Jake's Choice

There are times when our training has to take a back seat to a patient’s wishes. It feels as though it goes against everything that was drilled into us. It was Jake’s call, not mine. Nurses Announcements Archive

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"He's had a few close calls this past week," I was told has I prepared to visit this man who lived out in the mountains. "He's a crotchety fella and not too keen to go to the E.D. so do what you can if anything goes wrong."

"Great," I thought, "This should be interesting."

We'll call him "Jake." Jake was a 76 year old man who suffered from COPD, Diabetes Mellitus and Peripheral Vascular Disease. He was also a fairly recent double bilateral amputee above the knees. His struggle with COPD left him on oxygen 24/7. However, he didn't always wear it, nor was he always compliant regarding his neb use. In short, he often sabotaged himself.

Recently discharged from his surgery, he lived on a small farm up in the Maine mountains with his son, a developmentally disabled 22 year old, and his chickens and ponies.

He wasn't one of my regulars. His Case Manager was out for the day and I was asked to see him on the weekend.

I grabbed my supplies and headed out. Jake's place was about a 25 minute drive from town. When I arrived, I was amazed how long his driveway was. A dirt road off of another dirt road.

"If it was dark out, I would have missed it." I told myself. I slowly backed my vehicle off to the side being mindful of the chickens who insisted on escorting me up the walk.

I knocked and was greeted by Jake's son. "Dad's in here," he pointed to the living room. The T-V was blaring. Jake was seated at his kitchen table, in his wheelchair, baseball cap on his head. He looked tired and was having some difficulty breathing.

"Hi, Jake," I introduced myself, opening my bag after tossing down a barrier and whipping out my hand sanitizer. "My name is Cynthia. I filling in today for your nurse. Let's check that oxygen level and get you more comfortable." I was concerned.

His heart rate was high, skin was moist and his color was a bit gray. Even though he was a CO2 retainer, I cranked his O2 from 2.5 to 3.5 while I scrambled for a neb from his box. It can be dangerous to increase oxygen on a CO2 retainer as their body has compensated the lack of O2 for over a long period of time. Weaning them down too quickly can have deadly consequences. He denied chest pain.

But Jake had standing orders to increase his oxygen for saturation parameters, but to wean him slowly as soon as we could back down to his normal rate of 2.5L per nasal cannula. Of course, we were to let the Physician know.

I listened to Jake's lungs. Not knowing what his baseline was made it a bit tricky. I didn't like what I was hearing.

His sats were still in the mid 80's. "Jake," I said, "If I can't get you stable quickly, I should send you in." He grabbed my arm. I winced.

"No hospital!!!" He said emphatically, shaking his head forcefully. I glanced to his son, still sitting on the couch, watching T-V. He was oblivious to the distress, or maybe he was just use to it?

I could see the idea of going to the Emergency Room was making him worse.

"O.K., Jake," I relented. "You're the boss, but I am going to make sure you take your breathing treatments and I mean now. I cannot even begin to do your ordered dressing changes until I know you are breathing better. "I've got time, so what do you say?'

He nodded, and took his nebulizer. I began to document, listened to his lungs again, documented some more. Much improved. He coughed up a lot of mucous. His sats increased to 92%. I began the process of slowly weaning him down over the next hour.

I washed my hands again to set up the dressing for his bilateral stumps.

The wounds themselves actually looked good but nutrition, blood and oxygen perfusion would play a big part in his healing process. I glanced at the kitchen, noting the dishes in the sink and the dirty stove. With Jake's permission, I did a quick visual of what was in his refrigerator.

"Jake, what did you eat today for breakfast?"

"I ate eggs and coffee." He stated.

We had a discussion about food choices, the part that they play in building substrates for cells to mesh, etc.

"I know that it takes a lot of energy for you to eat, and it's great that you are eating protein so it's fine to go slow, but please try to eat vegetables, fruits and whole grains and all of it if you can."

"No one told me that!" I stayed silent because to keep good relations with clients and caregivers, there are times when one simply cannot rise to the bait. I am sure his caregivers went over this, as it was on his Care Plan. I reviewed the Care Plan with him instead.

My visit with Jake was long. Between the education regarding his disease processes, the need to use his medications and oxygen appropriately, the monitoring for infection regarding his wounds, it took some time.

But by nursing and God's grace, he was pulled back to his baseline.

His dressings changed, his vitals stable, his color much improved, his discomfort abated, for now at least, I felt I could leave his house.

As I said goodbye and thanked him for trusting me with his care, my gaze wandered to the window. The pastures so green, lilac fragrance in the air, the ponies scampering enjoying the summer breeze. For a while, all was well once again in Jake's world.....for now.

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