety with a tracheostomy, I was worried that something else was going wrong because she appeared to be breathing through her mouth and not her trach. All the secretions were coming into the mouth and should have been coming through the trach. I periodically mentioned that I thought she needed the trach assessed or removed and could we please call the on-call physician. The care nurse still didn't believe it was a problem and one told me to stop talking to her because she was transcribing orders and wanted to finish. She also happens to be an instructor at another school and I could tell she did not want to discuss the issue because it wasn't her patient. She also thought the patient wasn't in distress. I even asked her if I was overreacting. She thought I was and that I should accept that the drugs were doing their job and her saturations were acceptable.
Three or four times I asked two care nurses why we couldn't call the on-call pulmonary physician. I asked them to call RPT again and this time a therapist came up and agreed with what I was seeing, her sat were gradually going down even though we were titrating her O2 higher and higher. In this case, the R. Therapist could not even administer medications through the airway because it wasn't a patent airway. Bagging her failed as well. It appeared the trach was loose and blocking the airway. After being told several times to "stop being so intense" and this is not a problem, I was finally getting some answers. The RPT got her supervisor and we were able to open the stoma and see all this old gauze and secretions blocking the airway which we were able to clear, place the trach and cuff back in place and slightly inflate it to seal it a little better and she was back up to 99-100% SPO2 status after sitting at 88-90 on 65% oxygen. She had a blocked airway.
As I completed my charting, I saw that the last two shifts charted dressing changes on the trach site that clearly hadn't been done. I also saw that the PICC line was noted to be in the right arm when it was actually in the left. My charting always looks different in some way and I wonder if apathy at some point will kick in because I clearly am coming behind apathetic attention to detail and this isn't the first time. One oncology nurse took me aside last month and rechecked all my assessments because they were 'different' from the previous chart notes. She agreed with mine and signed below my name.
The care nurses tonight went behind closed doors to bag on me and one went to my instructor to say I was "too instense". The care nurse responsible for my patient told one of my classmates the same thing. The RPT went to my instructor and supported me in my assessment and said the patient had a risk for ARDS and coding without having a patent airway, and it was correct for me to want to get an order for the physician to reassess or remove the trach altogether. Since she is going to have a procedure in the AM everyone thought it could wait. I wasn't comfortable with it..neither was my patient. Difficult day or Chicken Little? Who cares? Another one of my classmates brought up a good point which actually made me feel a lot better about being such a pill tonight: If that was my mother, I'd be in the hallway naked screaming for someone to do SOMETHING! This is probably the first time since I started school, that I wondered if I wanted to work in an environment where your own colleagues refused to back you up.
I got in the car and felt close to tears but I knew I couldn't sleep tonight if I left the hospital with this patient snowed in with a closed/partially trapped airway. If that makes me Chicken Little, well then, the sky is falling...pick it up.
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7 comments:
Incase I didn't tell you, you did a great job today!! Whenever I peaked in, you were busy helping to keep your patient as comfortable as possible, which is why we are here. I even saw her smiling a couple of times. I'm sure she is greatful for you standing up for her and taking such good care of her. Not to mention sleeping good tonight ;) We live and learn everyday, and realize what kind of nurses we do and don't want to be. If chicken little means that you advocate and care for your patient the way they DESERVE to be, so be it... The sky must be falling...
Good job!
~Trudy
Hey Ms. Nursy.....
Remember the "drive by" assessments??? I believe you experienced the "drive by charting" and assessments here as well...plus a truckload of indifference!!!
Remember the little notebook idea of keeping it in your pocket at all times?
Name, date, time & place goes in there so you have a reference of what went on from YOUR prospective...so when the patient dies or the RN's play "screw the student", you have a discoverable handwritten record of what you did or tried to do.
The truth shakes out VERY suddenly when facts are presented in writing or spontaneous note form...especially when made by the assumed innocents.
I'd rather be "too intense" than too laxed.....I think you did a great job.
Now....tell me about this student that has a perpencity to be naked in hallways, screaming for someone to do something......hugs.....X
Way to stick to your guns, girl! You did the right thing, rather than the convenient thing. That's what it's all about. Please don't stop doing that. If I am a patient I want you, or someone EXACTLY like you, to advocate for me. You know what's right, and you CARE. Great job!! You made a difference this weekend.
~J
xoxo
T-J-X: Thanks...thanks and thanks.
Sorry you had to go through that. I have been a nurse for 16 years, and every day strive to do the best I can. Just as you do, and the majority of people in nursing. We make a comittment to our patients, one that involves trust. I have learned, though that "drive by charting" can happen to ANY good nurse who has more than a handful of crisis on a shift. Most nurses will give on the paperwork before the patient. Just a thought.
Tammy's patient wasn't choking to death on a chart...she was choking on a lack of proper assessment due to a series of RN's that were willing to "give on the paperwork" to facilitate the completion of their shift at the peril of the patient...AEB the failure to change and inspect the trach packing and patency of the airway. VERY basic life support issue any rookie with interest would see AEB Tammy trying to get some clod to help with an airway obstruction.
She should have only had to MENTION an airway concern for everyone at the RN station to stop what they were doing and assess her patient and address the issue, as opposed to covering eachother by throwing rocks at the student at the end of her shift.
And just how many years of experience does it take to reflect the truth in one's paperwork???
It's incumbant upon all RN's to protect the patient and not eachother.....any NORMAL, REASONABLE person would feel the same way...which also happens to be the task placed upon jury members when called to decide malpractice and criminal neglegence issues.....I'd much prefer defending Tammy's actions in this event, and think the RN's would be in a difficult position....hence the circling of the wagons and cheap-shot of the student...gotta "stick together or hang together" mentality. Very transparent.
Sounds like Comrade X hit the nail on the head. That nurse who went to your instructor to report that you were "too intense" was trying to cover her butt by throwing you under the bus.
By trying to discredit you, she was in effect trying to discredit your finding that the patients airways was compromised by her failure to perform adequate trach dressing changes, lack of adequate suctioning, and perhaps failure to inspect and change the trach inner cannula.
And I think you put it best when you wrote that "if that patient was your mother, you would've been out in the hallway screaming for help." That's exactly how I feel as well.
I think you earned a gold star for patient advocacy during that shift. And learned a lesson in the litigous reality of the hospital environment. Good job:)
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