Nursing (RN) Challenges

Miscellaneous and Personal Stuff I Must Share
1

I’ve been active in an IMHO thread re nurses and the stresses of the workplace. That sort of morphed into me talking about preceptorship with case studies (so to speak). So, instead of hijacking a perfectly good thread, I thought I’d start one with just LIKELY scenarios as a sort of mental exercise. Physicians, feel free to play along! We promise not to laugh (too much). Laypeople are welcome, too, but if you’re a butthead, I won’t answer your call light.

Another exercise in prioritizing (just can’t get enough of those). You’re on duty on a Sunday late morning- midday. It’s you and one other nurse, one CNA and a unit secretary in your little 8 bed unit. Your ratio is 1:4. Your acuity is similar to a stepdown unit-- continuous pulse ox, NIBP, bedside tele monitors. Most of your pts have drips, if only maintenance fluids (or K+ supplements/IVPB–that’s IVAB for the Aussie). A few may be on IV nitro or “renal dose” Dopamine (which my hospital still uses) or they may be newly diagnosed DM or acute asthmas–it’s kind of catch all unit. A vented pt is not unheard of. Your pt population is over 65, even mix of male and female. Here is your pt load:

#1 72 year old, obese, white female, speaks broken English/Serbian. Is up in a chair after gallbladder(open chole) surgery yesterday. VSS, except for her BP, which is trending higher than her pre-op baseline. She has family with her. Has one J-P (Jackson-Pratt, god knows what they’re called in Oz), a largish dressing. She is tolerating her clear liquid diet well.

#2 85 year old black male. Sundowns. In for CHF, exacerbated by his noncompliance with his diet and meds. VSS. Tele monitor shows ST w/ frequent PACs- a change from last night. He says he doesn’t feel well, but cannot elaborate.

#3 65 y/o black female, passed out yesterday at the mall, in for observation due to grossly abnormal labs. Lytes-off; BUN/Creat elevated. Required Kayexylate for K+ of 6.4 yesterday. She is alert, cooperative and very nice.

#4 74 y/o Hispanic male in for unstable angina. Speaks no English; has family at bedside. Pt is convinced his “dolor” is from indigestion. He is refusing any and all meds. His family is trying to convince him to cooperate and take his pills.

Ya know, this is harder to think up than it is to do it… Ok, we’ll start with easy and maybe work our way up to hard.(and some of these may be humorous) Here are your questions:

  1. which pt is LIKELIEST to become unstable?

  2. Give 2 reasons for Serbian lady’s increasing BP.

  3. Should mall lady’s K+ have come down by now? Why or why not?

  4. Where is your Spanish interpreter? Why do you need him or her?

  5. What happens in about 5 minutes that will make you job much more difficult?

2

I have a question about why my ratio is 1:4.

3

No reactionaries! Your ratio is 1:4 because GodNightingale (aka me) has so decreed. If you want to play, you gotta play by the rules–and no fair killing off one of your pts (I’ll give you a GI bleeder from ER). :stuck_out_tongue:

4

  1. Pt # 4 is likely to become unstable, since he is, not only not getting his required meds, but his family is causing him more agitation. I suspect he could arrest at an inopportune moment.

  2. Her pain isn’t being controlled, the J-P needs to be drained.

  3. It should have come down after the Kayexylate, but if it hasn’t, or is creeping back up, I need more information. Is she eating? What dietary restrictions? Is she putting out urine?

  4. AT&T has phone interpreters. The hispanic gentleman may listen to a healthcare professional better than family. It’s important he get treatment.

  5. Whatever happens, in 5 minutes, I will adjust. :smiley:

5

  1. which pt is LIKELIEST to become unstable?
    I’m going to be controversial and say that the 85 year old with ST and PAC and not feeling too hot is doing something funny and needs sorted out. CHF suggests IHD as an underlying cause- could he be having an MI or be going into pulmonary oedema? Could the fluid in his chest have become infected, so that he’s now brewing a good going pneumonia? I don’t know, but I’d like to find out.

  2. Give 2 reasons for Serbian lady’s increasing BP.
    Pain, family stressing her out.

  3. Should mall lady’s K+ have come down by now? Why or why not?
    She has renal failure. Her kidneys are not going to excrete that potassium until they’re sorted out. I suspect her potassium will still be over 6. The best you can do is drive it into the cells. Here, I’d use salbutamol nebs, and IV insulin in 50% dextrose, with calcium gluconate to stabilise the myocardium and do 4 hourly U&E checks. YMMV.

