I worked the last 2 days and have come home feeling drained both days. On Monday, I returned to work after 5 days off the unit. I show up and get report from the night nurses about my patients for the day. I always dread getting report from one nurse because she always gives crappy reports or there is something wrong w/ the patient that she didn’t fix before I got there. Before I get report from her, I get a call on my phone that this patient that I’m getting from her has a procedure at 8 am so the transporter is up at 7 am to get him. Ack… I hate my patients leaving before I get a chance to assess them. I quickly run in the room, do a quick assessment before he goes. F.S is a 69 year old male who’s left arm is completely flaccid and numb. He has clear speech, left ptosis and facial droop, and a left leg that is pretty weak. His lungs aren’t the greatest but he’s alert and oriented. Stable so I give the ok for this guy to go down to his procedure.
I get report from the night nurse on F.S. She tells me that he’s got a flaccid left arm but the left leg drifts. The right side is intact. He does indeed have a left facial droop and ptosis and had that since he arrived up from the ER. What blew my mind was that his heart was beating in a rhythm called atrial fibrillation for the last two days and nothing was being done about it. Atrial fibrillation is when the heart beats abnormally and the atria which are chambers in the heart quiver. This type of rhythm is dangerous because clots can form in the heart and get thrown out and cause heart attacks or strokes. Treatment for a-fib includes drugs that slow the heart down, cardioversion, and anticoagulation. On our floor anticoagulation is very common. His CT scan came out negative for a bleed and his carotids are completely blocked on one side and 50% blocked on the other. She also tells me that he’s able to reposition himself, take his pills w/o difficulty, has a heart healthy diet, and he’s able to toilet himself independently.
I called his neurologist after I see my other patients to ask why F.S. is not anticoagulated. She tells me that she does not know and that she will come see him after he gets back from his TEE. Curious, I look in the physician’s progress notes and the neurologist on call during the weekend and the cardiologist both note that he should be on either heparin or coumadin but neither put him on it.
I get the patient back from his procedure which was a transesophageal echocardiogram (TEE). A TEE gives the physicians a good look at the heart by sticking a camera down the patient’s throat and using sound waves to get the image. He comes back from the procedure sedated and I try to arouse him. He is able to talk to me and move his right side and his left foot. He says he has dull sensation in the left foot but he can feel me. After I get him comfortable, give him his morning medications, and take his vital signs, I let him sleep. I come in to see him about every 15 minutes to assess his heart rate, respiratory status, and blood pressure because he received sedation during the TEE.
At 1145, I come in to do a neuro check on F.S. and find that he has slurred speech, his left foot cannot move at al, he’s completely numb on the left side, and he’s become incontinent. I put a phone call into his neurologist and she asked me to get a stat CT scan on him. (For those who are curious, an MRI was contraindicated for him because he has a metallic hip) His CT showed he had a large stroke in his right middle cerebral artery. Yikes… this poor guy. I felt so helpless and I wondered if something had been done about his heart rhythm earlier if this would have happened to him. His poor wife came to the bedside in the afternoon to find her husband a changed man. I find out later, that F.S. had not wanted to have anticoagulation therapy because of the danger of bleeding and he was a jehovah’s witness who did not want blood transfusions. Now he’s willing to do whatever therapy will help him but the doctors think that anticoagulation would be to risky for him. Now, this poor guy can’t eat, he’s urinating in the bed, and extremely lethargic b/c of the stroke.
Now… for the crappy report. The nurse told me a whole bunch of things that were not true. Like, he had been retaining urine and that he’d been dribbling urine. She had no idea why he wasn’t on heparin or coumadin or if they were planning on cardioverting him. She couldn’t tell me why he didn’t have an MRI. She just made it hard for me to do my job. I guess I expect that when a patient is there for 2 days before I get there, answers will be available for the common situations that we have on this floor.
So I had him for the past two days… I’m exhausted and will spend the rest of the day studying for a test I have on Saturday. I knitted in the morning but of course want to do more. I have one front of the lacy airy wrap done. One more to go….