Tuesday, September 22, 2009

Testing... ... ...testing... ... ...

Today I kicked ass and took names. We had tests. I love tests. I especially love tests that have to do with little scenarios you read and analyze, then try to figure out what to do first, when to call the doc, and when to tell the patient to calm the heck down, everything's really and truly fine.

Of course, these were critical care scenarios. I am a med-surg nurse by training, so there was a certain amount of thinking that had to go into things. And, as a Minion heard recently, you can't always put down real-life solutions to test questions, because what the accepted nursing practice says is different.

For instance, take this scenario: a patient has a heart rhythm that's consistent with having too much potassium in their blood. What would I do in the real world? Why, I would draw a stat serum potassium. Then I'd call the resident. While waiting for the lab results, I would get a stat 12-lead EKG in order to get a clearer read on what was actually going on. I would check IV access and stop any potassium-containing fluids that were running, then call the pharmacy and give 'em the heads-up that I'd be needing Kayexalate soon. (Kayexalate is an oral suspension or enema that pulls potassium into the large bowel where it can be excreted.) By that time, the resident would've called me back and I could present her with all the necessary information.

Sounds pretty good, huh? I thought so. Unfortunately, I was totally, utterly, completely, unequivocably wrong. The first thing I should've done was page the resident. Paging the resident comes first in the book world, because in the book world, nurses aren't given as much autonomy as I've had for the last mmumphm years. In the book world, nurses do not act autonomously. They wait for residents--even if the resident is horribly underslept or doesn't know much about the patient--to make the call. The most we as nurses can do is make gentle suggestions as to courses of action.

If you've read this blog for more than five minutes, you know that is not the way Jo rolls. If I can save a resident from multiple phone calls, regardless of the hour, I will do so. Part of my job is making *their* jobs easier.

Anyway, I mostly kicked ass on the four-and-a-half hours of testing. The one thing I really quibbled about was when I was docked points for checking the output of a patient who'd recently had a neobladder created and who was complaining of intractable pain. The book answer was to treat the pain first (Pain Takes Precedent, another lesson I forgot) and then worry about output. My feeling is that if you've got a brand-new neobladder (that's a bladder that's made from a section of small intestine), you ought to be worried about output first, because the damn things can tear open if the catheter in them is occluded by mucus (a common neobladder problem), and then you've got a bellyful of hot piss, and then where are you?

But no. Tylenol first (TYLENOL? WHAT PLANET ARE YOU PEOPLE FROM??), then check output, then page the doc.


So I came home and opened all the windows. Now I have a pot of black bean chili on the stove and a happy Max-dog nuzzling my rib cage. Later I will eat large amounts of veggie black bean chili and take the rest to Pastor Paul next door, then fall into bed. Tomorrow, after all, I'll be back on the floor bright and early.


miss mouse said...

sounds like you are off to a good start! you know more than you think you do, and of course in real life you would assess that bladder before giving a mild analgesic! I tend to think of 'intractable' pain as having lasted for some period of time longer than an hour and having already NOT been relieved by simple measures such as an OTC analgesic that will need at least 45 minutes to take effect! enjoy the chili, and the doggie love!

Susan said...

The new trend at my hospital is admitting patients for "pain management," which is really fun when you look at their orders and all they have ordered for pain is Tylenol. Thank you, admitting doctor! (Whoever you may be, as I can't decipher your signature when the doctor on call asks me who admitted a patient for pain control without giving them pain medication...woo!)

Gotta love it.

Anonymous said...

I have a neobladder, so know first hand tynelol won't stop that kind of pain. A clogged cathetar is usually the culprit, but waiting for a doctor or resident to access is not realistic. Any nurse could handle this problem enough to know if the doctor needs to be called.