Well, I have finished week one of my practicum, and I must say, it started off on a most positive note. I wasn't sure what to anticipate initially, but my preceptor was fantastic at communication even before we met, so that made this transition process a lot easier.
Day one was spent in the ICU, and it was initially scary, realizing how critically ill our patients are, the sounds of venilators everywhere, and me having no ICU experience. However, my preceptor gave me a piece of practical advice, which set my heart at ease: Assessments are the same whether you are in the ICU or on a less critical unit. Look at the patient as a whole, evaluate their needs, and treat accordingly. With that, our day began with two patients: One had an anoxic brain injury due to a respiratory/cardiac arrest in December. He was young, and it was evident that he would not ever be returning full-functioning capacity. There were no voluntary movements, his Glasgow coma scale was 6 (anything below 9 indicates a coma), pupils were nearly non-reactive. It was a tragic case, and as I looked at the photograph at his bedside, taken not too long ago, I saw what once was a vibrant, healthy man. Before me was a patient with a blank stare, completely dependent on the care of others. However, as I've learned in school, just because a patient is deemed comatose, that doesn't mean that she was incapable of hearing what we were saying, and so with each intervention, my preceptor and I were conscious to tell the patient what we were doing. He later received a tracheostomy for continuance of respiratory care, but his secretions were so copius, even with the administration of anticholingerics, which aid in drying up said secretions. It definitely was a case that caused me to stop and evaluate the sanctity of human life, and what makes a person "alive".
Our second patient was a post-operative abdominal aortic aneurysm repair, who was recovering well physically, but emotionally was fragile, recalling the series of events that led to her emergent surgery. Chest pain had begun acutely immediately after a shower days prior, and he described a pain that was severe and non-relenting. Her husband had brought her to the emergency department, and per the patient, some time passed, as staff had ruled out a heart attack, but during a CT scan, it was identified that the patient had a dissecting ascending aortic aneurysm (read: EMERGENCY!!!) Post-operatively, the patient had some delirium, self-extubating, but the patient was heavily reflective upon her emotional trauma, so she and I spent some time conversing throughout the day, having a healthy therapeutic conversation about her experience and recovery. She had wonderful social support through her family, and would soon be transitioning to a step down unit.
Day two, my preceptor and I floated to the intermediate care unit. Our patients weren't especially heavy; two admitted for cervical spine fusion, and an elderly patient with diverticulitis, with a long history of heart failure, COPD, chronic kidney disease and a recent acute kidney injury, due to dehydration. Initially, when the patient had been admitted, he was hypovolemic, then inadvertently fluid-overloaded, but as his time in the unit progressed, the attempts to diurese him were unsuccessful; he had a poor urine output, with only 25-50 ml's out, every few hours, resulting in about a total of 100 ml's for the day. He had expiratory wheezes, dyspnea, no appetite, poor intake, tachycardia....clinically, he was not looking well, and a palliative care conference was planned for this weekend.
I had the opportunity to watch a heart echo, and afterwards, the technician showed me some prior cases of his that were definitely beneficial to my learning. I watched the heart valves opening and closing, and for the first time, was able to finally visualize what blood flow looks like; suffice it to say that it was an incredible learning experience. The technician also showed me an echo from a patient that had recently been in the ICU, admitted with a pulmonary embolism. In addition to his PE's, a clot from a DVT had also broken off into his heart, and, during the echo, the clot was seen, literally seen floating around the heart! Granted, as the tech explained, at that very moment, the patient was unconcious, intubated, and had multiple doctors surrounding him, attempting to save his life. Perfect time and place, for a patient with a clot in his heart, if one must have such an event happen. The imaging was unbelievable!
I'm really enjoying this experience and look forward to my development as a future nurse. I've already had an opportunity to place a dobhoff feeding tube, started an IV, and medication administration without being watched; which is a new, and exciting freedom. I am hopeful to gain more confidence in my patient care, especially when auscultating heart and lung sounds. I look forward to my continual development in patient care, managing multiple patients at once, providing total patient care. After graduation, I would love to be placed in a new grad nurse residency program, so my preceptor is helping to facilitate that by introducing me to managers on each unit. It is wonderful, and I am so thankful.
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