The NightShift Resistance (original) (raw)

An interesting evening.

I’m a little pissed because I made a good catch this morning but should have picked it up earlier.

I came on last night at 2245, got report and started my tour.

The only interesting thing on report was a fellow who had crappy lung sounds. He was started on Levaquim 500mg PO BID x10 a few days ago. Well, this AM he had a chest x-ray done and it came back as likely CHF, plural effusion, etc. No order for furosemide, which I would have expected and right there is where I should have started to get suspicious.

Anyway, since he was on report for the ABX he had to have his temp checked at least once per shift.

I went and checked on him and he was fine. Report said he had some breathing issues earlier but when I checked on him he was breathing fine with 2Lpm of supplemental O2 via NC. No s/sx of cyanosis. No dyspnea, SOB, etc. Basically, he seemed fine.

So I didn’t check his O2 sat. I should have checked it as soon as I saw the CHF dx, but when I saw him and he had no distress…………..

So around 0545 I see him on med pass and he just seems ‘off’. You know what I mean. You can’t put your finger on it, but you –know- something is going on, your nursing Spidey-Sense starts tingling and you start paying very close attention to whats going on.

I corral my CNA’s and ask them if they notice anything different about the resident and they say that he just seems ‘off’.

Now the thing that I and I think everbody else hates about our job is that we get to spend so little time with our residents/patients. I have 40 residents and spend maybe 3 minutes with each one per night. That’s it.

I bang out the rest of med pass as fast as I safely can. Check my watch. 45 minutes until shift change. I grab my stethoscope, sphygmomanometer, O2 meter and thermometer and decide to go play with Mr. CHF for a little while.

I go in and start with a pulse ox reading. He’s combative, as he always is, but I have weight, age and size on him.

Pulse 95. Ok, not outrageous especially since he’s fighting me.

Pulse oximetry…..%79-80. What the?!?!?

Run the pulse ox again in case his fighting gave me a false reading.

Pulse ox holding on %80. All the while he is still getting O2 at 2Lpm via NC.

Check his lung sounds. Bilat crappy w/ expiratory gurgling. Nail beds have good capillary refill, but are a little dusky.

That’s enough for me.

Off to get the supervisor. I tell her what the skinny is and that I want to call the doc and get some Lasix going.

She comes up to the floor and calls one of the admin nurses. The res is the father of one of the admin RN’s. She tells the admin nurse that I called the supv regarding the res and that she should come and join us to see what has got me so concerned that I had to get the supv.

I suspect she thinks I was overreacting. We get there and examine the guy. She greenlights me to call the doc and get some meds rolling.

Note to students and new grads: When you have to call the doc to report a change of status you’re going to find that there are two types of docs. One type will take your report and then say “Do this, this and this and then call me if there’s any change”. These docs are easy because all you’re doing is acting like a stenographer. He dictates the order and your off to the races. The other kind of doc is the one who takes your report and then says “..uhhuh…ok..so what do –you- want to do?”

What do –I- want to do? I want to do whatever the freakin’ guy who went to med school wants to do!! Although in a way I suppose it is a vote of confidence that the doc is asking what the person who actually has “boots on the ground” wants to do. I suggested 40mg IM Lasix and a bump up on the O2. Doc went with 30mg Lasix IM and supplemental O2 at 3Lpm via NC.

Done. 45 minutes later he’s sat’ing around %90 and is visibly more comfortable. His daughter, on the other hand, was a bit of a trainwreck.

Was it a good catch for me. Yes although I should have picked it up as soon as I came on. As soon as I saw CHF on the report I should have gotten an O2 sat right off even though there was no distress at that time.

Other stuff:
The CXR was done that AM. On the 24hr report it stated that the MD was contacted to give the results to but there was no note showing that he ever called back. That’s why he had no furosemide order; doc had never called back. 1500-2300 should have seen on report that a call was out to the MD and had not been returned and then followed up.

Stuff happens.

Lesson I learned: CHF = get a pulse ox right at start of shift/tour.

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Spoke to the admissions folks at the local diploma mill.

My transcripts finally showed up. I have to go by Thursday morning, meet with an adviser and get classes picked.