Place: Medical Ward
Tracie walks into the nursing station and heads to her usual chair. She moves the assignment book towards her and see that she has the same assignment as yesterday. That’s ok, she thinks. At least I know the patients. She looks up at the patient board and sees that there have been only two admissions since yesterday and one discharge. “Looks like it could be a busy discharge and admissions day.”
Jim comes down and pulls his chair close to Tracie’s “Hi Tracie, how’s it going?”
“So far so good, how was your night?”
“Night was quiet. Mrs. Johns required some adjustments in her Optiflow which the RTs took care of. Mr Alex had a bit of sundowner syndrome and was quite restless, but otherwise the night was pretty quiet.”
“Great. Ok, let’s do the report so you can get home.”
“Yeah, I have to get out of here quick. I’m taking the kids on a field trip later in the afternoon. Twenty-six Grade 2 kids. I can’t believe I volunteered to chaperone after a night shift.”
Tracie laughs, “Lucky you.”
Jim then walks Tracie through the night and updates her on changes to her patients. After reporting, Jim heads out, while Tracie quickly looks through the charts to plan her morning.
Tracie notes she has a lot of 08h00 medications so decides to prepare these meds and then do her patient checks at the same time.
Tracie makes her rounds and drops off all her medications. With that done, she notes to herself, Everyone seems all right now, having breakfast. I didn’t see any issues off the top. I’ll give everyone a few minutes and then do vitals, assessments and discharges.
Tracie sits down to check the RT’s note on Erin Johns when Erin’s call bell rings. She gets up from her chair and walks down the hallway to her room.
“Hi, Mrs. Johns. How can I help?”
“I can’t catch my. Breath. I took. My oxygen off. Just to eat. Put it. Back on. I am. Short of breath.”
“I want you to take some deep breaths. In through your nose and out through your mouth. Remember to close your lips slightly as you breathe out. I’m going to get the vitals machine and be right back.”
Tracie grabs a vital signs machine from the hallway charger and brings it into Erin’s room to take her vital signs.
“Ok, let’s start checking you out.” Tracie wraps the blood pressure cuff around Erin’s left arm, pulse ox on the right forefinger, and temperature probe under the tongue. About 30 seconds later she notes that the blood pressure is up a bit and oxygen saturation is down. Temperature is unchanged with the same low grade fever. Respiratory rate is up as well and heart rate is above 110. This is not going in the right direction, she thinks. I may need the RT to come see her.
|83% on RA
“Ok, Mrs. Johns, let’s listen to your heart and lungs.”
Tracie systematically auscultates, thinking, Not any change from what I remember from yesterday.
“How are you feeling now?”
“A bit better. Not great.”
“I’m going to ask the RT to come and see you right away.”
“Oh my. Am I dying?”
“Gosh, no, Mrs. Johns. The respiratory therapist is here to help both you and me. They manage your oxygen and help you with breathing.”
“I will be right back.” Tracie moves quickly out to the main hallway to the nursing station. She then asks for the RT to be paged and to come to Erin John’s room.
The unit coordinator looks up. “What should I tell them?”
“Mrs. Johns is quite short of breath and has low sats on Optiflow. I’m not sure what to do next.”
“Done. If they have any further questions, I’ll transfer their call to the phone outside the room.”
Tracie heads back to Erin’s room.
Tracie has the vitals machine do another cycle of vital signs but not the temperature. She reads the machine, thinking, Heart rate is down to slightly less than 100. Respiratory rate is still up and sats have only improved slightly. Tracie records all this information and her assessment into Erin’s chart. Just then Alexa, the RT, enters the room.
|85% on Optiflow
“Yes, you remembered. So you must also remember Mrs. Johns.”
“Yes I do, so her sats have not improved? You asked her to deep breath like yesterday?”
“Yes. She has improved slightly but not very much with the deep breathing.”
“Ok, let’s take a look. Hi, Mrs. Johns do you remember me?”
“Yes, you were. In Emergency?”
“That is right. I understand you are a bit short of breath?”
“Yes. A bit more. Than just a. Little.”
“Ok, I’m going to listen to your chest and then I may have to take some blood from your wrist again.”
Erin just nods. Alexa methodically assesses Erin’s respiratory system.
“Ok, Mrs. Johns, your breath sounds don’t seem much different they did in Emergency, but obviously you are not feeling your best. I think I am going to have to change your oxygen treatment to a face mask. Have you had a face mask before?”
“It’s a mask that covers both your mouth and nose. It allows me to give you a bit more oxygen than the system you are currently on. I am going to get the equipment to do so and we will see how you do with the new oxygen treatment and whether you need another needle poke in your wrist.”
Alexa steps out to the storeroom and selects a high flow mask with humidifier. Back in Erin’s room she sets the equipment up and turns the flow meter up as high as it goes. Looking at the humidifier bottle, Alexa notes a good amount of bubbling.
“Mrs. Johns, I’m going to take away those nasal prongs and place a mask on your face.”
Alexa then confidently changes the therapy and places the high flow mask on Erin.
“Now take some deep breaths slowly, and blow out through your mouth. How does that feel now?”
“A bit better. Thank you.”
Turning to Tracie, Alexa states: “I have placed her on .65Fi02 high flow face mask. Can you do another set of vitals for me?” Tracie hits start on the vitals machine.
Both health professionals and Erin look at the numbers as they appear on the screen.
|092% on High Flow FM
“Ok, Mrs. Johns, your oxygen level is better and your other vitals look the same as they did when I first came on shift. Are you feeling better?”
“Yes thank you.”
Alexa looks at both Erin and Tracie. “I have another patient to see next door but before I leave I will come back and see how Mrs. Johns is doing.”
