Yesterday I was writing about corneal abrasions and the medications that a physician will likely prescribe after such an injury occurs. It occurred to me today that listing some good links on "how to" administer eye drops (and other prescribed medications) to infants or toddlers would be a good idea.
Based on my past years of working as a pediatric registered nurse, I know how difficult it can be to medicate infants and toddlers. In order to give the medication with the minimum of fuss, it's best to swaddle (wrap) an infant gently but firmly in a receiving blanket so that the baby's arms are fixed at his/her side. For an older toddler, it may very well take two people to give necessary medication.
Here are two websites with rather nice information about how to give medication to infants and toddlers:
Great Ormond Street Hospital for Children: How to Give your Child Eye Drops
From the Ohio State University Medical Center: How to Give Your Baby Medicine by Mouth
Follow the Doctor's Orders
Give your child medication that is prescribed for him or her. Don't borrow or share medication meant for someone else. Store the medication as directed by your pharmacist's instructions. Most antibiotics will need to be refrigerated. Continue to give the prescribed medication for the entire period that the doctor has ordered. Don't stop the medication early because the child "seems better." Doing so can cause lingering infections that become resistant to the medication.
Do Not Give . . .
Never give aspirin to infants or children. Check the lable of any medication you intend to give. If any of the ingredients contain salycilic acids don't give your child the medication. Check the labels on all of your over-the-counter medications. Look for "black box" warning labels and other instructions to parents. Recently many cold and cough medications have been deemed dangerous to young children and the new packaging reflects such information.
Talk to your pharmacist . . .
Pharmacists do more than fill your prescriptions. They will gladly discuss over-the-counter medications with you and help you find appropriate options for your child. In addition, consult your pharmacist to determine whether or not the prescribed medication can be made more palatable for your child--by adding "better" tasting flavors by compounding the medication.
. . . .
Wednesday, December 16, 2009
Corneal Abrasion, Corneal Scratch, Pain and Sensation of Something in the Eye
“It feels like something is in the eye, and it's very painful.”
Why I’m compelled to write about this topic today: Recently one of my patients was expected back from surgery after undergoing a complicated procedure to repair a fracture. Shortly before the young man was due to arrive in his hospital room, the nurse from the surgical recovery care unit called to report that he was experiencing severe pain in one eye along with a sensation of “something in the eye.” The surgeon was aware and had ordered an eye flush. Although the nurses in recovery had copiously irrigated the eye with sterile water, the patient’s extreme discomfort persisted. The pain from his orthopedic surgery was nearly eclipsed by the pain and irritation in his eye. Close examination hadn’t revealed any obvious reason for the persistent eye pain. When he arrived on our floor, the patient’s affected eye was “bloodshot,” very sensitive to light, and he was writhing due to the combination of both eye and surgical incision pain. The surgery resident physician was soon at his bedside. She ordered an application of “Lacrilube” ointment to soothe the eye and diagnosed a corneal abrasion. Having participated in the surgery, she remarked that the affected eye “really wasn’t taped closed well enough” during the lengthy surgical procedure.
Corneal Abrasions
There are a number of reasons why a cornea might be scratched or irritated resulting in an abrasion. Although they are extremely tiny, corneal abrasions, are very painful . . . and why not? After all, even a paper cut to our fingertips can cause startling pain. Often a small corneal abrasion will heal itself within 24 hours. There is treatment that may soothe the affected eye, such as sterile artificial tears (see below for further discussion of additional treatments). Keep in mind, however, not all eye pain is due to a corneal abrasion, and not all corneal abrasions may be treated with home care alone.
Some Structures of the Eye
To understand what the cornea is, it’s useful to think of the eye as a room with the cornea being a window. The eyelids are similar to shutters that can be opened or closed. The space between the shutters and the window glass is the conjunctiva. The cornea functions as the window glass does; that is, the light flows through the cornea to enter the eye. Directly behind the cornea is the round, colored iris which functions in much the same way as curtains; the muscles of the iris expand and contract to allow more or less light inside of the “room.” The pupil is the space through which the light passes between the open curtains. The lens is yet another “window pane” that the light passes through before it enters the room. My suggestion is to think of the lens, for this example, as a large glass “sun catcher” suspended from the ceiling just inside the window. Vitreous humor is the gelatinous substance that fills the center of the eye just as normal atmospheric gasses fill up a room in your home. The retina is the back wall of the room just opposite from the window. As light strikes the “wall” (retina) there is inevitably a particular spot where the sunlight is more concentrated. The macula in the back of the eyeball is similar to that part of the room with the brightest exposure to the light. The fovea is an area of the macula which provides the sharpest vision; similarly the brightest spot in the room is best for reading or performing tasks that require sharp visual acuity.
