two transplants and a alcoholic. Not so bad !

What a day, I have two lung transplant patients.

One Lung transplant patient is 20 years old and it’s the patient first time at this hospital, the patient has never been hospitalized for 7 years. Diagnosis, pulmonary hypertension. This patient was admitted to the hospital because of possible infection due to her white blood cells being elevated, febrile and symptomatic. We admitted her and placed a PICC line which is a central line so that high concentrated drugs can be given as oppose to a peripheral line which some drugs can rupture the vein causing it to infiltrate and cause injury to the soft tissue. The patient was so sweet and curious about everything, never been hospitalized for seven years and the dad at the bedside assisting her. I would explain to her everything I was doing and the purpose. You can tell some of her curiosity was based because of fear. Here for antibiotics and in a couple of days after assessing and observing her she than should be able to go home for a course of 10-15 days on antibiotics. A nurse will be hired and follow up with the patient to do PICC line care, and administer her antibiotics at home, these nurses are called home health RN’s.

My second lung transplant patient is 60 years old but loves driving motorcycles. He has three of them. He said that he loves the feeling of driving a bike, the sense of freedom and air is what he looks forward too. Patient was also here because of an infection, was going to be placed on the same regiment as the first transplant patient, antibiotic treatment.

My third patient has pancreatitis, experiencing symptoms of abdominal pain like no other. He says that he use to drink 3 fourty ounce beers, a 5^th of vodka, and 2-3 four locos a day for two years making a joke out of it like if he was cool for doing that. I just stared at him. Now his in this massive pain and blames me because I’m not bringing his pain medications on time when I actually was. But he tries to trick me so I can bring them earlier telling me that I forgotten, tank God for electrical charting. Doctors, pain management, and psych have been involved in his care. It is so hard to treat patients like this because they are admitted into the hospitals all because they are noncompliant and they continue with drinking that precipitates their symtomes. Plus the patient has history of abusing vicodin and possibly other narcotic drugs. But during my whole shift I did not let his personality and aggressiveness take the best of me and was positive and straight forward with the patient. Patient ended up working with me, he was quite, and compliant, but because I stayed strong, kind, assertive, and straight forward, or maybe it was my bald head and muscles that result him to be compliant. Sometimes if you’re not like that patient that have this type of mentality will try to be abusive and aggressive and try to make your shift impossible. But when this occurs just keep in mind this is why we get paid for what we do, this is why we have what we have, etc.

Unable to cope and relax; can result to heart attack symptoms

Patient came in from a nursing home due to chest pain that required higher level of care and more indept investigation because of unknown ideology. Patient than went into “hypertensive crisis”, meaning her blood pressure was off the roof. Normal systolic blood pressure is in the 120s mmHg and it is considered a medical emergency when your systolic blood pressure is above 160 mmHg, hers was in 210-220s mmHg. We were very aggressive when she came in, diagnostic exams to rule out heart attack was performed and were negative. We gave medication to bring her blood pressure down slowly. If we are too aggressive her cardiovascular system can collapse.

Patient symptoms was pain (stomach pain, chest pain, head ache), and she was trembling as if she was anxious or had anxiety. Her concern was because she has an aneurysm in her head and was afraid that her blood pressure will rupture it and cause her to have a stroke. She refused taking any medication that were not her own.

I was thinking, ok, she is not fully with it, is forgetful, older individual, and totally not educated about what we are trying to do nor is she educated about her care. I explain to her and reassure her. I wasn’t sure that if her blood pressure being so elevated was because her anxiety, her pain, or something wrong with her heart. So far all exams were negative among the heart (EKG, 12-lead EKG, TTE, troponins). I explained to her that we have to control her anxiety and pain and after that we have to basically sit and watch for any abnormality of the heart. I gave her xanax for her anxiety, I gave her some morphine for her current pain, and oxycodone to hold her over once the morphine dose rubs off.

