{"id":644,"date":"2023-12-04T10:27:25","date_gmt":"2023-12-04T15:27:25","guid":{"rendered":"https:\/\/pressbooks.bccampus.ca\/dcbiol2200\/chapter\/3171\/"},"modified":"2023-12-04T10:27:25","modified_gmt":"2023-12-04T15:27:25","slug":"3171","status":"publish","type":"chapter","link":"https:\/\/pressbooks.bccampus.ca\/dcbiol2200\/chapter\/3171\/","title":{"raw":"Day 3: Medical unit","rendered":"Day 3: Medical unit"},"content":{"raw":"\n
\n

Day 3<\/h2>\n<\/div>\n
\n

Time: 07h00<\/h3>\n<\/div>\n
\n

Place: Medical Unit<\/h3>\n<\/div>\n
\n\nTracie walks slowly up the walkway behind a patient in a walker entering the hospital. She remarks to herself, \u201cWow. My third dayshift. I didn\u2019t think I would miss the changeover time to nights.\u201d<\/span>\n\n<\/div>\n
\n\n \n\n\u201cHere, let me get the door for you,\u201d Tracie says as she opens the door for an elderly patient who then asks directions to the Ultrasound Department. Tracie points him in the direction of the Diagnostics Department and explains that he can follow the blue line right to the check-in desk.\n\n<\/div>\n
\n\n \n\nTracie turns in the opposite direction and enters the elevator that takes her to the seventh floor. The doors open, and she is greeted with the familiar disinfectant smells. Walking quickly to the staff room, she shrugs out of her coat and puts on her duty clogs. Looking in the mirror, she moves errant strands of hair behind her ears and runs her hands over her uniform. \u201cI guess I\u2019m ready. Let\u2019s go see if anything has changed overnight.\u201d\n\n<\/div>\n
\n\n \n\nWalking out of the staff room to the main nursing station, Tracie finds Jim finishing off his night\u2019s charting.\n\n<\/div>\n
\n\n \n\nJim looks up. \u201cWow, I am glad to see you.\u201d\n\n<\/div>\n
\n\n \n\n\u201cOkay, that answers my first question. I have the same assignment as yesterday?\u201d\n\n<\/div>\n
\n\n \n\nJim smiles. \u201cYes, you do. I asked specifically to keep you with the same group of patients as you know then and it will provide some consistency.\u201d\n\n<\/div>\n
\n\n \n\n\u201cAre you ready to hand over to me?\u201d\n\n<\/div>\n
\n\n \n\n\u201cJust give me a minute to finish this last note and chart my meds that I just gave to Room 5. It has been very busy, and I have not really had a chance to sit down all night.\u201d\n\n<\/div>\n
\n\n \n\n\u201cOk, I am going to grab a glass of water. I\u2019ll be right back.\u201d\n\n<\/div>\n
\n\n \n\nA few minutes later, Tracie sits down beside an obviously exhausted Jim to get the handover report.\n\n<\/div>\n
\n\n \n\n\u201cWhere to start? Let\u2019s start with Ms. Miki Huang if that is okay?\u201d\n\n<\/div>\n
\n\n \n\n\u201cSure. I am hoping she had a quiet night.\u201d\n\n<\/div>\n
\n\n \n\n\u201cYes, she had a better night than her roommate and some of the other patients on the floor. Last night we needed to adjust her oxygen up as her sats went to 90% and even dropped further with movement. The RTs saw her a number of times but elected not to do an ABG at this time.\u201d Jim points at the vital signs flow sheet. \u201cHer heart rate, temp, and BP are up slightly from what you recorded yesterday. Ins and outs are even balance. She is due for lab work this morning, a CXR and potentially an ABG, especially if you can\u2019t decrease her oxygen.\u201d\n\n<\/div>\n
\n\n \n\n\u201cIf I remember correctly, the Physio will also assess her. Is she still on IV antibiotics?\u201d\n\n<\/div>\n
\n\n \n\n\u201cYes, it\u2019s only day two and we have no results from the sputum sample in the system. We could be changing them tomorrow if we get the culture\/sensitivities then. Her next antibiotic is due at 10h00 and she has some other meds at 08h00.\u201d\n\n<\/div>\n
\n\n \n\n\u201cGreat, who is next?\u201d\n\n<\/div>\n
\n\n \n\nJim then goes through the rest of the patient assignment.\n\n<\/div>\n
\n\n \n\nLeaning back in his chair, Jim rubs his hair through his closely cropped hair. \u201cThat\u2019s it for me. I\u2019m going to change into my gear and cycle home in time to take the kids to school. Any questions?\u201d\n\n<\/div>\n
\n\n \n\n\u201cNope. Have a good sleep.\u201d\n\n<\/div>\n
\n\n \n\n\u201cSee you tonight. I\u2019m scheduled to come in.\u201d\n\n<\/div>\n
\n\n \n\n\u201cAwesome.\u201d\n\n<\/div>\n
\n\n \n\nJim walks quickly to the staff room and then disappears through the door. Meanwhile, Tracie takes a quick look through her patient chart to plan her priorities for the day.\n\n<\/div>\n
\n\n \n\n\u201cBed 5 is ready for discharge, so should be okay for the next little bit. Beds 6 and 7 had a rough night. I will see them and then be off to check on Ms. Huang.\u201d\n\n<\/div>\n
\n\n \n\nSighing a little as she stands, Tracie heads off to Bed 6.\n\n<\/div>\n
\n

