Vent!

I work 6pm-6am. I had this particular patient 5 days in a row last week, and came in last night, after 3 days off, to have him again. Some background: He's been in the Hospital for 2 weeks. He was being treated for complete thrombosis of the portal vein, among other things, so he was getting Lactulose multiple times a day to try to prevent/help with hepatic encephalopathy (his ammonia level was 82 upon admission, but came down to normal within the first week he was with us). As time went on, He started to refuse his Lactulose. When I left him last week, he was still totally cognitive, competant, able to hold a conversation, although he was becoming increasingly lethargic.

I came in last night to find they had had to insert an NJ tube (after multiple NG attempts), put him in soft limb restraints (wrists), and he was made a 1:1 observation- He was confused, agitated, constantly trying to pull out his tubes and lines when he was unrestrained, even with the 1:1, and he had managed to pull out his foley before the start of my shift. The doctors were blaming the hepatic encephalopathy, and the fact he had refused several doses of lactulose, so he was recieving the lactulose and some Osmolyte because he wasn't eating or taking anything po. When the 1:1 order was written, it was for the 1:1 for 10 hours after the NJ tube was placed, to keep pt from pulling out the tube. He was still to be in the soft limb restraints if needed. Midnight rolled around, the 1:1 person left, as the time was up, but he was still decently confused and the charge nurse and I split up the rest of the night hanging out in his room with him.

GI were the ones who placed the tube, and they generally round between 5 and 6 am. I was going to ask GI if they wanted to continue the 1:1 (well, beg them), but I ended up getting caught up with my other patients, and GI hadn't rounded yet by 630. At this point, he was still restrained but sleeping comfortably, and i was out at the desk giving report. The phlebotomist went in to draw blood for labs, and the oncoming nurse and I were keeping an ear out, but not really worrying about him too much, because there was someone in the room with him. A good 5 minutes go by, and the phlebotomist comes wandering out, and says that he is pulling his tubes out. We rush into the room to find that he has indeed pulled his wonderful NJ tube out. He was still in restraints, but had managed to slouch down far enough and bend sideways at the waist enough to reach his hand to his nose to pull it out.

Now, this may just be me, but if I were the phlebotomist, and I go in to do a labdraw, and notice the patients' wrists are tied down, and he has a tube in his nose, and he starts trying to mess with it, I would be yelling out to the nurses to come and help, or at least try to keep his hands away and ask for him to be repositioned, or SOMETHING. Not just stand there and watch as he cheats through the restraints to pull a tube out. Who would do that? Granted, he wasn't technically a 1:1 anymore, and we hadn't talked to GI yet, but still. Let a patient pull tubes out? UGH!