After two hours, we had a better view of the patient’s heart; her blood pressure has been trending down and more controlled. She has denied pain and discomfort. It is possible that her blood pressure could have been precipitated because of her anxiety and pain threshold. It is crucial that we continue to observe her for the next couple of days to formulate a diagnosis. But for now because heart exams have been negative, only other probable causes are anxiety and pain threshold. We continue to monitor her heart continuously.   

If its not one thing its another

Today, not knowing what type of diseases or what type of people I was going to meet. I had a stressful day because I had my own personal problems and I was dealing with my good friend who just recently been hospitalized. So I had mixed emotions coming into work, sad and frustrated.

As I walked in I got report from a patient that I recently took care of. A single lobe transplant patient secondary to emphysema and COPD. The way he got emphysema and COPD was because he smoked for 10 years. Smoking or any type of smoking can possibly burn off the connective tissue and membranes that create the elasticity of your lungs which allows them to expand. This disease prevents that from happening allowing very minimum oxygen to diffuse thru the membrane into your blood stream.

Lungs transplant is a very unique organ because oxygen and carbon dioxide exchange happens due to diffusion and osmosis. A heart transplant is removing a heart and replacing it with a new one. It’s like taking off a plumbing pipe from the bottom of your house and replacing it with a new one. The flow of fluid will continue as accordingly. Now Lung transplant, how long for them to get better depends on the lung and absorption of oxygen which can be based on many factors such as the conditioning of the new lung, etc.

Like I said the patient was recently admitted, and just last year he received his right lung transplant. And it was a success, he has been responding to medications appropriately. Labs values have been within normal limits and have had no serious symptoms since his last admission. He was admitted because he had a routine bronchoscope exam per routine to evaluate the lung. During an x-ray, we notice on the left lung there was something that caught our attention. We did further examination and during the bronchoscope we received a biopsy what we found to be a mass on his non transplanted lung.

After the specimen was sent to pathology it was later found out that the mass is malignant. He now has cancer on his non transplanted side and prognosis is that he has 2-4 months to live. It was so hard to be in the room with him and the medical team to explain to him what was concluded. We said that we would be aggressive as much as possible but lung cancer really has low survival rates especially because he has stage four, meaning it has spread to his body (liver, pancreas, heart). Patient falls on his knees, with tears rolling down his face, saying "my son, my son"; I approached him and lay my hand on his back. "I want to be a grandfather; I want to see my kids grow up", his arms shaking and legs trembling. I was speechless. We as a team stood there with him for a moment and tried to stay as positive as we could. And only thing we can promise is that we will be as aggressive as possible to fight this battle that he is not alone.

He just got transplanted, his life was suppose to turn around, and his transplant suppose to give him extra time so he can have with his family, but cancer is something that we are still fighting till this day and can show up abruptly, once it’s there, there is no stopping it, it will take your life and every bit of happiness you have. I stood shock, and speechless, imagining if it was me. Oh man!

Back to back at change of shift

Coming onto the floor we had 31 patients and 9 nurses. Begining my shift I had three patients and my fourth was coming from an outside hospital that had an estimated time of arrival of approx at 2000 (8PM). 

From the initial three patient that I got, one was a admission that occured approx 1600(4PM) that required million amount of admission paperwork that was not performed by the previous registry nurse, go figure. 

Second patient patient arrived at 1900(7PM) from recover of ERCP that had complication of bleeding. Patient required frequent monitoring of blood levels (Hemoglobulin and Hemocrit) every 6 hours.

My third patient was a three hundred pound husky man with a wound vac to his leg and walks with a cane (risk for falls any time his walking), his wound is actively bleeding/leaking from a skin graft wound from his left upper thigh that requires frequent monitoring and changing of the linen due to bleeding. Skin graft requires frequent monitoring for color, texture, odor, pulse, and dressing changes every four hours.  