  4. Where is your Spanish interpreter? Why do you need him or her?
    To have a chat to the guy with the angina and ensure that everybody (family, staff, patient) is on the same page. “The pain is cardiac, the pills will make it better, please take the pills”.

  5. What happens in about 5 minutes that will make you job much more difficult?
    Sunday 12MD- either patient lunchtime, your nursing colleagues’ break time or the medical ward round will be about to start…maybe all of the above at once?

6

God, this is fun!

All very good answers. Not sure if I want to wait a bit (to see if more come in and post or if I should respond). I’ll give it another hour.

Love the answer to #5 picunurse–that is the correct outcome! :wink:

Irishgirl– What are q 4 U&E checks? Urine and ? Urea and electrolytes? :confused: How about a surgical consult for an insertion of a Quinton and in the very near future, an AV graft or fistula? The dextrose etc is just a (very) temporary fix. She needs dialysis. She also needs to be checked for latent type 2 DM and HTN.

Oops. :eek: Well, I’ll be back in a bit with the answers.

7

The board died on me. OK, since this thread is dying as well, I’ll go ahead and answer.

  1. which pt is LIKELIEST to become unstable?

#4. You don’t know the true source of his pain. He is in for just such a problem. I cheated a bit and didn’t give you any VS, but he has an evolving cardiac hx. Let’s not have it evolve on your shift.

I did not pick #2 for a few reasons. He is still in ST–the PACs are picking up and he looks like he really wants to flip into Afib. But he is stable–which means his CHF is ok right now, too. He was non-compliant at home re his meds, not here (perhaps that wasn’t clear). Even if he does flip into AFib, he is still more stable than unstable agina language barrier non-compliant guy.

  1. Give 2 reasons for Serbian lady’s increasing BP.

There any number of valid reasons for this. Pain should be your first guess; nausea (although she is tolerating her diet), peri-incisional pressure d/t the JP being full (but again, nocs should have emptied it at change of shift–if it’s that full again, I’d start monitoring q 2). Or she could have HTN, she is elderly and obese…

  1. Should mall lady’s K+ have come down by now? Why or why not?

Kayexalate can take hours to days to work. Irishgirl was on to a good thing re the dextrose and insulin therapy, but really this woman needs a renal workup and dialysis. So, to answer the question, her K+ could be down or maybe not. I’ve never known sorbitol (got tired of typing the other name) to not decrease a serum K+ at least somewhat. Certainly it it hasn’t come down–the MD needs to be called asap.

  1. Where is your Spanish interpreter? Why do you need him or her?

Often (IME) families of those pts who only speak Spanish say they speak English, but they really don’t–or they don’t well enough to understand complicated medical stuff and explain to the pt. Also, our hospital has gotten away from using family as the interpreter d/t possible liability issues. And, as was mentioned, an objective third party often does quite well with recalcitrant pts. Since the family won’t hear what is being said on the phone, this allows the pt to save face and “get new info” upon which to support his new cooperation. And then sometimes it doesn’t work at all.

  1. What happens in about 5 minutes that will make you job much more difficult?

It’s SUNDAY! It’s NOON! Time for all THE CHURCH PEOPLE IN GOD’S CREATION TO COME HOSPITAL VISITING AFTER SERVICES! You will see more dressed up visitors than any other day–and all of them want attention. :slight_smile:

If anyone wants to do another one, or submit one, I’m game. I just don’t want to go through the trouble of posting just for my own self…

8

As a not-even-nursing-student yet, I’m finding this fascinating. First, 'cause there’s so much I actually understand of your obscure jargony abbreviations :wink: even without knowing what to do with them, but also because it reassures me of the one part of nursing I thought I knew, but wasn’t certain of - that you have to use your brain. I DON’T want to be an automaton - I don’t want to be an extra pair of hands for someone in a white coat, but at the same time, I don’t want ultimate, final responsibility for figuring out what’s up. Sounds like it’s about what I thought - you do have to do a *lot *of thinking, fast, and detective work and prioritizing and decision making, but when push comes to shove, it’s the doctor’s call. That sounds good for me - I thrive in middle management. :stuck_out_tongue:

So, thanks, eleanorigby, for doing this thread, even if it didn’t get all the responses you hoped. (Although I might also add that starting it at 1:30 in the morning wasn’t exactly at prime time!) If you’re feeling bored, I’d love to read more. Although there’s too much technical stuff for me to articulate reasonable reasons WHY I’d choose anything, I did actually get the answers to 1, 2, 4 and 5 correct (with a “pass” on 3).