(See a nice depiction of the eyes' anatomy here: http://www.eyecareamerica.org/eyecare/anatomy /).
A Little More About the Cornea
As mentioned in the preceding paragraph, the cornea functions like the glass of our windows. It’s a protective structure for the more delicate features behind it, and it functions to let light flow into the eyeball. Although the cornea consists of five distinct layers, it is very thin—with a depth of only about 1 mm at its deepest point.
The cornea has an abundance of nerve endings, as a result it’s very sensitive to both touch . . . and pain.. That trait helps protect our vision from trauma as all of our instincts quickly react to try to prevent an injury to the eye. However, corneal abrasion is still one of the most common eye injuries.
How Does a Corneal Abrasion Occur
A person may have no recollection of trauma to the eye and there are numerous scenarios that may result in a corneal abrasion. A poke in the eye (particularly if a fingernail is involved), a branch from a tree, flying glass or metal shards, or a surgical drape or equipment brushing across your eye if it is exposed during a surgical procedure . . . any of these things can cause a corneal abrasion. Debris in the eye can also cause an abrasion, particularly when the eyes are rubbed vigorously or if a contact lens causes friction.
Prevention during Surgery
Taping the eyes closed is a standard preventive measure aimed at protecting the eyes from corneal abrasion. Some surgeries pose a greater risk of a corneal abrasion occurring. Those in which the patient is positioned face down, surgery on the head or neck, and any lengthy procedure carries more risk. Of course in some surgeries taping is contraindicated as the eyes may need to be opened during the procedure. In such cases the anesthesiologist or nurse anesthetist will use their judgment to make the appropriate decisions. Instillation of eye drops, gels or eye ointments may be the decided course of prevention, or special goggles, eye cushions or pads may be used.
Diagnosis
Your doctor may use a combination of fluorescent dye and either a cobalt-blue filtered ophthalmoscope or a “slit-lamp” to make a definite diagnosis of a corneal abrasion. The physician may instill drops to temporarily numb the eye during the exam. If they observe a foreign body present in the eye, it will also be removed during this examination.
Treatment
At one time eye patches were applied when patients suffered a corneal abrasion. This is no longer a standard treatment; however, in some cases your physician may determine that an eye patch is in your best interest. It’s more likely that eye drops or ointment will be prescribed for home use. The drops and/or ointments may include a medication to control the pain, an eye lubricant, a topical antibiotic, or a steroid. Steroid eye drops may be prescribed to reduce inflammation. (Please note, some of the eye drops and ointments may result in temporarily blurred vision). Occasionally, a pain medication to be taken by mouth will be prescribed as well.
If metal shards were responsible for your eye injury, a tetanus booster shot will be needed. If it has been more than 5 years since your last tetanus shot--or if you cannot remember when your last tetanus shot was given--you will should be given a booster shot after the eye examination.
Follow your physician’s orders and use the medications exactly as prescribed. Do not stop the medication sooner than the directions tell you to simply because the eye “feels better.” Continuing the full course of prescribed treatment is important to prevent possible complications later on.
If you have questions about your doctor’s ordered treatment, ask him or her. You have a right to know the reason for the treatment decisions that are made on your behalf.
How long to heal
A small corneal abrasion may heal in a few hours. Often after a night’s sleep the cornea has healed. In the case of a larger abrasion, it may take several days time for complete recovery. It is important to keep from rubbing the affected eye as that may delay healing. If the symptoms suddenly recur after the initial healing phase, consult your physician right away. Inadequate treatment of a corneal abrasion can sometimes lead to complications such as a corneal erosion.
First Aid for Eye Emergencies
Plan to seek treatment at your urgent care center or ER for any bleeding from the eye, chemical splash, visible scratch or penetrating injury, eye pain, double or blurred vision, nausea and headache.
Do not rub the injured or irritated eye. Wash your hands with soapy water. Remove contact lenses if they are in place. Do not attempt to use any tweezers or cotton swabs to try to treat eye emergencies at home.
Chemical splash to the eye: Start flushing the eye with cool clean water from a sink, bottle, hose, etc. Tilt the head back and to the side. Keep the affected eye wide open and pour the clean water gently but directly into the eye. Make sure the head is tilted away from the “good eye” so that chemicals which are rinsed out don’t flow into that eye during the flushing process. (A child might be more comfortable laying down in an empty bath tub to have the eyes irrigated.) Continue to flush chemicals from the eye continuously for at least 15 minutes. Call 911 or have someone drive you to the ER. If the chemical that splashed into the eyes is known, be sure to provide the name to the healthcare providers at the hospital. For more information see:
First aid tips for a chemical splash to the eye from the Mayo Clinis.