My fourth admission than arrived approx 2000 (8PM). Didnt know what to expect, but as a nurse we have to be ready for whatever comes into the front doors. This patient was a lung transplant from an outside hospital who was experience renal failure, symptomes of shortness of breath was progressively getting worst. When kidney fail, fluid is not excreted and backs up, when fluid backs up causing the patient to drown in its own body fluid. Also when admitted all evening meds were not given at the outside hospital, he was a hard stick meaning it took forever to find a vein to place in IV, patient was complaining of pain, and the information from the outside hospital did not show accurate current medication list that he was taking at home, luckily he was admitted recently so we access the data base and got him on the right drugs and got his breathing and medication in control.

This night just went pretty fast.

A day in the office

Today I worked at a stepdown unit, where the ratio is four patients to one nurse. Being it was my first day back, they assigned me to four patients. My first patient is 70 year old sweet senior citizen that cannot move because of surgery to her lower extermities, she also had recent bowel resection because her intestines stopped working for some apparent reason. They removed the dead intestine and make an ileostomy to allow the intestines rest so that there is no pressure on the incisions that were made inside her. Her ileostomy bag leaks and is causing maceration to her skin, and require frequent dressing changes and incisional care. Having the bag leak gives a horrific ordor that can wake up the dead.

My second patient was a 55 year old lady, but she looked allot older than she really was. She had a pacemaker that got infected in her shoulder and required several surgeries because she had an infection that was resistant to antibiotics. She also has allot of malnutrition problems and incabable to eat on her own because she is failure to thrive. Her labs showed (albumin and prealbumin levels) significantly low, we also did a 3 day calorie count and it was concluded that a tube in her stomach would be benificial. A PEG tube was than placed into her stomach to incorporate entereal feeding directly into her stomach. She is currently on total parental nutrition (nutritin by intravenous fluid), and IV fluids. She is max assist and is at times confused and wants to get out of bed when she is uncapaable of bearing weight on her feet. I was in there every hour checking on her, and making sure that she doesnt pull anything, my main concern was her central line that was located on her neck, if pulled out she can bleed to death.

Third patient just came from ICU at change of shift, perfect timing. This patient had a heart bypass, where they take a piece of an artery from your leg or breast area and replace it on one of the arteries on the heart so that the bottom or another area of your heart can recieve blood. Patient also had catheter in his bladder for irrigation because he also had surgery to remove his prostate earlier this month secondary to cancer. The goal is to keep his bladder constantly irragated with saline to remove blod clots and prevent them from developing. He also had two chest tubes into his heart and two chest tubes in his lungs so his heart and lungs  can drain the fluid from the inflammation process after surgery, this will promote healing, and prevent symptomatic symptoms. He is also moderate to max assist, and needs assistance anytime out of bed because of fall risk precautions. Imagine having all them tubes the size of a water hose, and catheter, and IV fluid lines. It was a head ache anytime when he was out of bed, but it is good for him and anytime he wanted to get out we promoted him.

My last patient, I had a patient going for a heart bypass today so I had to prepare him for surgery making sure that all diagnostic exams are current, consents are sign, patient and family understands the risk and benefits, labs are within normal limits, and patient safety. Not this patient was suppose to be my easiest patient but than was my most busiest. Patient also has historyof a kidney transplant, and requires stragtic monitoring of his labs of his immunosupprassants, such prograft. But his chemistry levels when he arrived was off. He arrived with a potassium level of 6.8 (normal is 3.5-5.0), whenever potassium is too high, or too low the heart muscle can slow down or even stop. For example, Thats why its important for runners to eat bananas, which are high in potassium, because running depletes your electrolytes and can cause you to have a cramp on your leg. We had to do so many measures to lower his potassium. making him go number two, given him insulin to push in the potassium back into the cell, than follow it with dextrose because his sugar can potentially drop also when we do this. We also gave him lasix a duiretic to make him void out his excess electrolytes. Finally at 5 am when they came to pick him up from surgery, his potassium was 4.8, and he was ready for surgery. What a night!
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