Getting the hang of it, maybe just a little: that sentiment epitomizes my third day on the floor of 9 Long.
The day was hectic and scattered, especially since my patient was scheduled for Ultrasound of his new Kidney and Pancreas transplant first thing in the morning, which delayed my care for him. I would have jumped on performing my am assessment of him before he left, however the RN I was shadowing preferred that she introduce herself with me since she was primarily responsible for his care and my patient was her lowest priority since her other three patients included a liver transplant who had high pain needs, a kidney transplant who was ready for discharge, and a recent admit for pancreatitis. By time we made it into my patient’s room we had just enough time to pre-medicate him before he left for ultrasound.
While he was gone, I found myself supporting the high pain needs of the liver transplant patient who had trouble swallowing his medications and required attention to monitor his respirations due to a bolus administration of his IV dilaudid PCA. It was certainly a challenge and I loved the experience, however as I worked with Marilyn hop from room to room, providing teaching and care that was modified to each patient’s needs, I began to really appreciate how far I must go before I’ll be ready to fill this role independently without the benefit of two instructors and an RN to shadow.
After my patient had returned from his ultrasound, which took several hours later than we had expected, my assessment of him found that his blood pressure was a concerning vital sign. Of course his morning metoprolol was 3 hours late, however even after a couple of hours of administration Marilyn and I contacted the physician and had his dosage increased. Several hours later, the increased metoprolol had not had an affect on his BP. This may have been due to an earlier IV albumin administration, however we knew the BP had to come down in order to reduce the stress on the new kidney and so we consulted a physician who prescribed amlodipine.
After we received the prescription Marilyn and I stopped in my patient’s room to inform him that we received the order for amlodipine and would be administering it as soon as pharmacy updated the Pyxis profile, however as soon as my patient heard the name of the drug he adamantly stated that he would not under any circumstances take amlodipine because he had taken it in the past and it caused him to cough uncontrollably.
After some consult with the patient we learned that he had taken clonidine in the past without suffering the same reaction so we consulted the MD to change the order. However when we spoke with the MD there was a young resident standing by who expressed that “some patients just associate getting sick with a medication and blame the condition on the medication,” however the senior MD ignored this claim by the resident and promptly placed the order for clonidine.
This experience was valuable to enhance my appreciation of several factors of the patient centered model of care.
First, both Marilyn and I had first-hand witnessed the patient’s reaction and therefore we trusted and honored that he knew his own body’s reaction to the drug and knew that even if the order was maintained as amlodipine that he would refuse the drug; after all, he was an HIV positive on HART who was well versed in all of his daily medications and how they affected his condition.
Second, the resident MD was quick to treat the condition and not the patient, as displayed by his disregard of our communication of the patient’s complaint.
Finally, although the original MD practiced standard judgment in placing the original order, I recognize that there was a small systemic breakdown in this process; perhaps if there was a list of medications that the patient had reaction to other than simply allergies, we could have avoided this process altogether and made the correct order in the first place. Additionally, the process involved in consulting an MD for an order without having the MD actually see the patient causes a breakdown in the MD’s ability to provide patient-centered care.
I see once again that it is the nurse is the face and voice of the patient.
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