Foreign body in the eye: Do not rub the eye. With clean hands, open the eye and allow tears to move the foreign body (such as an eyelash or speck of dirt). Rinse the eyes with cool clear water as explained above if tearing isn’t effective. If an object is embedded in the eye—do not attempt to remove it. Seek medical help in the ER or urgent care center immediately. For more information see: Mayo clinics advice on corneal abrasion and Mayo's first aid advice for a foreign body in the eye.
Bleeding from an eye: Do not put any pressure on the eye, gently cover it with a clean cloth and go directly to the Emergency Room. (The person with the injured eye should not drive).
2009 All rights reserved for content and photos, Carolyn Cooper, MPH, RN
References:
WebMD: http://www.webmd.com/eye-health/tc/objects-in-the-eye-home-treatment and http://firstaid.webmd.com/corneal-abrasion-treatment
Eye Safety for Emergency Response and Disaster Recovery from the CDC: www.cdc.gov/niosh/topics/eye/eyesafe.html
Wilson, S.A. and Last, A. (2004). Management of Corneal Abrasions. American Family Physician. Retrieved 12/16/2009 from: http://www.aafp.org/afp/2004/0701/p123.html
Verma, A. (2009). Corneal Abrasion. Emedicine from WebMD. Retrieved 12/15/2009 from: http://emedicine.medscape.com/article/1195402-overview
First Aid for Eye Emergencies from Prevent Blindness: http://preventblindness.org/safety/firstaid.html
Tarmey, N. & White, L.A. (2009). Chapter 5, Damage to the Eye. Risks associated with your anaesthetic, Information for patients: the Royal College of Anaesthetists. Retrieved 12/16/2009 from:
http://www.rcoa.ac.uk/docs/Risk_5Eye-damage.pdf
.
Tuesday, December 01, 2009
A patient with Down's Syndrome and ARDS; Carol was not "my" patient
Not My Patient . . .
“Your patient is being discharged,” my nursing instructor informed me as we started our clinical rotation on a medical/surgical floor in my first year of nursing school.
"Oh, just great," I thought to myself. I had spent hours learning about and planning the proper care for "my patient" who had recently suffered a basilar skull fracture. My sheaf of clinical documents, medication lists, and a large pathophysiology flow sheet, were now suddenly made obsolete by my patient's imminent departure to a rehabilitation facility.
“He’ll still be here for a couple of hours. We’ll find you another patient later,” she assured me.
I was relieved that my painstakingly-crafted flow sheet, care plan, and medication cards wouldn’t go to waste. Although I only had one patient, the preparation required for the clinical day was nevertheless tedious and often proved exhausting in addition to other demands of family, school, and life in general. Still, as a new nursing student with little experience in the healthcare setting, the advance preparation gave me confidence that I would know what to do for my assigned patient. I decided not to fret about it, and simply hoped I'd be able to cope with whatever came my way in the shift ahead.
Our group of 10 nursing students and our instructor assembled at the nursing desk waiting for the nurses going off duty to give change of shift report to the group coming on. We were working second shift, 3 pm to 11 pm that day. Each week we spent three days attending lectures at our nursing college and two days working in the hospital to practice the hands-on-nursing skills and put into practice what we learned in class. There was always a sense of heightened anxiety on our hospital days, particularly in the chaotic environment of our very large county hospital. This was a trauma center and the busiest hospital on the U.S. side of the Mexican border. It was also a teaching hospital, with a slew of resident doctors and interns managing most of the patient care.
“The patient in 410 has a fever of 101.5!” a nursing assistant called out as she passed the nurses’ station where the harried day-shift nurse was “reporting off” to the oncoming "real" evening nurse and our huddle of nursing students.
The nurse going off shift sighed, “I’ll call the doctor—the girl in 410 just transferred here from the pediatric floor a half-hour ago. She’s supposed to go to the OR for surgery, an ORIF of the femur, as soon as her mom gets here to sign the consent.” The RN turned to our instructor, “It would help me out if one of your students could give her an acetaminophen suppository for the fever.”
Although none of our group was assigned to care for this new arrival to the surgical floor, we were always ready to perform a clinical skill to check off our list. Therefore, an entourage of three students and our instructor entered room 410 where 18-year-old Carol, afflicted with Down's Syndrome and a fractured femur, would prove to teach me more than any other patient that day.
