Saturday, February 18, 2012


Okay, so first off let me start with something pleasant. I am (nearly) officially "underworked - overpaid". I will be expecting a 60 % boost from my previous salary in my past job in exchange for 12-hour shifts for 4 days/week and an average daily census of 5. Plus, i have an Attendant. It's like working overseas but with Filipino salary. :DDDDD

Now, on with this week's rant. :/

How could anyone be so stupid to not anticipate the problems of a patient? The diagnosis was T/C UGIB, and yet there was no order to perform gastric lavage. History suggests possible bleeding from the upper GI for obvious reasons: number 1 - the patient hasn't had any decent meal (in fact the patient has not eaten for more than 2 weeks!); number 2 - prior to consult, SO's claimed vomitting of gastric contents mixed with "dark" blood. Number 2 alone is indicative of GI bleeding, it may not be active, but it is possible that there is presence of it. And here i am again, about to compare this to how we used to do it back in my previous workplace. A health worker who cares for his/her patient would do something like this: order NPO temporarily, inserts NGT, performs gastric lavage until output is clear, hooks NGT to drain. Not all physicians are always right. In fact, they are human too like the rest of us health care workers in the "lower" heirarchy (this is how we are being treated in this country), but then, if you are a keen observer, and you know your job well as a nurse (which is to CARE for the patient, as easy as that), and you observed that what the physician ordered is just plain silly, you would not bother suggesting or even better, correcting the physician of his/her mistakes. Because in the long run, if you, the nurse, allowed these mistakes pass, you will be the one who will suffer. Referrals after referrals after referrals. The key here is to ANTICIPATE future problems. I remember the post-op order of a visiting OB-GYN from my previous work, even if her orders occupy an entire page of the Doctor's Orders sheet, you can see that every order is relevant. She's anticipating what to order if certain complications arise from her post-CS patient. It is not being lazy to do rounds in her part, it's more like encouraging the Nurse in charge of her patient to literally just focus on her patient. Because if she does not anticipate, and base all orders on what already happened, it would be time consuming for her and for the nurse. Referring problems/progress of the patient can eat up alot of time when rendering care. Patients need undivided attention from their nurses. The chart, computer or intercom is not our client.
Going back, here's what happened when this patient was endorsed to me. The patient has a history of mental illness. If you would go back to the basics of mental health, a clear indication of mental illness is neglecting normal ADLs -- meaning, the patient won't bathe, eat etc. In the case of this patient, she wouldn't eat for fear that the food would be stuck in her throat, choking her to death. I reviewed the orders: no diet was ordered. Again, going back to the nurse being (actually we are REQUIRED to be) a keen observer, the admitting nurse would've noticed the absence of Diet in the orders. So i asked the admitting physician, he/she said "Soft diet, encourage the patient to eat." So i did, i ordered the diet from Dietary. Then i had an epiphany and started questioning why there is no NGT, why lavage wasn't done in the ER, why the physician is ordering Soft diet when the patient wouldn't eat for the past 2 weeks. Okay, so the last one was so-so for me, when the patient was coming to her senses, she would ask for water and actually drink some sips of it. Then miraculously she asked for food. We offered her the food but she always ended up refusing. This went on for a couple of times. I was about to refer her to her attending when the Neuro-Psych consultant arrived. Thankfully, the consultant ordered NGT insertion if the patient can not tolerate or continues to refuse solid food. We tried feeding her again yet she still refused. I informed her attending, and we inserted a NGT for feeding. I performed lavage, output was not as clear as NSS, but in my experience, the output would pass as clear since there were no clots in it, actually it was a bit yellowish. The attending ordered for milk feeding. Her laboratories arrived and it showed possible failure of the kidneys (Crea and BUN were through the roof) and electrolyte imbalance. The next day, the patient showed progress, she looks less weaker, with some lucid episodes. OF feeding was started by the day shift. During my shift she complained of abdominal discomfort. I asked the outgoing nurse if they performed lavage. She affirmed, saying the initial output was coffee-ground, but they were able to were able to obtain clear output. Good, this is progress, Omeprazole is working. Pior to feeding i performed lavage, output was clear with some residuals, but not enough to hold feeding. But throughout my shift she kept saying her belly aches. I learned from her SO's that aside from the OF, the previous shift was also feeding her with milk, with an hour interval. Immediately i checked for residual. I was able to remove almost half a liter. This can't be good. I had to hold her last feeding. I observed relief, but she's started to grow out of her lucidness again, and would scream at me whenever i go near her. This is the hard part of being a nurse, maintaining your composure amidst all the screaming you get from your clients. I was able to endorse her to the next shift resting. None of these would have happened if her needs were anticipated in the first place.

So the moral of the story is to never always rely on what is being ordered. If your instincts tell you something is wrong, voice it out. We are all human, we make mistakes, as the cliche goes. It is not illegal to question your fellow health worker as long as you think you are right. We are no longer in 19-kupong kupong, the nursing profession has evolved into one of the most sophisticated and noble vocations and is currently being recognized as one in developed nations.

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