she's a sneaky one

i got to work in the unit the other night at work. because we had an extra person, i got to actually shadow one of the rn's around for the night and participate in care. i got to focus care on one of the patients who was stable, but still on full support vent with trach collar.

she had been in there for 2 weeks and is now a bit more alert and oriented. unfortunately for her, the icp from the trach secretions has caused her to blow out all of the vessels in her eyes. it looked horrible. and painful, to me anyhow. so they were trying to d/c her soft wrist restraints (which are needed for most people on a vent who can be alert at times to prevent them from pulling out the tubes). her ativan drip kept going off as occluded.. i was told that with a drip only running at 5 cc/hr or if even at kvo, it can sometimes just not be enough to keep the line patent. we flushed the line... and she taught me that when flushing the cvc, to use positive pressure rather than just straight pushing. after that was finished, we decided to check her residual on her tube feeding and do the flush while we were in there. she had explained to the patient about trying to keep the restraints off while i was doing the flush. got her all straight in the bed and walked out. it wasn't 2 minutes later that she was trying to get up in the bed and had her feet half off of the bed. the nurse cut the light on, we got over there to get her back up when we noticed that her feeding tube had come out. i hurry up and shut it off so we don't have a huge mess, then go and get a new tube to put in while the nurse gets her straight back in the bed. lucky for me.. i get to put in the new ng feeding tube, which went so very well. no resistance, no coiling up in the back of the mouth.. straight on in. it was beautiful. and she was pissed. she was not a happy patient. i can understand... i wouldn't want all those tubes in me either. we just had to keep reminding her that it takes time to come off of all of this stuff and right now it was helping her. she finally took a good nap once her ativan started kicking back in. and we were able to leave the restraints off.. until she woke up.

she starts moving around in the bed again. i go in there, and she is very restless. i calmly but firmly tell her she cannot get up. help get her moved back in the bed. she keeps making a face at me and i can tell something isn't right. so i ask her if she is in pain. she shakes her head no. she burps and makes that face. the one that looks like move it.. vomit coming soon. i ask her if she feels like she is going to vomit. she shakes her head yes. in the meantime i am steadily keeping her hands down from pulling on her trach. i really didn't want her to pull it out. so i hook her hands up and go tell the nurse, who is in with another patient, that mine is nauseated. see they teach you in school (which i am sure this is common knowledge to all nurses, or it should be) that vomiting + intubation/trach/etc = aspiration. which is bad. so she is nauseated.. and i cut off the feeding. residual is 0. we assess and think it is probably just gas causing the nausea as her bowel sounds are hyperactive. since she cannot talk, we unhook her hands again so she can point to where the discomfort is. she points to her belly. responds yes to the pain question this time. she is actually cooperating quite well. then she wants to pull her hands up to her head again. the nurse says, "let's just see what she is going to do." she asks the patient, "do you want to scratch your nose?" she shakes her head yes. so we let her. she moves her hand ever so slowly up to her nose and then with the speed of lightning grabs that ng tube and starts pulling. what she didn't realize was that the nurse was ready for that and grabbed it at the tip of her nose and kept it in place. i giggled a bit and told her she couldn't take out the tube and pried her hand from around it. and so we hooked her back up, gave her some demerol for her pain, & let her sleep for a few more hours.