Carol had been struck by a car as she crossed a busy street the day before. The fractured leg was her only known injury. She appeared to be sleeping deeply, with regular, but deep and fast respirations. Her eyelids fluttered as I explained that we needed to give her a suppository. Working together, we students gently repositioned her, mindful of the Buck's traction supporting her injured leg. A slight groan was Carol’s only acknowledgement as we cleaned her bottom (she had been incontinent with a bowel movement), before I inserted the suppository. Our instructor pointed out scattered petechiae on Carol's chest as we snapped a fresh gown across her hot skin and turned her to replace the soiled linen on her bed with clean sheets.
“These petechiae are probably the result of the trauma from her car accident,” our instructor explained, as she gestured towards the splash of flat pink spots that looked to me like tiny red freckles.
Back at the nurses' station our little group reassembled to continue shift report. We told the nurse about our interventions and reported Carol's limited response to our actions.
“They gave her an injection of Demerol before she was transferred from the pediatric unit," the nurse mused, "And we don’t know her baseline mental status, she has Down's, and for all we know she could be profoundly retarded.”
I was absorbed in my clinical experience for a few hours. The care for my basilar skull fracture patient proved to be very minimal. One of our nursing students needed a helping hand with a very complicated dressing change for a young man who had lost a leg in while trying to jump aboard a moving train. And I was pleased to learn that another patient needed a new intravenous needle placed. I was lucky enough to get the chance to do the venipuncture. I suspect that I caused that patient a great deal of pain with my novice attempt, but with a seasoned nurse over my shoulder talking me through it, the result was satisfactory. I kept busy in this way helping the staff nurses and other nursing students with their tasks until my patient was officially discharged. My instructor disappointed me then by suggesting that I return to Carol and follow up on her care. It seemed a puzzling assignment to me, I knew there were no meds to pass, IV's to start or dressings to change in that room--and I was here to learn nursing . . .
In Carol’s room I found that her mother had arrived from out-of-state. She was regarding her daughter pensively.
“She won’t wake up,” she complained.
I repeated the explanation that the nurse had given us in report earlier, that Carol had been medicated with Demerol.
“When did they give that? And how long will it last? Something’s just not right,” she continued.
Her questions were good ones. I set out to find the "real" nurse to explain the mother's concerns, but the nurse arrived at that moment with a syringe in hand to give Carol another intramuscular injection of Demerol for her pain. The busy nurse briefly attempted to reassure Carol's mother before rushing back to care for her other nine patients.
As I continued to converse with Carol’s worried mother, I became uneasy. She described a high-functioning independent young woman who lived in a group home while attending a vocational educational program in the city. Demerol or not, the Carol we were observing didn't fit the girl her mother described.
Carol occasionally writhed and moaned, seeming to struggle to wake as her mother tried to arouse her. Her breathing was audibly harsh with a frequent moist cough. The family doctor was alarmed at her appearance when he made informal rounds to check on Carol. He wasn't in charge of her hospital care which was in the hands of the attending physicians who were on staff at this hospital, but he asked that the chief trauma resident be called to see her right away.
Before the staff nurse could return to Carol's room, the senior trauma resident appeared at the bedside and started questioning me. He examined Carol while I slipped out to get her nurse who told me she would "be there as soon as she could."
Awkwardly, I waited with Carol's mother as the resident considered Carol. He wondered aloud why she hadn't gone down to the OR earlier as scheduled. I reminded him of the fever and as he listened to her lungs, I casually pointed out the petechiae, which was more diffuse across her chest now.
The resident was suddenly abrupt and to the point, it seemed he'd slapped the last piece into a puzzle. “She’s thrown a fat embolus from her fractured femur--get her to ICU stat.” Then he turned on his heel and was gone before I could say a word.
I had enough of the classroom experience in nursing to fear a pulmonary embolism (a tiny blood clot that lodges in the lungs), but I didn't have a great deal of insight into the prognosis and treatment for a fat embolus. The hours that Carol's condition had progressed undetected were haunting me. Right away I knew that Carol needed her nurse, and I needed my instructor.
It took some time to find Carol’s nurse and convince her that the resident wanted her patient transferred to ICU. She made the requisite phone calls to confirm the orders and set the wheels in motion so that the ICU would assign Carol a bed. Meanwhile, Carol's chart was nowhere to be found. It was misplaced somewhere on the surgical floor. I nervously looked for the chart while the nurse arranged for Carol's transfer.
