Nurse Jobs London

So this week it’s back to work, and my first night back I picked up a new admit. It seems that the Short Stay unit is pioneering a rapid admissions model, but I hope this patient wasn’t indicative of what they’re going to do, because they didn’t do much of any of the admitting process. That would have been bad enough, but my unit had only 2 nurses for the patients they had, and she made #7.and there was no tech. Needless to say, nobody was very happy. The patient is a 62 year old female with cancer who’s been in either the hospital or rehab since March. She looks far older than her stated age and has already made herself a DNR. At this point she was just sick, diagnosed with pneumonia and a heart rate in the 140s. She was on an amiodarone drip and it didn’t seem to be working all that well. She was also on antibiotics even though her white count was only 6.6, not indicative of bacterial pneumonia (hello, antibiotic resistant bugs!) and basically felt like hell. She just wanted to be left alone.
A couple of other rather unremarkable patients kept me at least somewhat busy. Last night I came back to find she was still there and I also had another patient who was a total train wreck. This one had been in NeuroVascular ICU since January! She’s an old (1999) heart transplant and dialysis patient who showed up on New Year’s Day with altered mental status and seizures. Her course had been one horror after another.brain abscess, craniotomy to drain that, prolonged time on the vent with failure to wean, which led to a trach, blood clots which meant she got a filter to deal with that, PEG tube with feedings which she sometimes did not tolerate, just one thing after another. She came to us on the one day I had off before I started this weekend. And guess which one is NOT a DNR? Last night she refused her 4 am feeding, did not want a bath, and only wanted the bare minimum of care. Well, if I’d been in ICU for 7 months, I wouldn’t want to be messed with either! When you’re in there, someone is always doing *something* to you, there are lights on most of the time, and the noise level can be pretty hideous, if not your alarms, the ones in the next room.who wouldn’t want nights of dark and quiet and minimal messing-with? I personally think baths on night shift are pretty barbaric unless the patient doesn’t really know what time it, and both my ladies were alert and oriented x3 and well within their rights to refuse a 5 am bath.

All this only strengthens my resolve that I will NOT be that kind of patient. I do not want to be in the hospital having things done to me if my outlook is that bleak and I have no better quality of life than these ladies. Of course I don’t want prolonged dialysis either. It’s a tossup whether dialysis or a trach would be worse, but I guess it would depend on how well I could get around. In point of fact, I don’t want either. Just give me my pain meds, leave me alone, and let me go wherever it is I’m going. Thank you very much.

In recent weeks I’ve had a lot of patients with gastrointestinal (GI) issues. Some are pretty straightforward, the usual sort of tummy bug that will put our frail and elderly in the hospital just because they get dehydrated. Then there’s the “interesting” stuff, of which I’ve had a good bit recently.

The first was a lady I admitted about 3 weeks back who had been suffering with nausea, vomiting, diarrhea, abdominal pain, anorexia, and weight loss for several weeks. She didn’t know how much weight she’d lost, but her family said it was “a lot,” and her admission weight was 98 lbs. She was clearly miserable, but she’d delayed seeing a doctor, maybe because she was afraid of a diagnosis, or maybe because she was depressed over a number of deaths in her circle recently. In any case, I pegged her as *really sick*, and over the next few days I got pretty impatient with her primary doc, who was one of the new hospitalists. I wasn’t the only one who seemed to think there was more to this than met the eye. When I came back the following weekend, she’d been through a bunch of tests and was diagnosed with a diverticular abscess (for the uninitiated, a little outpouching pocket in the bowel that had got infected). She’d had an incision and drainage and there was a drain in place, but it wasn’t draining a whole lot of anything and she was still in major pain. She kept getting progressively worse and her belly was all blown up when I came back again, and I came to the conclusion that she had an ileus, which basically means that things were NOT moving right along down there. The next night I was back again to find that the primary had finally been galvanized into action, called in the GI doc and re-consulted the surgeon. The patient had a tube down her nose into her stomach and was having a bit less belly pain, but was complaining of her throat hurting and extreme thirst, and she wasn’t being allowed even ice chips in any quantity. Still, she was much better until about 4 a.m. on Monday, when she suddenly snapped and accused the CNA who went in to change and turn her of trying to kill her. When I went to check on her she had just thrown her telemetry box across the room and was ranting that we were all trying to kill her. I medicated her, and she seemed to quiet down. Just before report in the morning, it was reported that she was swinging her legs over the rail. We barricaded her in, or so we thought, but right in the middle of report the day charge nurse came by and said she’d found her up at the sink, all tubings mercifully still intact, drinking cup after cup of water! She got medicated, and that was the last I heard. When I came back this past weekend she’d been to surgery and had moved to the surgical floor and due to confidentiality rules that’s all I know.

