What a shift I had yesterday........only four patients, but two of them took 95% of my time, and everything that could have gone wrong, did. Both were male dialysis patients in their early 30s, both had non-functional dialysis catheters, and both had parents in the room throughout my entire shift who hovered over them as if they were 2 years old. Naturally, they expected me to do the same, and if I had other patients, too bad for them........these people were literally following me everywhere I went, to the med room, to the supply room, even to the break room! I finally had to tell them that if I didn't take a break and get some food into me that I would NOT be able to take proper care of their sons, and that bought me about 20 minutes' peace. :angryfire
Part of the problem was the fact that one patient's doctors could NOT agree on what to do with him---his electrolytes were way off, and he needed dialysis NOW, but with a bad fistula, it was impossible. One MD said he wouldn't put in a new one till the next day; another said let's put in a catheter for tonight and then do the other procedure the next day; still another said why wasn't he already in surgery? Then the patient refused to sign consent for the temporary catheter, said he didn't like them. The nephrologist finally talked him into it, and suddenly there's an IV to be started, forms filled out, pre-op meds to be given, and it all needs to be done an hour ago! (They even wanted me to push 2 amps of bicarb into the IV I hadn't started yet....something we rarely, if ever, do on the floor in a non-code situation.)
In the meantime, the other patient's family wants me to get the dialysis nurse to come to the hospital NOW and do the TPA instillation. Fine....only the pharmacy has sent up the wrong stuff, and she gets upset at having to wait for it. I get things moving fast, she does the instillation.......but there's no one from the dialysis center available to try to aspirate the TPA four hours later, or flush the catheter if it's patent. So guess who has to do that, a med/surg nurse with NO peritoneal dialysis experience.....and the pt. already has peritonitis. She walked me through the procedure, and her instructions were very good, but I was extremely nervous about the whole thing.
During all this, the parents are telling me how THEY take care of this 31-year-old man at home, a man who, as I learn later, is very capable of caring for himself, and even has a personality when they aren't around. I won some brownie points with them when I didn't insist that he take his sliding scale insulin.......seems his sugars crash every time he uses it, and I figure, well, he knows his body far better than I do, so who am I to push the issue? I just told them that I would document the refusal and notify the MD of why he was doing so, and that seemed to win their confidence.
Meanwhile, my other patient has had the new temporary cath put in, which clotted off in the middle of dialysis, and he's back on the floor with systolic BP in the 250 range.....but demanding his dinner that the doctor promised him he could have when he got back to his room. By this time it's 2200 and the kitchen's been closed for three hours........the family erupts into outrage when they learn there is no tray available and he will have to make do with what we can scrounge up on the floor. "But the doctor promised
us Steve could have a tray when he got back," Mom insisted, to which I flatly stated that he SHOULDN'T have promised that, the kitchen closes at seven PM and we don't have dietary services after that. Now get this: he's supposed to be on a renal diet, and Mom goes and gets him fried rice, sweet-and-sour pork, and a 24-oz Pepsi.......then proceeds to spoon-feed this 34-year-old from the containers.
I must have done something right, though, because when my 3-11 shift finally, finally ends, the parents are genuinely sorry that I won't be with their son throughout the rest of the night. His BP has leveled off, he's comfortable, he's full, and that makes Momma and Poppa happy so the nurse gets the credit. I could use it.......I've busted my hump all evening for these two patients, virtually ignored my other two (thank God my one lady with bacteremia never went into septic shock, and the other never needed anything for pain), and I feel like I haven't accomplished anything......I couldn't aspirate the TPA, although I was kind of proud of myself for having had the courage to go ahead and do something totally new and outside my usual practice. It wasn't hard, or even very complicated, just different, and I performed it safely and documented my non-results. And today the on-call dialysis nurse who was supposed
to take care of this gets to explain to her facility's medical director why a med/surg nurse had to perform this specialized procedure.
And today I won't be there while a thirty-something man is fed by his mother, or while another thirty-something man's parents tell the day nurse how to do her job, or while a frail, 92-year-old lady who just lost her husband two weeks ago lies in bed stoically, without anyone to talk to. But I'll be back tomorrow.....and hopefully, I'll be able to take a few minutes to listen.