9

You got #5 right?! Good ole pagan you!? Good on ya!
Sundays were some of my favorite days to work–except for the church people. Most of them were very nice, but there were those that just demanded everything. Not sure if it was because they were dressed up or on their day off. I used to crack up (privately) at the sight of the “church nurses”–what a contrast! The actual nurse: blue scrubs, pockets crammed with pens, tape, scissors, stethie, bandaids, alcohol wipes etc, ponytail coming undone, ink on arms vs “church nurse”: white Jackie Kennedy hat, with veil, immaculate white dress, white hose, white shoes, Bible and hanky. It was surreal.
Nursing requires excellent time management and critical thinking skills–at the same time. Actually, in real time. There is no sit down and plot your day, as in well, I’ll do 451’s dressing change at 11, and 449’s teaching at 2. You can certainly make a plan, but you need to write it on water.

10

Well, I went back to read the time of day (“lunch? rounds?..too early for sundowning, right?”) and noticed how specific you were about the DAY itself, and that sort of clued me in.

I also grew up down the street from a Catholic church, and Sunday between 11:30-Noon was when you didn’t even try to exit the subdivision by the north, you went all the way around to the south exit, 'cause it was quicker that way, even if you were ultimately headed north.

And I know you snicker, but I privately mourn the passing of the actual white hat and hose nursing uniform. It’s just so…*professional *looking. I hate scrubs, they look so schlubby. (Although I’m sure keeping those whites white was no mean feat.) ETA: Plus I hate being in a hospital and not knowing if I’m taking to a nurse, a respiratory therapist or the chick who brings the lunches, because they’re all dressed alike.

11

OK, I’ll set up one more. Same unit, same ratio, same staffing. AND some of the same pts (much like RL), but this is the next day, late afternoon. Updates in different color font.

72 year old, obese, white female, speaks broken English/Serbian. Is up in a chair after gallbladder(open chole) surgery yesterday. VSS, except for her BP, which is trending higher than her pre-op baseline. She has family with her. Has one J-P (Jackson-Pratt, god knows what they’re called in Oz), a largish dressing. She is tolerating her clear liquid diet well. She is transferred to a GMF (gen med floor) by afternoon. On a soft diet now.

#2 85 year old black male. Sundowns. In for CHF, exacerbated by his noncompliance with his diet and meds. VSS. Tele monitor shows ST w/ frequent PACs- a change from last night. He says he doesn’t feel well, but cannot elaborate.He did indeed flip into a rapid A fib at 1 pm yesterday. He was digitalized and the monitor now shows a controlled A fib. Other VS stable. As the evening draws in, he starts to complain of strange lights and things “looking funny.”

#3 65 y/o black female, passed out yesterday at the mall, in for observation due to grossly abnormal labs. Lytes-off; BUN/Creat elevated. Required Kayexylate for K+ of 6.4 yesterday. She is alert, cooperative and very nice.Her K+ remains 5.9. A general surgeon is called in and you assist him with inserting a Quinton catheter at the bedside. She is now undergoing a 4 hr hemodialysis treatment. She is tolerating HD fine.

#4 74 y/o Hispanic male in for unstable angina. Speaks no English; has family at bedside. Pt is convinced his “dolor” is from indigestion. He is refusing any and all meds. His family is trying to convince him to cooperate and take his pills. Interepreter got him to understand that he needs to take his pills. He continues to c/o of dolor. He is unable to rate it on a pain scale. He points to his chest and his abdomen, equally.

New #1 This is 46 year old black woman admitted 2 hours ago for exacerbation of asthma. She is alert, cooperative. VSS, and she looks comfortable, although she is audibly wheezing. Her nebs are ordered q 4 and prn. (neb is albuterol). She states she has been coughing up some “yucky stuff”. She is also worried about her 11 year old daughter, left home alone after school until pt’s mom is off work.