My instructor, aware of the unfolding drama, gave me a brief suggestion, "Just help where you can with the transfer."
Carol's mother, numb with worry, was making phone calls to advise her family members of this turn of events. A sense of urgency was consuming me as I returned to Carol’s room. Carol's nurse was still on the phone making arrangements for the transfer. Suddenly the resident reappeared and scolded me. “This patient should have been in ICU already! Get her there now!!”
But no such luck . . . The nursing unit had their own procedures to follow. They set about taking a complete set of vital signs, "It's required that we do so before transferring a patient."
The nurse's aide who was trying to check Carol's blood pressure was having a hard time because, "This machine can't be right, her pressure's way too low." She went to search for a manual blood pressure cuff that affirmed the hypotensive state of the patient.
Carol’s nurse returned with a respiratory therapist who placed a pulse oximeter on Carol's cool, pale finger and advised, “She needs oxygen, her oxygen saturation is only 65%!” Her saturation should have been at least 92. The oxygen set-up for transport through the hospital to the ICU floor would have to wait for a few minutes while someone went looking for the missing key to the metal portable oxygen cylinder. The precious moments SLOWLY passed as these tasks to make Carol ready for transfer were completed.
I felt useless as the evening nurse and an aide prepared the bed for transport. “What can I do to help?” I pleaded.
“You can carry the patient’s bag of belongings and make sure not to bring her flowers, she can't have them in ICU,” the staff involved in this whole situation seemed snappy and angry. I thought it was a waste of brain cells for the nurse in charge to even think about the flowers under the circumstances. In retrospect, I'm sure I was sensing the staff's anxiety and concern, and I have to believe they all shared my frustration with the obstacles that slowed the transfer to what seemed like a crawl.
My neck flushed as we awkwardly maneuvered the Carol's bulky hospital bed into the hall and then, after all the delays, ironically took off running for the elevator leading to the intensive care unit. There wasn't enough room for all of us on the elevator. Carol's mother and I rode together on an adjacent elevator.
The small ICU waiting room was overflowing with visitors waiting to be allowed in to see other patients. I said farewell to Carol's mother and urged her to call her ex-husband to let him know what was happening.
I'd never before been through the sliding doors that isolated the large intensive care unit from the rest of the hospital. No matter, I found Carol’s room easily. Nearly every nurse in the ICU was at her bedside, hooking up monitors, taking vital signs, putting in an additional IV, preparing suction, and hanging fluids. I could see the resident doctor with his interns assembling supplies. In a few minutes time Carol would have a tube in her trachea that allowed a mechanical ventilator to breathe for her.
I layed down Carol's bag of belongings lingered in the background for a few minutes. Clearly Carol was in good hands, these nurses were calm and in control of the situation.
Suddenly my shift was over--it was time to meet my instructor and the rest of the clinical group before going home. But I was sad and miserable. I went beyond my required textbook reading that night. Fat emboli and acute respiratory distress syndrome (ARDS) consumed my thoughts. I grieved for Carol's mother and lamented that I hadn't known enough to help expedite her care that evening.
Two days later as I skimmed the morning paper, I was shocked--but not surprised--to see Carol’s photograph smiling brightly from the obituary column. I cut that little clipping out of the newspaper and pasted it into my tiny notebook of nursing tips. To this day I still carry that notebook in my nursing work bag. I guess Carol's legacy has been with me every day that I've worked as a nurse, now that I think of it.
Technically, Carol was never "really" my patient. No medication cards, flow sheets, or care plan followed me to her room that evening and my education and experience to that point certainly didn't prepare me for the gravity of her situation. Of course, ironically, it was the deepest and most vivid clinical situation I experienced as a student. I always recognized that I contributed little, but benefited much from this experience. Many of the lessons learned are so obvious that they don't bear repeating.
An obvious lesson that does bear repeating, on the other hand: never assume nor underestimate any patient's baseline mental capacity. Good communication with a responsible party who can provide definite information on a patient's usual abilities is absolutely vital so that care is not compromised or delayed in the event of important neurological changes. That's Carol's legacy to me.
All rights reserved 2009 Carolyn Cooper MPH RN
. . . . ,
“Your patient is being discharged,” my nursing instructor informed me as we started our clinical rotation on a medical/surgical floor in my first year of nursing school.
"Oh, just great," I thought to myself. I had spent hours learning about and planning the proper care for "my patient" who had recently suffered a basilar skull fracture. My sheaf of clinical documents, medication lists, and a large pathophysiology flow sheet, were now suddenly made obsolete by my patient's imminent departure to a rehabilitation facility.