Tracie nods and follows Alexa out of the room. “What do you think is going on? Why did her saturations drop, Alexa?”
“Her pneumonia might be progressing a bit. Sometimes that happens even with antibiotics. Antibiotics take about three days to really work well. In the meantime if she could stand it, we should see if Physio can see her and maybe get her moving, which will help with chest expansion. One of the worse things to do is to just lie about. Is she due for a CXR?”
“Yes, I saw that she will be getting one around 2 PM this afternoon. Can she go down with that mask on?”
“No problem. I will make sure there is a full tank available. Tony is the RT in Emergency and he also covers X-ray if need be. I will let him know in case there is an issue while she is down there.”
“Ok, I will talk with the doctor about a physio order and let him know you have adjusted her O2.
“Thanks. I will look in on her after I see my other patients on this floor. If her sats stay up where they are, I don’t believe she needs a blood gas.”
“Awesome. Ok, see you later.”
“Hi Dr. Hunicutt, I’m Tracie. One of my patients, Erin Johns, is under your care.”
“Aw, yes the older lady with COPD and pneumonia. How was her night?”
“Night was pretty good, needed some adjustment on her Optiflow but otherwise slept well. My concern is what happened this morning. She became quite short of breath and anxious. I called the RT and we made some adjustments and moved her to high flow face mask at .65. Sats responded and she improved to 93% and has stayed there for the past hour. Appears quite relaxed now. No other changes in breath sounds or temperature. Very little sputum production.”
“Very good. Let’s go and see her now and see if I need to make any further adjustments.”
Both Tracie and Dr. Hunicutt walk down the hall to Erin’s room. As they enter, they see Erin sitting in bed with a green oxygen mask on, flicking through the TV channels.
“You have a lot more channels than I do at home, but nothing is on. This darn mask blocks some of my view as well. How much longer do I keep the mask on?”
“Hi, Mrs. Johns, my name is Dr. Hunicutt, and I am the doctor helping to care for you. I see you are less short of breath right now. Would you mind if I listen to your chest?”
“Sure, but I am feeling a bit tired of all the people looking at my chest.”
“I understand Mrs. Johns, but this is one way we can assess how well you are doing and if we need to change treatments.”
Dr. Hunicutt takes his stethoscope out and systematically listens to Erin’s heart and lungs. Then he proceeds to examine the rest of Erin.
“Very good. Thank you, Mrs. Johns.”
“If it was very good, I wouldn’t be here.”
“My apologies. It is ok. Your lungs are not the healthiest due to your COPD, and by listening to your chest I can see that you do have lots of consolidation in both lower lobes.” Dr. Hunicutt points to where he heard the bronchial breath sounds.
Erin looks down at her chest to see where Dr. Hunicutt is pointing. “Oh my, that is about half of each lung.”
“That is about right. Not all is lost. I believe you are on the right antibiotics. We are still waiting for the sputum test to tell me that, and you will also get a chest X-ray today to confirm that the pneumonia is not spreading more. Tracie, is there something more you would like to do for Mrs. Johns?”
“I would like to have Physio come and see her and get her moving a bit more.”
“I think that is a very good idea. I will write the order. They may not come today, but that doesn’t mean Mrs. Johns cannot sit in a chair or stand at the bedside. I don’t want her doing too much, but she does need to move a bit more.”
“We can do the chair. What about bathroom?”
“Commode at bedside until she is below 50% oxygen. Anything else?”
“Alexa the RT said she would wait to do another blood gas as her sats are ok right now.”
“I agree. But I will write an order for another blood gas tomorrow morning to see how we stand with CO2 and PaO2. I want to ensure that her COPD is not getting worse as well. At this point, our other option is BiPAP which I’m pretty sure Mrs. Johns will not be happy with, so let’s see if we can manage her without going to intensive care.”
“Thank you. I think that will do. Mrs. Johns, do you have any questions?”
Erin, looks back at them from the TV. “Can my dog visit?”
Dr. Hunicutt looks at Tracie who shrugs her shoulders “Yes I think that will be ok as long as it’s well behaved and ok with your roommate to have her in this room.”
“Trixie is very well behaved and a small dog. She will be so pleased to see me.”
Both Dr. Hunicutt and Tracie smile, nod at Erin and leave the room.
Outside the room, Dr. Hunicutt asks if anything else needs to be done. Tracie points at a couple of other rooms where she has patients and explains that two patients need discharge orders, and two others need lab work looked at, as pharmacy is stating that antibiotic coverage may not be appropriate. Dr. Hunicutt nods his head and gives her the thumbs up sign as he heads to the chart rack to begin the process of discharge and looking at labs.
Tracie begins the process of recording the interaction with Dr. Hunicutt and Erin.
Over the course of the day, Tracie was able to get Erin up twice to the bedside commode and twice to a chair for 30 minutes each time. Erin’s saturation stayed stable along with her other vitals signs.
When the shift changed rolled around, Tracie was very happy to see Jim come into the unit. “Wow, I did not think I would see you tonight.”
“Me neither. They called me for overtime during my chaperoning of a school trip.”
“Man, you must be exhausted.”
“Yeah but no more than usual. Got some shut-eye before coming in. Anyway, how was your day?”
Tracie gives an overall report of two discharges and two new admissions. She updates Jim on changes to Erin’s oxygen levels and her increased orders for activity.
“Awesome. Thanks. Will I see you in the AM?”
“I believe you will. I’m doing four days in a row. I traded my night shifts so I could attend a play with my husband. We have had so little time together with him finishing his PhD, and my shift work. He promised not to talk research, and take me out on a real date if I would change my night shifts.”
“Wow, I am so jealous. Well, have a good sleep and we will see you in the morning.”