When patients are admitted to the hospital, they have an admitting doc/nurse then once they become inpatient, they have a doctor who manages their overall care, then consults are added for various specialty areas. Then the patient is assigned an RN (bedside nurse) who carries out the orders of the docs, but also coordinates the care between the different departments, administers and educates the patient regarding meds and treatments, and reviews what labs, meds, and treatments the docs order and call them if there are any discrepancies or needs for adjustments.
*disclaimer* Docs have MANY MANY more patients than RNs on a given shift and mistakes can and do happen. (just like they can with an RN). That's why good RNs are invaluable to a doc. We protect their patients by being their last line of defense before a med or treatment is given. The pt. scenarios discussed in this blog entry highlight instances where a knowledgeable, prudent RN (me, shockingly lol) can make a huge impact on the quality of patient care.
First patient. 84 year old woman with frequent PVCs and PACs and periodic atrial fibrillation presents with a CVA in the frontal region of her brain. (A fib can be responsible for strokes because when the heart beats ineffectively (as with a fib) blood clots can form from the pooled blood in the heart.) The docs were unaware the pt had any history of a fib until I looked at the monitor and realized it and called them.. (it later became apparent on her EKG). As soon as the stroke was diagnosed on the MRI, she was ordered aggrenox (it's like super aspirin). After the afib diagnosis, they started her on Pradaxa (prevents strokes in pts with afib, specifically). But two different drs ordered it. and I have never given those two meds concurrently, so I called the dr to clarify and make sure he knew she was taking both. He said it was okay to take them both. Printed out literature and handed it to her Ok great. Next day they start her on betapace/sotalol (beta blocker for arrhythmias) Great. Print out patient education, review it.. says right on it not to give to patient if they are on amoxopine. I called the pharmacy, they tell me it's a class D interaction and can cause a prolonged qtc interval (which can lead to Torsades de Pointes, which lead to dizziness, fainting and potentially a deadly cardiac rhythm). I called the Dr. and he was not aware she is on amoxipine and he said to hold the dose until he comes in tomorrow. (he wanted to think about some alternatives before giving it).
Next patient. 78 year old gentleman with a history of a coronary artery bypass graft presents also with a stroke. Has a history of renal stents, creatinine level (lab that tests kidney function) 1.9 on admission (around 1.1 is normal), drops to 1.2 after getting IV fluids (but only 500 mL at a time and at 60 mLs and hour so as not to fluid overload him) few days later, creat jumps to 1.7. Call Dr., get another 500 mLs ordered. Look through the orders, see the cardiologist sending him to the cath lab in the am (to see if he has any blockages in his heart since his CABG was 20 years ago and his ejection fraction was half of what they originally though it was)). What do they use when doing a cardiac cath? DYE. what does dye do to kidneys? It fucks them up! Which is why we use a sulphur based med called mucomyst routinely as a prophylaxis on our patients-- even ones with GOOD kidney function. (Studies have shown is has a protective quality on the kidneys when patients have the dye injected into them in the cath lab.) Patient had no mucomyst ordered! Called the attending (really like him) and let him know this. His response? "Holy shit! Has renal been consulted?" Me "no, renal was not consulted...that's another reason I am calling you. He has kidney stents. He needs a renal consult" He added a consult and a stat dose of mucomyst. (I doubt the cardiologist realized this guy's creat was 1.7 otherwise he probably would have said to hold off on the cath. I am thinking he probably was not cathed today, but the mucomyst/acetylcysteine is something that should be dosed for several days prior to being cathed in a pt with renal compromise anyway, so it was still a good thing I called).
Next patient was a woman in her late 40s with a dissected internal carotid artery (99% blocked) presenting with EXTREMELY bad neck pain, unequal pupils, difficulty swallowing, and a left facial droop. Usually this type of dissection can occur after a trauma of some sort but the patient was a very good historian (she's extremely intelligent and has a high profile type of job, but I don't want to say much more about her than that) had no injuries to her neck. I don't know if I ever mentioned this in the past, but in my patient with dissecting aortic aneurisms (ones that are growing in size) they experience excruciating back pain that radiates from the site of the aneurism. So, it did not surprise me at all that this woman was having horrible pain at the base of her skull. She was getting morphine 2mg IVP Q4, Dilaudid .5mg IVP Q8-- it wasn't cutting it. She actually started vomiting after her morphine dose so I had to give her Zofran (I always automatically get a zofran dose out with morphine when I know a pt. is even the tiniest bit queasy). Called the Dr. got her changed to dilaudid 1mg Q3, and added 1 percocet Q4. Finally her pain was much better managed. Treatment plan for a dissection like hers is to anti-coagulate the blood with a non weight based heparin infusion and coumadin until her INR level is between 2 and 3, then the Heparin can stop. She will probably stay on the coumadin for 3-6 months until a follow up scan of the carotid shows that the dissection has resolved on its out. There are surgical options I heard the vascular surgeon talk over with her, but they are hoping the coumadin therapy and time will help it to resolve on its own. Meanwhile we were closely watching her neuro status to be sure her stroke symptoms do not progress. The risk of a carotid dissection rupturing are about 2% so that fear was much less for me after I read up about her condition. She was a WONDERFUL patient and I hope her pain stays away. She was a pleasure to talk with and take care of. :)
I was doubting my knowledge base and getting impatient with myself for a while there, but this weekend proved to me that I know more than I thought I did and it felt wonderful to be able to help my patients not only with direct patient care but with knowledge. Being a nurse can be the most rewarding and wonderful job in the world. :)