“He’ll still be here for a couple of hours. We’ll find you another patient later,” she assured me.
I was relieved that my painstakingly-crafted flow sheet, care plan, and medication cards wouldn’t go to waste. Although I only had one patient, the preparation required for the clinical day was nevertheless tedious and often proved exhausting in addition to other demands of family, school, and life in general. Still, as a new nursing student with little experience in the healthcare setting, the advance preparation gave me confidence that I would know what to do for my assigned patient. I decided not to fret about it, and simply hoped I'd be able to cope with whatever came my way in the shift ahead.
Our group of 10 nursing students and our instructor assembled at the nursing desk waiting for the nurses going off duty to give change of shift report to the group coming on. We were working second shift, 3 pm to 11 pm that day. Each week we spent three days attending lectures at our nursing college and two days working in the hospital to practice the hands-on-nursing skills and put into practice what we learned in class. There was always a sense of heightened anxiety on our hospital days, particularly in the chaotic environment of our very large county hospital. This was a trauma center and the busiest hospital on the U.S. side of the Mexican border. It was also a teaching hospital, with a slew of resident doctors and interns managing most of the patient care.
“The patient in 410 has a fever of 101.5!” a nursing assistant called out as she passed the nurses’ station where the harried day-shift nurse was “reporting off” to the oncoming "real" evening nurse and our huddle of nursing students.
The nurse going off shift sighed, “I’ll call the doctor—the girl in 410 just transferred here from the pediatric floor a half-hour ago. She’s supposed to go to the OR for surgery, an ORIF of the femur, as soon as her mom gets here to sign the consent.” The RN turned to our instructor, “It would help me out if one of your students could give her an acetaminophen suppository for the fever.”
Although none of our group was assigned to care for this new arrival to the surgical floor, we were always ready to perform a clinical skill to check off our list. Therefore, an entourage of three students and our instructor entered room 410 where 18-year-old Carol, afflicted with Down's Syndrome and a fractured femur, would prove to teach me more than any other patient that day.
Carol had been struck by a car as she crossed a busy street the day before. The fractured leg was her only known injury. She appeared to be sleeping deeply, with regular, but deep and fast respirations. Her eyelids fluttered as I explained that we needed to give her a suppository. Working together, we students gently repositioned her, mindful of the Buck's traction supporting her injured leg. A slight groan was Carol’s only acknowledgement as we cleaned her bottom (she had been incontinent with a bowel movement), before I inserted the suppository. Our instructor pointed out scattered petechiae on Carol's chest as we snapped a fresh gown across her hot skin and turned her to replace the soiled linen on her bed with clean sheets.
“These petechiae are probably the result of the trauma from her car accident,” our instructor explained, as she gestured towards the splash of flat pink spots that looked to me like tiny red freckles.
Back at the nurses' station our little group reassembled to continue shift report. We told the nurse about our interventions and reported Carol's limited response to our actions.
“They gave her an injection of Demerol before she was transferred from the pediatric unit," the nurse mused, "And we don’t know her baseline mental status, she has Down's, and for all we know she could be profoundly retarded.”
I was absorbed in my clinical experience for a few hours. The care for my basilar skull fracture patient proved to be very minimal. One of our nursing students needed a helping hand with a very complicated dressing change for a young man who had lost a leg in while trying to jump aboard a moving train. And I was pleased to learn that another patient needed a new intravenous needle placed. I was lucky enough to get the chance to do the venipuncture. I suspect that I caused that patient a great deal of pain with my novice attempt, but with a seasoned nurse over my shoulder talking me through it, the result was satisfactory. I kept busy in this way helping the staff nurses and other nursing students with their tasks until my patient was officially discharged. My instructor disappointed me then by suggesting that I return to Carol and follow up on her care. It seemed a puzzling assignment to me, I knew there were no meds to pass, IV's to start or dressings to change in that room--and I was here to learn nursing . . .
In Carol’s room I found that her mother had arrived from out-of-state. She was regarding her daughter pensively.
“She won’t wake up,” she complained.
I repeated the explanation that the nurse had given us in report earlier, that Carol had been medicated with Demerol.
“When did they give that? And how long will it last? Something’s just not right,” she continued.
Her questions were good ones. I set out to find the "real" nurse to explain the mother's concerns, but the nurse arrived at that moment with a syringe in hand to give Carol another intramuscular injection of Demerol for her pain. The busy nurse briefly attempted to reassure Carol's mother before rushing back to care for her other nine patients.
