• Rachel Ogilby

A Day in the Life of a Nurse-Caring for Mrs G

This is a true story about caring for a patient who had a significant impact on me as a nurse.

The day already started out with a feeling of unease. As I stepped onto the Medical-Surgical nursing unit where I worked, I noticed it was louder than normal. There were more people on the unit, and pings and chirps from various medical equipment were singing their tunes with fervor. Before giving me report, the off-going nurse said, “I’ve got to get out of here before another patient codes. It’s nuts up here today.” I immediately became slightly irritated and a bit concerned. If it’s really that bad, shouldn’t we let our supervisor know? Shouldn’t you offer to help on the unit for a few minutes instead of rushing out? I quickly received report on my five patients, with a nursing student alongside me who was assigned one of my patients as well. Butterflies flipped around in my stomach. What challenges will we face today?

The nursing student would help with the patient’s needs, such as walking, toileting, getting food or water, and changing linens. I normally liked having students, and while today was no exception, I wouldn’t be able to spend as much time explaining things to her. The patient she would help care for, Mrs. G, was a Spanish-speaking patient admitted with gastrointestinal (GI) problems. She was also on contact precautions for MRSA, a disease that could easily be transmitted to myself or other patients without the proper protective equipment or hand washing. Additionally, she had a low hemoglobin and hematocrit and was getting a blood transfusion. She’d had surgery a few days prior, and the assumption was that the blood loss may be due to her surgery.

After a brief overview of my five patients’ recent vital signs, allergies, code status, medications, and orders, I decided to start my morning assessments with Mrs. G. Before entering the room, I saw one of our Rapid Response nurses who was on the unit caring for another patient. Our Rapid Response nurses aren’t always on call, but when they are, they are great resources for nursing staff. They are comprised of a team of expert nurses who have experience caring for very sick patients and can give expert care to a patient who is decompensating. When you see them on a Medical-Surgical unit, it usually means something bad has happened; we call them when we need help. He was in the process of taking a patient to the Intensive Care Unit (ICU) to be monitored more closely. “Hey, Rafael,” I said. “Can you circle back up here later? I just have a bad feeling about today.”

Since Mrs. G was on contact precautions, the student and I put on gowns and gloves to enter her room. I knocked on the door and entered, smiling and saying, “Buenos dias!”. I immediately approached the translator phone to use for communicating with the patient. Though I could potentially get by the rest of the day with the Spanish I know, it was always important to me to establish rapport with the patient at the beginning of my shift to create trust. I wanted to make sure the patient fully understood the plan for the day, the medications she would get, and my role in her care. I also wanted to set a good example for the student and make sure she understood how important it was to speak to the patient in their preferred language.

I dialed the number to the translator and put the phone on speaker so the student could also hear the conversation. After a few minutes of waiting on hold, we heard, “Hello, my name is Jared and I’ll be your Spanish translator today, number 2214765. Is your client with you?” I introduced myself and we began the conversation with the patient. “My name is Rachel and I’ll be your nurse today until 7pm. This is Stephanie, a nursing student who will also help care for you. How are you feeling?”

Though our conversation was uneventful, I still had a feeling that something wasn’t quite right. I explained to the patient that I would be listening to her lungs and heart and performing an assessment. I asked her if she had any questions for me before I hung up with the translator. “No, gracias,” she said.

The patient was unable to eat or drink normally due to her surgery, and we had placed a corpak (a type of naso-gastric tube) through her nasal passage and into her stomach the day prior. This allowed her to get nutrition even though she couldn’t eat normally; I would administer her oral medications and provide her with her tubefeed this way.

Best practice for assessing the placement of these tubes are by x-ray. The provider views the x-ray results and writes an order for the nurse to use the tube. An improper process can be deadly; without proper care, it was possible to accidently give the patient her medications or food in the wrong location, such as her lungs or brain. Depending on the placement, this could cause pneumonia or even death. Once, in nursing school, I was shown an x-ray of a patient who had a history of facial reconstruction. She was given a corpak and its placement had not been checked appropriately before she was given medications. The corpak had gone to her brain, and she passed away. After seeing this, I would never forget to follow proper placement checks.