Questions:

  1. Was the post-op Serbian lady ok to be transferred? Why or why not?

  2. What could be a reason for #2 pt’s c/o? What else should you watch for in him?

  3. Would you say that Hispanic man is stable? Does the MD need to be called? What else could you do before you call the MD?

  4. Why is asthma woman still wheezing? Are there intervening variables that may be exacerbating her condition? If so, what are they?

12

Oh, no–I snicker at the hose and hat. I loved whites. Nothing is as crisp or professional looking–unless you put us all into navy flight jackets (which would look :eek: on many nurses). But, sadly, nurses don’t always… dress appropriately underneath for whites, if you follow me. Also, while nothing looks as crisp, nothing looks as slovenly as dirty whites.

13

Oooh! Can I play?

I’m worried that #3 has an aneurism rather than angina.

On #2, did that a-fib dredge up a clot - could a minor stroke cause the visual weirdness?

14

Thanks for playing! I’m going to allow some time for at least one other post prior to answering. Good thinking on the Afib and clot, though.

15

I’ll play-

#2 may have digoxin toxicity if the doctors loaded him with dig and he has poor renal function.

#4 you can do an EKG before calling the MD, but also check pressures in both arms and pulses in both legs if you suspect aneurysm.

#5-Asthma lady is partially wheezing because of anxiety. Also, Q4 nebs likely won’t hold her. She needs steroids (for the long-term) if not already getting them but for acute treatment you could increase the nebs and make sure she has enough O2 and get somebody to check on the daughter.

16

What about Serbian lady?
Yes, yes, and yes. Did I make these too easy? :slight_smile:

Dig toxicity can cause visual disturbances, a yellow haze around lights. (personal note: this was a Board question. The only reason I got it right was because my mother–an old L&D nurse-- told me it had been a question on HER boards!).

Not only an EKG, but also ask re his appetite, his bowels, and more in depth about his pain. It could be aneurism, although that pain is usually back pain and excruciating; it could be gallbladder or ulcer or gastritis. Or it could be an inferior wall MI. I’d get enzymes as well as the EKG and then call the doc to update.

I have seen this so much with asthma pts (and COPDers)–anxiety fuels so much of their disease (not a criticism, just an observation). Take away her worry (as much as you can) and her wheeze may settle down too. Then again, she may be allergic to latex or the dust in the curtains… I’d put 2L of O2 on her and check her frequently.

17

The Serbian lady sounds good for transfer if her BP ever trended back down. If not, the MD needs to be notified - perhaps not called in the middle of the night, but maybe on rounds.

The CHFer is having classic symptoms of digoxin toxicity. I’d draw a stat dig level and call MD for digibind if level is high.

On the asthma patient, she needs another treatment stat. What did she get in the ER? Did they do a sputum culture? She could have pneumonia.

18

This is no fun if nurses are going to all the answering! :smiley: I forgot to mention the possibility of pneumonia for asthma lady. I’d do a sputum as well. Also, since she seems to have a productive cough, we might want some mucomyst–something to ask the RT about and mention to the doc. We want a prn order for those treatments as well as a scheduled dose, too.

Serbian lady is fine! Her BP was due to pain–gas. She’s ready to go home!

19

This is fun!

  1. Was the post-op Serbian lady ok to be transferred? Why or why not?
    Did the BP settle once the family left and the pain was under control? If so, safe on the t/f, if not, not.

  2. What could be a reason for #2 pt’s c/o? What else should you watch for in him?
    Check a Dig level, could be Dig overdose (causes yellow vision, tremor, vomiting), could be a stroke, most likely to be sundowning.
    I no likey confused old people, they suddenly have the strength of 10 men and the stubbornness of 20. Needs frequent obs, and make sure he doesn’t go bananas and start wrecking the place. Make sure he’s written up for any regular night time sedation (confused old people withdrawing from sleeping tablets is double plus bad).

  3. Would you say that Hispanic man is stable? Does the MD need to be called? What else could you do before you call the MD?
    Call your doc. Inferior MI/AAA leakage/aortic dissection/perfed peptic ulcer all possible differentials. None are good. Have the vitals ready before you call, crash call if any of the VS are newly dodgy, especially BP.
    Your doc will love you if you arrange the following before they show up: ECG, Troponin level (a new raise is not good), IV accessx2, catheterise, FBC, urea and electrolytes, co-ag, ABG, CXR… the list goes on. Have all the bits ready so your doc can give IV morphine.

