Evan's ePortfolio

When updating my profile, I chose to add some more personality to my site, including some color and bold graphics, so that it is easily readable. I love sunflowers and sunsets, which I incorporated into my homepage. I also added an About Me page, which gives future employers a summary of my clinical experience, as well as the job offer I have currently accepted and intend to start in July.

Context: This is a narrative reflection of a day on an ambulatory care unit where I experienced circumstances that challenged my team’s ability to communicate and implement timely nursing interventions.

During my first shift on the ambulatory care unit (ACU), I was assigned to the endoscopy/colonoscopy wing, meaning that I was in charge of preparing and receiving clients undergoing those procedures. When I began my shift at 6AM, I was still groggy and didn’t really know what to expect. It seemed like it might be a slow day, as the clients were told to arrive two hours before their procedure time, and we only had five clients scheduled for exploratory scopes.

When our first client arrived, I walked out to the waiting room, called the name and brought the older gentleman back into the ACU to his room. As soon as they changed into their gown, I took their vitals, which were baseline for them, as they had a history of hypertension and was a current smoker. While I was finishing up the vitals, my nurse began asking the pre-procedure questions, which consisted of confirming NPO status, getting a brief health history and assessing for ambulation or balance difficulties. They reported that their last liquid consumption had been “a beer or two” the night before. At the bottom of their past medical history, a reported 60-70 beer/week habit was indicated. My nurse silently circled her mouse around that number, telling me that we needed to be paying attention to that. She took a brief social history, and clarified the information we had with the client, asking “How many drinks do you typically have in a day?”. The client mumbled, “I don’t know… 6? 7?”

Once we had finished our documentation, we left the client’s room and sat down in the charting room to debrief. My nurse explained monitored anesthesia care, also known as propofol, would be used during the client’s EGD to provide comfort to the client. She described the dangers of consuming alcohol after being sedated and voiced her concerns about how she anticipated this being a problem for the patient after we discharged him. He seemed to be strongly dependent on alcohol, and it was doubtful that he would be able to go home and not drink a beer. 

When the client returned from the procedure, they were very sleepy; almost obtunded. They were not easily arousable and would go back to sleep immediately after responding. When we took vitals, we found that their blood pressure was very low, around 60/40, and we immediately lowered the head of the bed. My nurse also increased the drip rate of the IV to give a fluid bolus to improve their volume status. We determined that their status was probably due to dehydration. After they had recovered and their pressures improved, the first thing the client asked for was a beer.

My nurse and I did some post-procedure education for the client and emphasized the importance of avoiding alcohol for the rest of the night. They were very reluctant and didn’t seem willing to go without a beer when they got home. My nurse asked what fluids they might be able to drink at home other than beer. The client informed us that they don’t drink water at home, and only drinks beer. After more questions, they added that they sometimes drink chicken broth in the morning.

Clearly, the client had a complicated and multifaceted health history; one that required interventions outside of our scope of practice and time constraints. However, listening to how my nurse communicated with the client and asked clarifying questions in a respectful, non-judgmental way was very informative and I have definitely internalized her methods of influence in this situation. She also knew when to delegate tasks and had me get repeated blood pressures while she did documentation and alerted her charge nurse of the situation. She prioritized bolusing the patient before alerting the team, making sure she did everything she could before leaving the client’s room.

This experience taught me many things, including how to identify, anticipate and address discharge concerns, how to remain calm and task-oriented during a crisis, and how to communicate in a therapeutic and nonjudgmental manner.

During my most recent clinical rotation, I was assigned to a middle-aged man who was admitted for cellulitis and had a PICC line for antibiotic administration. I met him during his second hospitalization related to this diagnosis, as it was discovered that he was not self-administering his antibiotics at home.

This client did not have a stable job or a steady source of income, while also having three kids at home, of whom he is the primary caretaker. One of his children is severely autistic and requires constant care. He is HIV+, and has been diagnosed with T2DM, ADHD, anxiety, hypertension, and asthma. He is a current smoker and has a history of substance abuse.

I can imagine that this client is always stressed. He is a single parent with multiple health problems, poor economic stability, a high school education, and now must remain hospitalized due to an acute condition. While he was able to find transportation to and from the hospital, it sems that he’s lacking support medically, socially and emotionally at home. I think the staff at the hospital should have paid more attention to his home life and taken that into consideration before he was discharged with a PICC line and IV antibiotics. Maybe he couldn’t continue his treatment due to caretaker overload, or because he didn’t receive thorough and comprehensive education about how to administer the medications. Social work or home health could have followed up with him to make sure that he was comfortable with the regimen and staying on track with his scheduled antibiotics.

I also wish that the system had provided him with resources for his family and daughter. Clearly this patient was not going to be able to balance taking care of his medical conditions and his kids, let alone afford the treatments that he needs to stay alive on top of feeding three other people. I wish that there was a more rigid policy within hospital systems that required staff members to evaluate a patient’s home life and be able to designate resources and additional support as needed.

On a personal note, I definitely could have done more investigative work regarding the client’s mental health status, support systems and access to resources. I often feel that as a student nurse, I don’t have as much of a voice, but I know that I probably could have at least advocated for this man.