As I continued to converse with Carol’s worried mother, I became uneasy. She described a high-functioning independent young woman who lived in a group home while attending a vocational educational program in the city. Demerol or not, the Carol we were observing didn't fit the girl her mother described.
Carol occasionally writhed and moaned, seeming to struggle to wake as her mother tried to arouse her. Her breathing was audibly harsh with a frequent moist cough. The family doctor was alarmed at her appearance when he made informal rounds to check on Carol. He wasn't in charge of her hospital care which was in the hands of the attending physicians who were on staff at this hospital, but he asked that the chief trauma resident be called to see her right away.
Before the staff nurse could return to Carol's room, the senior trauma resident appeared at the bedside and started questioning me. He examined Carol while I slipped out to get her nurse who told me she would "be there as soon as she could."
Awkwardly, I waited with Carol's mother as the resident considered Carol. He wondered aloud why she hadn't gone down to the OR earlier as scheduled. I reminded him of the fever and as he listened to her lungs, I casually pointed out the petechiae, which was more diffuse across her chest now.
The resident was suddenly abrupt and to the point, it seemed he'd slapped the last piece into a puzzle. “She’s thrown a fat embolus from her fractured femur--get her to ICU stat.” Then he turned on his heel and was gone before I could say a word.
I had enough of the classroom experience in nursing to fear a pulmonary embolism (a tiny blood clot that lodges in the lungs), but I didn't have a great deal of insight into the prognosis and treatment for a fat embolus. The hours that Carol's condition had progressed undetected were haunting me. Right away I knew that Carol needed her nurse, and I needed my instructor.
It took some time to find Carol’s nurse and convince her that the resident wanted her patient transferred to ICU. She made the requisite phone calls to confirm the orders and set the wheels in motion so that the ICU would assign Carol a bed. Meanwhile, Carol's chart was nowhere to be found. It was misplaced somewhere on the surgical floor. I nervously looked for the chart while the nurse arranged for Carol's transfer.
My instructor, aware of the unfolding drama, gave me a brief suggestion, "Just help where you can with the transfer."
Carol's mother, numb with worry, was making phone calls to advise her family members of this turn of events. A sense of urgency was consuming me as I returned to Carol’s room. Carol's nurse was still on the phone making arrangements for the transfer. Suddenly the resident reappeared and scolded me. “This patient should have been in ICU already! Get her there now!!”
But no such luck . . . The nursing unit had their own procedures to follow. They set about taking a complete set of vital signs, "It's required that we do so before transferring a patient."
The nurse's aide who was trying to check Carol's blood pressure was having a hard time because, "This machine can't be right, her pressure's way too low." She went to search for a manual blood pressure cuff that affirmed the hypotensive state of the patient.
Carol’s nurse returned with a respiratory therapist who placed a pulse oximeter on Carol's cool, pale finger and advised, “She needs oxygen, her oxygen saturation is only 65%!” Her saturation should have been at least 92. The oxygen set-up for transport through the hospital to the ICU floor would have to wait for a few minutes while someone went looking for the missing key to the metal portable oxygen cylinder. The precious moments SLOWLY passed as these tasks to make Carol ready for transfer were completed.
I felt useless as the evening nurse and an aide prepared the bed for transport. “What can I do to help?” I pleaded.
“You can carry the patient’s bag of belongings and make sure not to bring her flowers, she can't have them in ICU,” the staff involved in this whole situation seemed snappy and angry. I thought it was a waste of brain cells for the nurse in charge to even think about the flowers under the circumstances. In retrospect, I'm sure I was sensing the staff's anxiety and concern, and I have to believe they all shared my frustration with the obstacles that slowed the transfer to what seemed like a crawl.
My neck flushed as we awkwardly maneuvered the Carol's bulky hospital bed into the hall and then, after all the delays, ironically took off running for the elevator leading to the intensive care unit. There wasn't enough room for all of us on the elevator. Carol's mother and I rode together on an adjacent elevator.
The small ICU waiting room was overflowing with visitors waiting to be allowed in to see other patients. I said farewell to Carol's mother and urged her to call her ex-husband to let him know what was happening.
I'd never before been through the sliding doors that isolated the large intensive care unit from the rest of the hospital. No matter, I found Carol’s room easily. Nearly every nurse in the ICU was at her bedside, hooking up monitors, taking vital signs, putting in an additional IV, preparing suction, and hanging fluids. I could see the resident doctor with his interns assembling supplies. In a few minutes time Carol would have a tube in her trachea that allowed a mechanical ventilator to breathe for her.