Though this process was completed appropriately for Mrs. G, I knew that the student was learning an additional way to check placement in school. She was taught to place a syringe on the tube and pull back to assess for gastric contents. This would hint at the proper placement of the tube. Though this didn’t always work well with corpaks, I went ahead and showed her how to do it anyways since it was part of her curriculum.

In a correctly placed nasogastric tube, aspirating gastric contents would result in a visualization of bile or tube feed. However, when I pulled back on the attached syringe to assess the gastric contents, I saw frank red blood. Aha! I thought. This is why I had a feeling something wasn’t quite right. It appeared the patient had an active GI bleed, causing her low blood levels, and resulting in her need to receive a blood transfusion. “Stephanie, can you see if Rafael is still on the unit?” I asked, and the student hurried out of the room after removing her protective equipment and washing her hands. “No, he’s gone,” she called into the room. I told the patient, “Yo vuelvo”, or I’ll be back in Spanish, and also exited the room.

I paged the patient’s on-call resident on-call. She was on the Green Team, a surgical team dedicated to GI patients. While documenting my findings in the electronic medical record, the resident called back. I informed her of my findings. She responded by thanking me for calling her and advised me she would be ordering some new tests and medications. Most, if not all of these tests and medications would require the patient to be transferred to a higher level of care for more frequent monitoring. With four other patients to care for, it would be near impossible to give Mrs. G the attention she needed to get her well.

I paged Rafael and told him of my findings. “Anticipate an order for a continuous proton pump inhibitor. You’ll also get serial CBCs on the patient.” He confirmed my suspicion that this patient would need to be transferred to the ICU. “You know”, he said, “You have a good eye for critical care. Are you sure you don’t want to come work in the ICU?”.

I entered Mrs. G’s room and called the translator line again. “Hello, this is Gabriella, Spanish interpreter number 0036795. Is your client with you?”. I explained to the patient that we found some blood in a location we hadn’t expected, and there were some new tests and medications ordered. I told her that her doctor would be bedside soon to talk with her more about it, and that some of the medications she needed could only be given on another nursing unit. She would be transferred there sometime today. She nodded with understanding. “Is there anyone you want me to call for you to let them know what’s going on?” I asked.

Within 10 minutes I had new orders for medications and tests. Another 30 minutes passed, and the resident was on the unit assessing the patient. Rapid Response was back and ready to take Mrs. G to the ICU. I breathed a sigh of relief. Though it was an exciting day for the nursing student who would now follow the patient to the ICU, I was grateful to be able to now spend my energy on my other four patients. I knew that the ICU beds wouldn’t always be so readily available, and it was possible I would get a call soon from the ICU to transfer another patient to me. I typed an update into the patient’s chart explaining the scenario that had unfolded. After all, we’re taught that if you don’t chart it, it didn’t happen.

I talked with the charge nurse to make sure she knew the situation and the new bed assignments. Discharging a patient from the unit usually meant that we would get another patient soon. Thank goodness we had such an excellent nursing team focused on teamwork; even though I now only had four patients, the other nurses knew I had had a busy morning. They would likely try to help me catch up on my work for the rest of the morning if their patients were stable.

I never found out exactly what happened to Mrs. G, but I heard through another nurse a few weeks later that she eventually recovered. Certainly, one of the most challenging part of the situation was the language barrier between us. Using a translator takes double or triple the time to communicate as it would normally, and relaying my thoughts and assessments to the nursing student also required more time and energy.

This clinical situation is important to me for many reasons. As fate would have it, I eventually found myself working alongside ICU nurses in a new role as a Clinical Nurse Specialist a few years later. The words of Rafael stuck with me. If he, a highly respected ICU nurse with years of experience and expertise, believed that I could make it in an ICU setting… shouldn’t I also believe that? I also learned to trust my instincts through this clinical situation. Something hadn’t seemed right with my patient, and, well… something wasn’t right. She had a GI bleed that we hadn’t identified yet. It was fortuitous that a nursing student was with me that day which resulted in my additional assessment of the nasogastric tube – without it, I’m not sure I would have identified the cause of Mrs. G’s dropping blood counts.

This clinical situation is one of many that helped shaped the nurse I am today. Wherever you are, Mrs. G, I hope you are doing well and feel that you were well cared for during your hospital admission!

*Names were changed in this story to protect the privacy of those depicted

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