Delirium Project

The last year was spent conducting research gauging the nurses attitudes and beliefs about Delirium in our ICU patients.  I did this research with two co-workers, my charge nurse Shelly and fellow nurse Jodi.  We also had lots of help from our Clinical Nurse Specialist, Kari. 

We conducted a pre-survey, rolled out education and then a post survey to evaluate if there were any changes in their beliefs and practice.  

Surprisingly, we saw change!  The nurses are now using the word delirium, more conscious about dementia vs delirium vs another underlying problem and using the appropriate medication to help relieve symptoms of delirium.  For example, using Haldol vs Ativan.  They are also quick to mobilize their patients and try and get them out of the ICU and to the floor where it is quieter, less intrusive and closer to home!  We also saw 155 days without any falls in our unit after the education was rolled out.

One of our Trauma Surgeons, Dr. Justiniano, is a huge proponent of delirium prevention and he gave an excellent talk about delirium.  The head Trauma Surgeon, Dr. Mangram, is also very keen to treat patients over the age of 60 (and those susceptible to delirium because of age) quickly and appropriately for their age. 

In the meantime, we have presented at two conferences and won an award at one of the conferences.  Also, two days ago, we found out that we won a $10,000 grant for our research and its benefit to increasing patient safety!

All very cool things and hopefully it all keeps patients safe in the end.

1 Peter 4:9-11

These verses have really been ringing true for me in life but also in my job and service as a nurse...

"Offer hospitality to one another without grumbling. Each of you should use whatever gift you have received to serve others, as faithful stewards of God's grace in it's  various forms...if anyone serves, they should do so with the strength God provides, so that in all things God may be praised through Jesus Christ"

I know a lot of times when a call light goes off it takes me away from whatever I was doing and I definitely have an internal (and external) sigh of frustration...but I need to remember, they are usually helpless in there and can't help but ask for help in their time of need.  (now of course, there are other situations where you need to lay down boundaries and explain there are some things they can do themselves but overall, they do really need your help and aren't trying to be a "bother")

I also like how because I am using my gift God has given me i am an active and tangible part of God's grace, to me, that is a cool idea. 

When I am at work and feeling a bad attitude coming on, I remind myself of these verses and the true purpose which is so do all this so that God may be praised.

Moyamoya Disease

Took care of a patient diagnosed with Moyamoya disease which is a very rare vascular disorder made even rarer that it normally takes place in childhood so that I took care of an adult with this disease is pretty exciting. I may never take care of someone with this disease again.

Moyamoya is a Japanese word meaning puff of smoke because that is what it looks like on an angiogram showing the blockage of the arteries in the Circle of Willis and the appearance of the vessesls that have developed to compensate for the blockage (pretty cool, huh?)

So essentially, Moyamoya disease is the progressive narrowing and blockage of the arteries in the Circle of Willis which causes irreversible blockage to the carotid arteries that feed the brain. This can be fatal, obviously!

My patient had hypertension, was of Asian descent and had been experiencing continous TIA's (transient ischemic attacks). Her treatment by a neurosurgeon was creating a bypass around the blockage just like bypasses in the heart. For me, neurologically she was confused but moving everything...but it was really hard to really assess what she was saying as she didnt speak a lick of English. She was also blind from her many TIA's.

Overall, my actual interaction with the patient wasnt that interesting...it was a smooth and easy night of providing care but her diagnosis was interesting and I wanted to share and document it!

www.mayoclinic.org/moyamoya-disease

Learning to be "flexible"

"Have any of your patients died?"

"Yes, they have"

"Do they die on the floors?"

"Yes, they do...but I think I would love to be home surrounded by my own things, in my own bed, with comforts of my home when I die...not here in this cold hospital"

"I haven't thought where I want to die yet"

This was one of the conversations I had with my patient given a 4 weeks to live diagnosis. It is amazing how these death conversations aren't as hard to have as one would expect and it is needed...they need to talk and express and think through this thing of death which we all have thought about but haven't faced yet.

I was in the ICU overflow in the PACU this past week, the ICU was full of bad traumas and we needed to use the flex space for the less "critical" patients. It was a pain! Noisy, monitors we werent use too, and constantly running back to the unit for this-or-that which you didn't realize you didnt have until you needed it.

At first, I wasn't a happy camper! But by the end of my 3 days in this overflow area I realized I was blessed by my patients and I was there for a reason. I was able to truly care for these patients and let them know someone thought they were special and worthy of love. It is when you are pushed out of your comfort zone, literally, you can experience the beauty of life.

Fresh Meat...I mean New Grads!

