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Clinical Assignment Nov.27th-Dec.3rd

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1 Clinical Assignment Nov.27th-Dec.3rd on Mon Dec 05, 2011 6:50 pm

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12/05/2011 Michael McDonald
Clinical Assignment Nov. 27th -Dec. 3rd

This past week, one of my patients had fallen of off a ladder and sustained a left comminuted fracture of the ankle. He was in his early 40’s, with a history of fibromyalgia and neuropathy and anxiety. He was trying to repair a spotlight when he fell from his ladder, the impact causing the fracture. He was a chronic pain sufferer with prescriptions for oxycontin, Xanax, and Methadone. Therefore he was in a lot of pain from the fracture and the Dilaudid PCA was not enough to keep his pain under control. Every time I went in to check on him, I asked about his pain, and he always replied 11/10. His PCA history showed 49 attempts, and only 9 administered, from a period of 0800 to 1030 when they were able to take him to surgery. I often found myself at a loss as to what to say to him. He was in so much pain, and the Dilaudid was making him loopy. Fortunately, I had already read Marcus’ chapter on not saying “I understand how you feel.” I’m not sure I would have said that, but it crossed my mind to not say anything like it. I really and truly felt helpless, he had medication, we tried to reposition him, and nothing really seemed to help. I was hard up to find the right thing to say to him. In the end I tried to communicate that I understood he was in pain, and kept checking on when he could go to surgery. That seemed to help, knowing that surgery was close and people were working on relieving his pain.
Sometimes in clinical, I have reported to the primary Nurse on the wrong patient and have to back up and correct myself. Sometimes, I have just started in on talking about a patient, not giving a name or room number, and the Nurse has to stop me and clarify. Also there have been times when I have information, but have not been quick enough in reporting it. All have been learning experiences, especially because it is embarrassing to mess up in these ways.
Two experiences with patients who did not want me around come to mind. The first was a patient who was Post-Op for a laparoscopic appendectomy. When I first went in to see him in the morning, he told me my cologne (I wasn’t wearing any, at all) was making him sick on his stomach. I tried to cover my body with a yellow gown, but the patient eventually requested that I not be in his room. I was a little upset at this, but what the patient wants and needs has to come first. My other experience was a elderly gentleman with dementia, during the course of 0800 vitals, I discovered that he had soaked his bed with urine, and the CNA and I were trying to clean him up. He emphatically did not want anyone near him, touching him, or talking to him. With the help of his family, we eventually got him cleaned up and as the morning wore on his aggressiveness wore off.

Hirschsprung Disease
1. Assessment: Failure to pass meconium in 1st 48 hours.

2. Assessment: Abdominal Distention

3. Assessment: Bilious vomiting.

4. Medical Management I/R: Monitoring for infection. Because the bowel is not moving as appropriate, the megacolon could rupture and peritonitis could set in.

5. Medical Management I/R: Maintaining hydration. Because the bowel is not optimally functioning, water absorption may not be adequate.

6. Medical Management I/R: Managing pain. Very painful for the child, providing pain relief will help with overall comfort, and this sets up a more conducive healing environment.

7. Pre-op Surgical management: Clear fluids the day before surgery. This makes sure the bowel and stomach contents are emptied, for anesthesia and surgery

8. Pre-op Surgical management: Maintain IV access. This will help establish good pain control and hydration, along with eventual induction of anesthesia.

9. Pre-op Surgical management: Possible rectal irrigations. This will further help to evacuate the bowel before surgery.

10. Post-op Surgical management: Maintain IV fluids and nasogastric tube. This will be necessary to hydrate the patient and possibly administer medications.

11. Post-op Surgical management: Monitor intake and output. Both urine and eventually stool. This will give an indication of the homeostasis of the body.

12. Post-op Surgical management: Administer pain medications as prescribed and monitor VS. Comfort promotes healing, so controlling pain is of utmost importance. Monitoring VS will help with catching possible complications.



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