  4. Why is asthma woman still wheezing? Are there intervening variables that may be exacerbating her condition? If so, what are they?
    Start steroids, ABx, oxygen, help sort out child care and reassure the lady! Anxiety not helping, sounds like LRTI is underlying cause!

eleanorigby- I’ve seen potassiums of 7 with renal dysfunction that didn’t require dialysis and settled with fluids. We don’t use sorbitol here.
If you’d said the creatinine was over 500 and the urea was in the 30s my answer might have changed.
U&E is urea and electrolytes (I think you call it a chem 7?) it consists of: Na, K, chloride, urea, creatinine, eGFR. We usually add a bone profile (calcium, albumin, Alk phos, phosphate), magnesium and CRP to it.

Edit: Damn, you all answered while I was replying!

20

I guess I’m a glutton for punishment. Here goes scenario the third. Same deal.
Same unit, same ratio, same staffing. AND some of the same pts (much like RL), but this is the next day(now day 3), mid-morning. Updates in different color font.
#2 85 year old black male. Sundowns. In for CHF, exacerbated by his noncompliance with his diet and meds. VSS. Tele monitor shows ST w/ frequent PACs- a change from last night. He says he doesn’t feel well, but cannot elaborate.He did indeed flip into a rapid A fib at 1 pm yesterday. He was digitalized and the monitor now shows a controlled A fib. Other VS stable. As the evening draws in, he starts to complain of strange lights and things “looking funny.” His dig level was high, but doc ordered no Digibind because his renal function is ok. He is in SR. VSS. He says he’s not making it out of Cecil Adam’s Memorial, though. His monitor shows runs of bigeminy. His ankles are now 2+ edema, up from trace edema yesterday.

#3 65 y/o black female, passed out yesterday at the mall, in for observation due to grossly abnormal labs. Lytes-off; BUN/Creat elevated. Required Kayexylate for K+ of 6.4 yesterday. She is alert, cooperative and very nice.Her K+ remains 5.9. A general surgeon is called in and you assist him with inserting a Quinton catheter at the bedside. She is now undergoing a 4 hr hemodialysis treatment. She is tolerating HD fine. She responded well to HD and has been transferred off the unit.

#4 74 y/o Hispanic male in for unstable angina. Speaks no English; has family at bedside. Pt is convinced his “dolor” is from indigestion. He is refusing any and all meds. His family is trying to convince him to cooperate and take his pills. Interepreter got him to understand that he needs to take his pills. He continues to c/o of dolor. He is unable to rate it on a pain scale. He points to his chest and his abdomen, equally. He has spiked a fever of 102. He has + BS x 4 quads; abd soft. Still c/o dolor to abd and chest. VSS, except for temp and light ST.

New #1 This is 46 year old black woman admitted 2 hours ago for exacerbation of asthma. She is alert, cooperative. VSS, and she looks comfortable, although she is audibly wheezing. Her nebs are ordered q 4 and prn. (neb is albuterol). She states she has been coughing up some “yucky stuff”. She is also worried about her 11 year old daughter, left home alone after school until pt’s mom is off work.
She feels much better with the O2 on. Also, she has spoken to her daughter and is reassured. She has provided a sputum specimen. She puts her light on, c/o of a sharp pain to her right chest upon inspiration. VSS.

New pt #3. A 76 year old white man, hx of ETOH abuse, admitted from ER with acute upper GI bleed. He was scoped in the ED and is now on an Octreotide drip at the standard concentration and dosage. His Hgb and Hct are now 8/34. He is awake, alert, and wants dinner, despite being NPO. His other hx is unremarkable, as is his physical assessment. He does admit to smoking (cigarettes). He has no family.
Questions:

What needs to be done for #2, #4 and #1? They all need the same thing. What is it?

For #2–what can you do specifically for him before you notify the doctor?

For #3: what are your priorities in terms of his care? What more do you need to know about him?

Re #1–is this new development an emergency? What should you do next?

More questions as I think of them. (this is harder than it looks!)