Week Three Med-Surg Journal

By  Leigh Ann Tatnall, SN


What happened?

Day one: My patient was a 73 year-old male that had just undergone a facet injection for lower back pain and left-sided sciatica. He had a history of atrial fibrillation, coronary artery disease, hypertension, hyperlipidemia, Type II diabetes, renal insufficiency and a high PSA. I performed my assessment and noticed that he had a hard, distended abdomen and hypoactive bowel sounds. It had been four days since his last bowel movement. The only other abnormality with the assessment was the diminished pulses in the lower extremities were at a +1. The night was full of teaching. We discussed his dietary options, which were diabetic and heart healthy. He was very aware of how the carbohydrates cause a spike in blood sugar and since his body’s tissues have become resistant to insulin or his pancreas isn’t producing enough insulin, his body’s tissues cannot take in sugar normally. Over time, persistent high blood sugar levels may damage blood vessels and in the body, increasing your risk of eye, heart, blood vessel, nerve, and kidney disease. Maybe this is one of the reasons he had to have his CABG surgery that was necessitated by the coronary artery disease. *BONUS – My patient from day two last week came in. She looked great! She just dropped off a thank you card and some treats. I asked if she was feeling better. She said she was feeling better five minutes after it (the TIA) happened. I asked if she was taking her medication like the doctor had prescribed. She said that she was being a good girl and taking the medication like she was supposed to do. She is a fireball. But, I am glad the patient education is paying off.

Day Two: I was assigned the same patient and the patient next door, a 26-year-old male who had a repair for a meningiocele after laminectomy. Since I had two patients today, I had to do some prioritizing before I could do anything else. I first printed out the RN patient reports to see if anything had changed for the original patient, because I had an idea of what he already required. The second patient was in a great deal of pain and had different needs, so I had to be sure I knew exactly what was happening and if his needs were more urgent than the other patient. The first patient had meds due at 1700 and the second patient was getting morphine via IV hourly so he was going to be buzzing around 1600.

Both patients had stable vital signs and no critical problems, so at 1610, the second patient actually requested to be discharged. This was pre-approved by his doctor earlier in the day and discussed at report by the nurses. So, we went in and gave him his 2mg morphine via IV. Then, Gina (RN) and I went over the discharge paperwork with the patient and his wife. The discharge process is pretty simple. You go into the computer and select the discharge summary and print it out. You should also go to the Micromedex and print out information on any prescriptions they will be filling. You run through it with them, answer any questions and then they leave. There are no signatures required.

After that patient left, I then did my assessment on my other patient and he was stable without any change from the day before. The only thing I had to do was give a Fleet enema, reinforce teaching about diet, medications and ambulation and do multiple assessments. Thankfully the enema worked. When I reassessed his abdomen it was semi-firm and his bowel sounds were still hypoactive, but more active than earlier. The patient reported being more comfortable. I had a lot of charting to do. I did actually have to hold Hyzaar because his BP (systolic) was less than 120. So this was new for me when charting, but I did it correctly.

Your Critical Thinking:

It is important to understand the pathophysiology of diseases. It helps in patient teaching and it also helps you understand how it can lead to other disease processes. Several things I had to focus on were proper medication administration, proper charting and patient comfort level. For medication administration it was vital to remember the Five Rights – right drug, right dose, right patient, right route, right time and then proper documentation. The multiple medications and multiple patients made that more challenging, but nonetheless important to check each time a medication was delivered. The proper charting needed to be maintained and it became especially important when the extra patient was added. It was important to have up to the minute information available as the doctor needed to be updated regularly. With two patients, it is important to get the newest RN patient reports and then prioritize patient care in order of critical urgency.

Importance or influence for you:

active listening, knowledge, assessment, developmental level, pharmacology, pathophysiology

Outcome met this week:

Physical assessment/psychological needs (1), critical thinking/systematic problem solving (4), appropriate communication techniques (5)

Goal for next week:

I would like to perform a bladder scan and a Foley cath (if possible).


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