Documentation
We do a shitload of documentation on each patient. Our manager has concluded that for safety reasons, we need to do an entire hospital admission process for everyone who comes in. The outpatients, that is - inpatients should already have that done. For every patient we need to:
- Do the admission process in the computer system which includes:
- Review of all medications they are taking.
Do you have any idea how many people have no clue what medications they take and when???. Horrifying - Validate all of their medication sensitivities and allergies.
- Get information on their legal status regarding durable power of attourney, living will, etc. If they have one, I need to find it and get it on the chart if possible.
- Investigate their living situation, and see if there are any dependents
- Get contact information for family and/or friends
- Screen for domestic violence
- Find out if they are in any medical research study and if so, get the contact information
- Assess their ability for self care, such as independent grooming, toileting, etc.
- Investigate their use of tobacco, alcohol, and illegal drugs
- Are there stairs in the house to the essential rooms (bed/bath/laundry/entrance)?
- Evaluate if the patient is at nutritional risk
- Ask the patient if s/he has experienced any major life changes in the last 6 months.
- Finally, get the patient's stated goal for his/her hospital stay.
This, I think is stupid. Most people say "to get out." Well, duh. Management has decided that this is important, so we do it.
In addition to this, I am supposed to validate the medication administration record against the doctor's orders (and against what the patient tells me), I need to run EKG analyses, at least 2 per shift (pre and post procedure), develop a plan for the day, and evaluate the plan of care for the patient.
Then there is the "normal" nursing documentation that is done every shift (or more) on all patients: assessment, nursing note, record intake, output, pain, etc.
It is true, I have most of the day to do all of this for each patient. I try to get it all done as quickly as possible, because who knows what the day holds? I could get really busy with critical patients and not have time to do all of this.
Post Procedure
After a patient comes back from procedure, we assess again, settle the patient back into the room and begin frequent monitoring. Most patients require vital signs every 15 mintues for the first hour, then every 30 minutes, then every hour for 4 hours. This is fun when you have more than one patient on 15 minute vitals. It is even more fun when several patients return from the lab at the same time.
I receive report from the procedural nurse, and follow the protocol as ordered by the doctor for the patient, based on what happened during the procedure.
Cardiac or Peripheral catheterization
A cardiac cath is when thin wires are threaded through the femoral artery or vein up to the heart. They are looking for blockages in the arteries of the heart (mostly..there are a few other things one can do with a cardiac cath). A peripheral cath is when these wires are directed down the legs to look for arterial blockages. If warranted, the doctor can "fix" these blockages with a stent, which is a wire mesh tube used to prop open an artery.
Our most frequent procedure is the cardiac cath. Patients usually come back with tubing (a "sheath") in one or more groin punctures. That is, there's tubing sticking out of their femorial artery. If blood thinners were used during the procedure, we have to wait to remove the tubing until their blood thickens up enough to hold a good clot. The patient has to lie flat on their back until that time, although we can tilt the bed so his head is higher than his feet. They can't eat until we get the tubing out.
Pacemakers
Some patients have a pacemaker placed or the battery on a pacemaker replaced. Occasionally we have an explant or entire replacement of device. These patients come back with an incision in their chest, usually the left side just under the clavicle. They can eat when they're awake, they can sit up in bed, just not move the arm on the affected side.
Ablations
Another procedure we do pretty frequently is an ablation. This procedure uses thin wires to go up to the heart and zap (e.g. burn, electrically) portions of the interior of the right atrium of the heart. Occasionally the left atrium needs to be zapped. These patients come back with multiple sheaths in their groins in the femoral veins, usually bilaterally, and sometimes they have a catheter in their internal jugular on the right side. These patients often have had blood thinners as well, so they must wait flat on their backs as well.
Other variations
Devices are available that seal up the puncture. We use two types: starclose and angioseal. The former is like a little staple. The latter is a plug of collagen that closes up the hole and eventually gets absorbed by the body.
