Who's Caring For You?

By Sherry Shaffer Ratajczak

Do you really know what a nurse does?

All nurses, not just critical care nurses, have tremendous knowledge and skills that are not well known, not well understood, and not well recognized. This book explores all that nurses do on a regular basis.

Sherry Shaffer Ratajczak, who has worked as a nurse in different settings for more than forty years, answers questions such as:

How do you choose a nurse education program?

What is it like to work in an intensive care unit?

Why should you be aware of compassion fatigue?

What does it mean to be critically ill?

She also highlights new technology available to nurses, daily routines that every nurse must master, cases of infant abuse, and the stressors that caregivers must overcome.

If you’ve ever thought about becoming a nurse and want to know how to thrive in the field, this book will be a valuable resource that you’ll consult for years to come.

• Language: English
• Publisher: Archway Publishing
• Release date: Mar 19, 2024
• ISBN: 9781665756433

Sherry Shaffer Ratajczak

Sherry Shaffer Ratajczak has been a nurse for over forty years. She was a diploma-educated nurse in an intensive care unit, served in critical care settings for many years, and was a nurse manager of a neurosurgical ICU and a renal transplant unit. She completed a baccalaureate degree in nursing then a master’s degree in nursing management. She has worked in teaching, publishing, and has also worked as a primary care pediatric nurse practitioner.

Book preview

THE NEW ADMISSION

It was a state-of-the-art Intensive Care Unit (ICU). It was small—only five beds, with four in a row in an open section and the fifth a private room. This private room was to be used (hopefully) to contain any highly contagious pathogens that a patient might have and stop the spread to other patients. Sepsis, for example, has a high mortality rate. The unit had all the new technology in place to provide excellent care to critical care patients.

One new technology—the pulmonary artery catheter—was being used to monitor cardiac hemodynamic information. Originally referred to as the Swan-Ganz catheter (after its creators), this catheter had only been available for about the past sixteen months. The trauma fellow, Doctor Jakoby, was in training for trauma. Being a fellow meant he’d already completed his internship and residency and was now taking an extra year to become an expert in managing critically ill, trauma patients. Dr. Jakoby was brilliant and pretty much lived in the unit. He was always there, monitoring cardiac, pulmonary, gastrointestinal, and other organ system information on patients to provide best-practice treatments and interventions. It was exciting to be a nurse in this unit. State-of-the-art ventilators and all the stocked supplies we’d need to care for critically ill patients were here.

It was rare to have an empty bed. We started the night shift with four patients, all of whom were in the open section. That night, it was the private room that had the available bed, and we’d just been notified an admission was in the emergency room and would be coming up shortly.

Kenny had been admitted to the Emergency Department (ED) in the evening. He was a heating, ventilation, and air conditioning (HVAC) repairman. While working on a furnace, something happened and hot air was released. The owner was home, but he told her he thought he was okay, and he’d be back the next day to finish. It was his last job of the day and he went home.

He didn’t think much of the event. He saw that his face was red and knew it was burned, but it was similar to a sunburn. He wasn’t too concerned, until a bit later when he started to have trouble breathing. His wife drove him to the ED.

The ED staff stabilized him, started diagnostic testing—blood work, chest X-ray—started two IVs, dosed him with an antibiotic, and gave him some intravenous morphine. Morphine is a great drug when used appropriately. It makes it easier to breath, helps to manage anxiety, and provides pain relief. He had all of these physiologic responses, and he responded appropriately to the morphine.

Kenny was sent up to the unit around ten that night. The evening shift nurse tried to do an admission assessment. Her questions were briefly answered, but he was short of breath, so a full patient interview was deferred. The nurse did complete a physical assessment and documented this in the chart.

The patient was alert and shook his head no to having any drug allergies, past surgeries, and any significant medical history issues. Between breaths, he said other than some mild high blood pressure (BP), which he was managing with one antihypertensive drug, he was in good health. He said (again, between breaths) he was trying to lose weight, but that wasn’t going so well. He smiled. He was in his late thirties and worked full time in HVAC. He nodded in the affirmative when asked if he felt his general, overall health was good.

At eleven, the night shift started. I obtained his vital signs: BP, heart rate, respiratory rate, and temperature. His temperature wasn’t elevated beyond 99.4 degrees Fahrenheit, so that meant we could check it every two hours. Everything else we would check hourly. His heart rate was just a tad above the normal range, about 114 beats per minute (normal is considered 60 to 100 beats per minute), but he was anxious and had some pain. The heart rhythm wave itself was normal in formation, just a bit faster rate than the normal range. His breathing was about twenty-four breaths per minute, so above the normal range.

Kenny was alert, but not talking much. His heart rate and respiratory rate were checked hourly and were slowly creeping up. By four in the morning, he was having about twenty-eight to thirty breaths per minute. His heart rhythm was still normal morphology, but his heart rate, too, was slowly creeping higher to 122 beats per minute. I asked if he needed anything, and he shook his head no. I told him I’d be here with him—literally staying in his room to monitor him. Originally, there were only two registered nurses (RNs) on the night shift because the unit had only four patients. However, the night shift supervisor pulled a licensed practical nurse (LPN) to help us once we received Kenny from the ED.

And then it was 5:00 a.m. It was time to start thinking about preparing for the day shift, scheduling patients for any off-unit testing, and preparing them for those tests. The night shift readied patients for the day shift. The day shift readied patients for the evening shift. The evening shift readied patients for the night shift.

