Reflections

By Lorraine Dale, RN

Chaos

Seven patients, one half hour. They call this nursing?

R ounds begin with a quick check of my patients to see that they’re all breathing and that nobody’s in acute distress.

Patient number one, who has an admitting diagnosis of unstable angina, complains of chest pain. He rates it a 3 on a scale of 1 to 10. I put on O₂, call for STAT electrocardiogram (ECG), and give him a nitro. Vitals are good, color is okay, no diaphoresis. I make a mental note to check back in five minutes to see if he needs another nitro. I wish I could stay but I have to see other patients on the floor.

Patient number two, Mr. Van Zandt, seems to have been here forever. He has a tube in every natural and surgically created orifice. He’s completely helpless. I have to reposition him because he’s tangled up in the bed sheets, which hampers his breathing and puts him in danger of aspirating his tube feeding. I do the best I can alone, but he weighs 230 lbs. and is lying in his own feces. I’ll have to finish these rounds quickly and then find someone to help me clean him. Patient number one still has chest pain, although it has abated, so I check his vitals and give him another nitro. The ECG still hasn’t been done.

I go on to patient number three, Ms. Caldie, who was treated for pneumonia but is ready to go home. This should be a quick check, but as I walk in the door I see her sitting up, dressed, arms across her chest, with an impatient look. “I’ve been ready to go for half an hour,” she says. A doctor discharged her while I was getting report. Now I have to do the paperwork and give instructions. I calm her a bit and convince her to wait another half hour while I finish my rounds.

Patient number four is still in the cath lab. I don’t have to worry about him yet. Patient number five returned to the floor a half hour ago after having a cardiac catheterization. I check his groin for bleeding and hematoma. Pulses okay. Vitals good. I’ll have to check his cath site every 15 minutes to make sure he’s not bleeding. He needs to lie flat and still for two more hours but he’s fidgety from pain, so I promise him medication before leaving his room.

I recheck patient number one. His chest pain is worse, his color ashen. I check his vitals and give him another nitro. His oxygen saturation is down, so I turn up his O₂. I finally get his ECG, which does indeed show signs of cardiac ischemia. I page the physician, anticipate his orders, and prepare to administer morphine and start a nitro drip. I finally receive orders to transfer him to a nearby hospital for angioplasty or bypass. I administer the morphine and the nitro drip.

As I move on to the next patient, I walk by Ms. Caldie, who gives me a dirty look.

Patient number six has Alzheimer’s disease and has been admitted because of a gastrointestinal bleed. His hemoglobin is down to 8; he’s getting a blood transfusion and a bowel prep before tomorrow’s colonoscopy and cautery. I quickly auscultate his lungs and hear signs of congestive heart failure. I’ll have to call the physician for diuretics. His hands are restrained because he keeps pulling out his IV; this one will need very close watching all night. My beeper goes off: the ED wants to admit a patient to Ms. Caldie’s bed. I say I can’t take that patient yet. I’ll probably hear from the supervisor about this.

One more patient to check, but first I check patient number one again. Then I medicate patient number five and check his groin for bleeding. I walk past Mr. Van Zandt’s room and notice his oxygen mask has slipped off. I feel bad knowing that he’s still lying in feces. As I fix his mask, I consider giving Ms. Caldie her discharge instructions, but I better at least look at patient number seven first. I’m glad that I do because I find her halfway out of the bed, insisting on going to the bathroom. She had suffered a stroke the day before and hasn’t accepted that she can’t walk. She’s oblivious to her IV, which has been pulled out in her struggle to get to the bathroom. I turn off the IV that’s dripping on the floor and stop the bleeding from her arm. My pager goes off as I help her to bed: Patient number four is returning from the cath lab.

All of this in the first half hour of my day. Would it be too much to ask for better staffing and working conditions? It seems the administration can throw any working situation at us and just say: “Sorry, we don’t have any more help. Just do the best you can.” And I do. We all do. But I wonder if these seven patients would believe us.