Sometimes pacemaker patients will have a groin sheath as well. During the procedure, if the doctor cannot place the pacemaker leads properly from the incision (via the mammary vein), she will thread catheter wires up through the femoral vein to assist.
Some of the variations for cardiac caths are to measure blood pressures in the hear as it's functioning, measure pressure of blood in the lungs, and assess the functionality of the left ventricle.
Bedrest
Patients are on bedrest post procedure while we are monitoring them frequently. Many patients are still somewhat sedated so they are pretty cooperative. Most of them don't have a lot of pain, again because of the sedation and the local anaesthetic. They come back to us cold, frequently. The cath lab and the EP labs are kept in the lower 60s.
Patients don't like bedrest. Many patients have back problems and it is painful to lie on their backs for hours. Most patients, particularly the younger ones, will repeatedly let me know their backs hurt and that nothing I can do for them helps. No one likes to use a bedpan. At least the men can use a urinal.
Now, we have the annoying variation of the older man with enlarged prostate. Mostly they are embarrassed about it, so they don't say anything until they can't pee and their bladder is extended to the point of pain. Then it's panic time because they are so uncomfortable. But no, they couldn't have said something earlier and we could have placed a catheter. When their bladders are distended with urine, it displaces everything internally, which makes it that much more difficult to place a foley catheter. If I can't do it (and failing at placing a urinary cath hurts!!! Succeeding at it isn't much fun, either.) I have to call the urology doctors and wait for them to come. More pain while we wait.
As you can tell, this process bugs me. Men, get over yourself and let me know, so I can help you. Don't let it come to panic time!!
It's kind of amusing how some people will try to negotiate to get off bedrest early. What am I supposed to do...let them? NO! What if they bleed? People don't realize how high-pressure a femoral artery is and that in a matter of minutes they'd bleed to death if it opens up. I shake my head in disbelief. I guess because they feel OK, they don't realize how vulnerable they are.
They also want to eat. I can give them clear liquids, but nothing else until that sheath is out. The reason for this is that when we do the sheath pull, the vagal nerve may get stimulated, which can cause them to throw up. And if they aspirate the food, then they stop breathing. Not good.
In the end, almost everyone complies. As the bedside nurse, I get to hear about how awful it is. A lot. I wish the doctors would impress upon the patient how long they typically must stay in bed. Patients seem so surprised when I tell them 6 hours of bedrest is required. I think the doctors gloss over it, mutter it under their breath, and patients don't think about what it will be like.
My self care during the Workday
Caring for people is emotionally and physically demanding. Fortunately, we have good teamwork where I work and we help each other out. I try to get my morning "snack" break around 1030 - that's when I usually start feeling kind of light headed and hungry. I like to have a cheese stick, some crackers, a cup of coffee. I like to take lunch around 1330. Of course my self care is variable based on my patient-care demands. Some days I don't get much of a break.
It is so very tempting to eat too much. Like many people, women in particular, I get an emotional lift from having a treat. There is they physical hunger and the emotional need to be cared for given the demands of the job. There isn't much time for anything else, really (a back rub? Leave the unit and breathe fresh air outside? Oh, come on, seriously...)
My little indulgence is to read the newspaper which I bring in from home. I also keep the water at my workstation so I can keep hydrated. I have a terrible habit of not drinking enough. I have gone entire shifts without having to pee. That is not good.
Honestly, though, my unit is not really that bad for self-care. We help each other out, and there are lulls in the chaos when you can get a bite or go pee. When I used to work on a regular inpatient unit, I frequently had to make the choice between getting behind in my work or eating lunch/using the bathroom. I mean, when a patient is in pain or crashing, nobody gives a damn if the nurse is going to crap her pants because she hasn't gone to the bathroom in 6 hours. She should have done that earlier...and no one gives a damn if there wasn't time to do that earlier.
The nurse must assert her own self care in a safe and judicious way.
Coming next: The workday, part 3: The sheath pull.
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