Kenny’s face appeared a bit puffy and stayed red—like he had been on the beach and got a sunburn, which is actually a first-degree burn. That’s what he had: an actual first-degree burn. He was awake but not talking much because he was breathing faster than normal. He was aware of what was going on.

He was on oxygen by nasal cannula (that little plastic tubing that goes under the nose). His two IVs were providing fluids. An arterial blood gas (ABG) test, which provides information about oxygenation in the blood, had been obtained in the emergency department when he was admitted. Dr. Jakoby repeated the ABG at 4:00 a.m. and noticed Kenny’s carbon dioxide level was dropping, which aligned with his increased respiratory rate. There was no pulse oximetry (finger probe) to monitor a patient’s saturation of oxygen in the red blood cells because this technology wasn’t available in the United States until 1980. Monitoring pulse oximetry did not become part of the standard of care until 1987. We monitored his vital signs, watched his cardiac rhythm, listened to his lungs, and watched his chest movement to assess how much effort he was using to breathe. His effort to breathe was increasing, so I elevated his head of bed.

Many of the IV drugs ordered for ICU patients have dosages that are weight based, which is why it’s so essential to assess the patient’s weight every day. This way, if weight-based drug dosage adjustments were needed, or new drugs were added, a current weight would be figured into the calculation to provide an appropriate, patient-specific dosage.

Since one of the duties the night shift performed every morning between 5:00 a.m. and 6:00 a.m. was to weigh patients, we had to weigh Kenny. Weighing a critical care patient was a two-person job. It required placing the patient on a sling. The sling was then connected to an apparatus that would elevate the patient off the bed. Once lifted, then the weight was obtained. Today, scales are integrated into the beds themselves. Before such better bed technology existed, one night shift nurse needed to stop what he or she was doing for the patient(s) and help you with yours. Because all of the patients had to be weighed, the nurses worked together down the line to weigh all the patients. Sometimes we were lucky and had a medical student or resident on nights who would help us. Usually, the nurses did this job.

Patients were log-rolled: one nurse put the sling under the patient, then the patient was rolled to the other side, and the second nurse pulled the rest of the sling through. Then the patient was turned onto his or her back and the sling was connected to the scale mechanism. Once in the sling, the patient was lifted up so the weight could be obtained; the patient had to be fully off the mattress.

The dynamics of the procedure were made more difficult because patients typically had so much paraphernalia. They usually had multiple IVs: one or two in an arm vein and then another multiple-port IV in a larger vein (the subclavian or jugular veins were typically used). ICU patients were attached to ventilators and cardiac monitoring systems (cables with multiple wires attached to those sticky patches on a patient’s chest that provided the cardiac rhythm on the monitor). They might have multiple drainage tubes and indwelling urinary catheters that drained into a urine collection bag.

Nurses were always careful when weighing a patient. We worried when it came time to roll the patient onto the weight sling because even something that seems so easy was a delicate and precise job because of all the paraphernalia critical care patients have. As the patient’s nurse, you had to be sure nothing became dislodged or disconnected. Each of these items was part of a composite supporting that patient’s life.

Once on the sling, the patient was raised off the bed and was essentially floating above the bed. The other reason the nurses were cautious was because the patient’s paraphernalia also had to be off the bed had so it would not become part of the weight. A distorted, incorrect weight could negatively impact weight-based drugs being delivered to the patient. For the few patients who were awake and aware, this procedure was anxiety producing and a bit unnerving. Some were fine with this procedure after the first time.

Once the weight was determined, the sling was lowered to the mattress, and the patient was again turned side-to-side. When on one side, the sling was rolled und tucked under as close to the patient as possible. Then the patient was turned to the other side and the sling was removed. The patient was made comfortable.

Kenny’s wife, Loretta, came early, just before six in the morning, to see him. We told her he’d done okay through the night, that he was still short of breath, so his breathing rate and heart rate were a bit elevated, but he was alert. Then we asked Loretta to step out of the room for a couple of minutes so he could be weighed. Calvin, the other nurse, reassured Loretta it wouldn’t take long—just a few minutes—and then she could come back in the room to be with her husband.

Calvin, will you grab the scale? I’m ready to weigh Kenny now.

Calvin brought in the scale and we began the process of weighing him. When we first turned him, he was facing Calvin, so I could coordinate putting the sling under him and confirm that all Kenny’s tubes were intact. Calvin had a hold on him and was talking to Kenny, reassuring him because this was Kenny’s first experience being weighed in a sling apparatus. Kenny nodded ever so slightly that he understood.

Within seconds, I heard Calvin say, Kenny? I looked at Calvin and saw the look that critical care nurses know indicates there’s a serious problem.

Calvin looked at me and said, He’s not responding. One of us yelled code into the larger ICU space as we put Kenny on his back.

I was twenty. I was not quite a full year out of nursing school and was so excited to be a RN, a registered nurse. Not only that, but I was an ICU nurse in a state-of-the-art critical care unit in a major city. Students could choose their final clinical experiences as they would, ideally, continue to prepare them for the real world of nursing. I chose this unit so my transition from student to ICU nurse flowed nicely.

Being twenty years old, I couldn’t yet legally drink. Because of when my birthday fell, I’d not been able to vote when the voting age changed to eighteen years old. However, this patient was coding, and it was my job to begin measures to save his life. Calvin ran for the code cart and I started CPR.

The trauma surgeon was already in the unit. He never left the unit once Kenny came into the unit. He was brilliant and truly cared about the patients. He was there when the patient was weighed and was immediately there to help with the code.

CPR went on as