We have hired 3 new grad nurses into our unit! Whoo! I'm not the least experienced in the unit anymore! ;) I am looking forward to working with some new nurses and encourage them on their journey and their first stressful year as a new nurse in a trauma icu like i was encouraged by my fellow co-workers.

Connections with Patients

The best times of my job are when I connect with my patients...and more importantly, when I can bring a smile to their face. Comfort, rest, peacefulness. I don't always achieve that goal...maybe as much as I try, their pain can't be controlled, the situation is too much to handle for an already anxious person, or we just dont "click". I click with almost all of my patients, but they are people too and we are all different.

This past week I had three moments with patients that bring a smile to my face as I think back on them. I wish my patients knew that they bring as much joy to my life seeing them smile as they tell me I do to them.

My patients name was "Esther"...just like my mom! I started my night out letting her know my mom's name was Esther and people are always forgetting the "H". She loved that. She had just suffered a MAJOR complication with a throat surgery so she was in pain, tired, and worried. No doubt! I was able to get her cleaned up, wash/brush hair, warm lavender lotion back rub, new gown, new linens, tuck her into bed and get her pain under control. She slept like a baby for the rest of the night. For the rest of our interaction (until I discharged her to the floor the next night) she held my hand, called me "mija"and gave me lots of kisses before she left.

My other patient was a very sick, tired and worn out Vietnam Vet (who may or may not have been homeless...either way, living on the edge of poverty for sure, so sad). He wasn't really opening up to me, I just couldn't get him to smile! Halfway through the night, my back was turned getting some medication ready for him and I must have left an alcohol swab on his covers so I see this alcohol swab sailing through the air for a basket into the trashcan...it missed. Before I turned around I said with a laugh in my voice "I saw you miss that basket!" The smile on his face when I turned around was like a kid laughing at an inside joke. We had a great two nights after that...he also was discharged to the floor my last night, which is always a good thing!

Finally, there was a chronically sick patient of another nurse that I was helping with. Just through the entire interaction his gummy smile was one of the best smiles I have seen. It brought a smile to my face and heart.

I am thankful for these moments with other human beings in my care.

Beringer White Zinfandal

Beringer White Zinfandel...whose tasting notes read "Beringer’s winemakers highlight Zinfandel’s characteristically bright, fruity characteristics to create a light, refreshing blush wine. Immediately following gentle destemming and crushing, the must (pulp, juice and skins) is quickly chilled to preserve its fresh strawberry, raspberry and orange peel aromas and flavors. Just as a slight rose hue develops, the juice is pressed off the skins and fermented at carefully controlled, cool temperatures. To impart a slightly creamy texture and round out the vibrant berry and citrus flavors with notes of pear, apple and nutmeg spice, Beringer’s winemakers blend in approximately twenty-percent barrel-fermented Chardonnay" (http://www.beringer.com/)

Ah, this all sounds very nice and can be quite enjoyable on a hot summer day or evening in Phoenix when we are living in temperatures in the 100's. And everyone knows that I enjoy a nice glass of wine and appreciate it for what it is; however, when I am at work alcohol, wine, drugs, etc are NOT tolerated, by my hospital or by me!

This all leads me into the ridiculous story I have to share about this inexpensive wine. I had a patient (who I had been warned earlier that the friends were a little "suspicious"). She was on the floor but had developed a high fever, increased HR, and decreased blood pressure and they were worried she was going septic. They wanted to watch her overnight in the ICU...give her some good 1:1 care...watch her vitals, give her fluids, antibiotics, etc. No problem. Well, around 1 am her friends start arriving (would you visit your sick friend at 1am in the morning if they were at home??) and I noticed this one kid acting really boisterous and arrogant. I go to get her antibiotic drip and when I come back I see the curtain is completely closed....uhhh....thats a no-go in here. Unless there is a reason that has been discussed with the nurse, curtains aren't closed like that in the ICU. So as I walk in, the kid tries to keep me from coming in (that wasn't happening!) and as I walk around the side of the bed to the IV pole...what do I see open on the side table?

I went from 0 to 10 immediately on the anger scale. There are so many reasons why, the first being the idea you are trying to develop trust with your patient and vice versa...well, that was a big slap in the face and out of the question now. Second, I am giving this patient IV narcotics every hour for her pain and now I have the suspicion she could be consuming alcohol? And the audacity of these people to not respect the environment they are in. Not only are you in a hospital, you are in an Intensive Care Unit! I told them it was completely inappropriate, I couldn't believe they had the nerve to bring this in and that now I am under suspicion my patient may have been drinking. It was absolutely not tolerated, they needed to leave and I escorted them out.

Guess that is just one more night in the Trauma ICU....sure this won't be my first go-around with something like this!