This past weekend I had a patient who’d come in with a small bowel obstruction which was resolving. He, too, had an NG tube, but he felt enough better with it in that he wasn’t complaining or trying to pull it out. He was very nice, and no trouble whatever. In fact, he wasn’t even complicated!

And then there was Sunday. I was told in report that I was getting a patient from ER, a 29 year old GI bleeder. Hmmmmm, thinks I, 29? When I got report (and ER was most insistent that report had to be given NOW) it seems there were some complicating factors. Not only was he puking up bright red blood, but there was alcohol involved, and they’d had to sedate him because he took rather violent exception to having an NG tube put down. I told my charge nurse there was no way he could go in the room he’d been assigned to since we could not easily see him there and there were significant factors that bore watching. She agreed, but in order to put him where we needed him, we had to move another patient and get the room cleaned. I called the ER nurse to advise her of this and that we would have the room cleaned as quickly as possible. Her charge nurse got on the phone and was as ugly to me as any peer has been in some time.the first time I’ve experienced that at this hospital. “Get that room cleaned STAT,” she barked, “because I’m sending him in 20 minutes. We’ve had that room assigned since 5:00!” Yeah, I thought, and you just now called report, while *we* were in report, and until then we had no idea that alcohol was involved since no one mentioned it. I did *not* say any of that, however, just went about getting ready. When the patient came up he had “uh-oh” written all over him. The first indication came when we tried to move him from the stretcher to the bed. He hovered in midair between the two, and when I tried to assist him over he pushed me and let loose with a lot of language. His girlfriend, who was with him, tried to apologize for him, saying “He just hates all medical stuff.” Well, too bad, buddy; you’re sick enough to be here, go along with the program. Fortunately, once we actually got him to the bed, he lapsed into his previous somnolent state. Then I connected the NG tube to suction and was not cheered by the amount of bright red blood I saw. The hospitalist on duty was paged and I waited for him. And waited. At some point I said to my charge nurse, who was aware of the patient’s condition, “He’ll probably drag up here in about 3 hours and then he’ll get all irregular about everything.” Which is, of course, what happened. When he finally did get himself up there, indeed 3 hours later, he immediately decided the patient should be transferred to ICU. I managed to get detox orders also, not a moment too soon, as the patient’s mother hove on the scene and he started acting like a bratty toddler, threatening to yank out his NG and leave. At this point, Ativan is your friend! I had to try to shut him down, soothe mom, who was of course freaking out, call report, take care of the girlfriend, and get him to ICU without losing his IV or NG tube. Somehow it all got done and I left him to the tender mercies of the ICU nurses, who weren’t particularly amused by his antics. Speaking as a nurse, I could have handled him right where he was; I’m used to this kind of thing. But on reflection, he really didn’t belong on our unit, and I think some of the other nurses would have been really freaked out. The patient I got to replace him was far preferable, even though he was a guest of the county (i.e. a prisoner). At least he was cooperative.

Just five more shifts left here, and then back to Tennessee until the next assignment shows up.