I layed down Carol's bag of belongings lingered in the background for a few minutes. Clearly Carol was in good hands, these nurses were calm and in control of the situation.
Suddenly my shift was over--it was time to meet my instructor and the rest of the clinical group before going home. But I was sad and miserable. I went beyond my required textbook reading that night. Fat emboli and acute respiratory distress syndrome (ARDS) consumed my thoughts. I grieved for Carol's mother and lamented that I hadn't known enough to help expedite her care that evening.
Two days later as I skimmed the morning paper, I was shocked--but not surprised--to see Carol’s photograph smiling brightly from the obituary column. I cut that little clipping out of the newspaper and pasted it into my tiny notebook of nursing tips. To this day I still carry that notebook in my nursing work bag. I guess Carol's legacy has been with me every day that I've worked as a nurse, now that I think of it.
Technically, Carol was never "really" my patient. No medication cards, flow sheets, or care plan followed me to her room that evening and my education and experience to that point certainly didn't prepare me for the gravity of her situation. Of course, ironically, it was the deepest and most vivid clinical situation I experienced as a student. I always recognized that I contributed little, but benefited much from this experience. Many of the lessons learned are so obvious that they don't bear repeating.
An obvious lesson that does bear repeating, on the other hand: never assume nor underestimate any patient's baseline mental capacity. Good communication with a responsible party who can provide definite information on a patient's usual abilities is absolutely vital so that care is not compromised or delayed in the event of important neurological changes. That's Carol's legacy to me.
All rights reserved 2009 Carolyn Cooper MPH RN
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DVT, Blood Clot, Deep Vein Thrombosis
Preventing a DVT is certainly much easier than curing the condition. In hospitalized patients several methods are used to enhance the flow of blood to the lower legs. First and foremost, being up and around as soon as possible, and as much as possible after surgery or while recovering from an illness is a major advantage in increasing venous flow and decreasing the chance of clots forming. Tight white compression stockings (TED hose) may be prescribed depending on the level of risk for the specific patient (see below). Mechanical "pumps" squeeze the lower legs at regular intervals in another means of prevention. For patients at the highest risk of DVT, blood thinning medication is injected daily under the skin of the abdomen.
Greater Risk of Clots for Some Patients
DVT (Deep Vein Thrombosis) can occur in almost anyone. However, certain individuals may be at increased risk for developing a DVT. Risk factors include but are not limited to:
- Recent surgical procedure (and greater chance of a DVT with a long, intense surgery and joint replacement surgeries)
- Restricted mobility from bedrest, paralysis, traveling for many hours without taking a break to walk around
- Active Cancer
- Congestive Heart Failure (CHF)--if you take "water pills" and are not sure why--ask your doctor if you have CHF
- Age greater than 40 years old
- Pregnancy and the postpartum period (6-8 weeks after delivery)
- Injury to the leg or the deep veins of the leg
- Smoking
- Use of certain medications such as birth control pills and estrogen
- Dehydration
- Polycythemia
- Obesity
- Current smoker
- Past history of having a blood clot or an inherited family tendency to develop blood clots
Check out their website to learn more about DVT and related conditions such as:
- Post Thrombotic Syndrome (PTS) After a DVT is treated and resolved, this chronic condition may result in up to 40% of all individuals. It's the result of damage done by the clot to the valves that move blood through the vein.
- Pulmonary Embolis (PE) Blood clots in the smallest vessels of the lungs.
- Thrombophila Blood that clots too easily. Hypercoagulability is another word used to describe this condition which can be inherited.
- Chronic Venous Insufficiency results when the valves in the veins that move blood don't function properly, often occurs from injury to veins caused by a DVT, from varicose veins, or as the result of an inherited condition.
The Vascular Disease Foundation has a variety of full-color brochures available for download including a great pamphlet called "Focus on Clots." (This publication was previously called "Spot a Clot," but otherwise it's the exact same informational card.)
You may also request a copy of these brochures by calling toll free: 1-888-833-4463.
- Vitamin K and Warfarin (Coumadin): http://www.nattinfo.org/documents/KandWarfarin(Web).pdf
- Family Testing for Clotting Disorders http://www.nattinfo.org/fam-test.pdf
- Sanofi-Aventis (makers of the blood thinner Lovenox) provides tips about DVT's, Risk Factors for DVTs, and includes a risk assessment tool.
A plus: Deep vein thrombosis article from eMEDtv.com
eMedTV.com has many wonderful patient education videos.
Here's a two-minute presentation that explains how unwanted blood clots occur in the vein and why they are dangerous from the: Heart Disease Health Channel on eMedTV.com
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