Time: 08h15<\/h3>\n<\/div>\n
\n\n\u201cGood morning Ms. Huang, how are you doing? Good to see you too, Linda.\u201d\n\n<\/div>\n
\n\n \n\nTracie looks towards Miki and sees a very sleepy elderly woman. \u201cWow, she looks like she has aged even more since yesterday,\u201d she thinks to herself.\n\n<\/div>\n
\n\n \n\nMiki looks up and attempts to say something, but it comes out as \u201cArgg argg.\u201d Her voice is muffled by the mask and the sound of the bubbling from the humidifier.\n\n<\/div>\n
\n\n \n\nLinda frowns, \u201cWhat\u2019s that, Mom?\u201d\n\n<\/div>\n
\n\n \n\nTracie also furrows her brow. \u201cHmm, that doesn\u2019t sound right,\u201d she mutters to herself.\n\n<\/div>\n
\n\n \n\nShe pulls the vital sign machine up to the bedside and hooks Miki up. Immediately, she notes that Miki\u2019s oxygen saturation is down again to 90%, then thinks to herself, \u201cOkay, I am going to have to call the RT. May need to adjust her FiO2.\u201d About a minute later, the machine beeps and the vitals are displayed on the small screen. Tracie records them on the vital sign flow sheet.\n\n \n\n\n\n\n
Day: 3<\/strong><\/td>\nPulse Rate<\/strong><\/td>\nBlood Pressure<\/strong><\/td>\nRespiratory Rate<\/strong><\/td>\nTemperature<\/strong><\/td>\nO2 Saturation<\/strong><\/td>\n<\/tr>\n
Time: 08h00<\/strong><\/td>\n96<\/td>\n170\/90<\/td>\n22<\/td>\n36.5\u00b0C<\/td>\n90% on FM<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n
\n\n \n\n\u201cMs. Huang, I am going to listen to your lungs and heart.\u201d\n\n<\/div>\n
\n\n \n\n\u201cMom, she\u2019s just going to check your lungs and heart, okay?\u201d Linda translates.\n\n<\/div>\n
\n\n \n\nMiki nods her head, \u201cI do feel really tired though.\u201d\n\n<\/div>\n
\n\n \n\nTracie places the stethoscope in her ears and bell against Miki\u2019s chest. She quickly moves the bell around her chest in a systematic manner. Standing up straight and stretching her arms out after leaning over the bed, she thinks, \u201cThere seems to be slightly coarser sounds mid to lower field bilaterally. A few wheezes on expiration. Heart sounds are normal.\u201d\n\n<\/div>\n
\n\n \n\n\u201cMs. Huang, I am going to give you some Ventolin and ask the RT to come and see you to make sure you are on the right oxygen setting.\u201d\n\n<\/div>\n
\n\n \n\nMiki doesn\u2019t react to this, but Linda nods worriedly and tells Tracie that her mother is very tired.\n\n<\/div>\n
\n\n \n\nTracie heads over to the nursing station and asks the unit coordinator to page the RT for her.\n\n<\/div>\n
\n\n \n\nA few minutes later, the RT, Herman, calls back.\n\n<\/div>\n
\n\n \n\n\u201cHey, this is Herman; I am the RT covering the floors today.\u201d\n\n<\/div>\n
\n\n \n\n\u201cThank you for calling back so quickly. Did you get the report on Ms. Miki Huang?\u201d\n\n<\/div>\n
\n\n \n\n\u201cShe\u2019s the lady on the seventh floor with pneumonia and COPD, and on high flow face mask?\u201d\n\n<\/div>\n
\n\n \n\n\u201cYes, that is Ms. Huang. This morning when I assessed her, she mentioned being pretty tired. Sats are around 90%, RR is up slightly along with HR and blood pressure (BP). Breath sounds are a bit coarser in the lower fields with wheezes on expiration in the upper. I have just started her on some Ventolin. I am not sure about adjusting her FiO2 further or whether her COPD is getting worse which is causing her to feel tired. There is an order for an ABG if there is a change in patient\u2019s condition. I would like you to come and see her.\u201d\n\n<\/div>\n
\n\n \n\n\u201cSounds like I should pop up there. I am seeing a patient on the fourth floor right now and titrating his oxygen. Can you wait about 10 minutes?\u201d\n\n<\/div>\n
\n\n \n\n\u201cI can. I am pretty sure Ms. Huang will be okay as well. I will recheck her saturations after the Ventolin treatment.\u201d\n\n<\/div>\n
\n\n \n\n\u201cThat\u2019s an excellent idea, I will be up as soon as I can.\u201d\n\n<\/div>\n
\n\n \n\n\u201cThanks.\u201d Tracie hangs up the phone. Pushing back the loose strands of hair behind her ears, she stands up and heads down the hallway again to Ms. Huang\u2019s room. Entering the room, she finds a very tall, fit, woman leaning over the bedside of Ms. Huang.\n\n<\/div>\n
\n\n \n\n\u201cCan I help you?\u201d Tracie asks.\n\n<\/div>\n
\n\n \n\n\u201cHi, my name is Gladys. I am a Physio student doing a preceptorship, and Ms. Huang\u2019s name is on our list of patients to see today. I thought I would come by and see Ms. Huang to see what physio she needs and then plan a time to come back to do physio with her.\u201d\n\n<\/div>\n
\n\n \n\n\u201cOh, okay. Sorry, I didn\u2019t see your name tag. My name is Tracie, and I am the nurse caring for her. I don't think this morning is a good time. Ms. Huang\u2019s oxygen saturations are down a bit and her breath sounds are a bit coarser than yesterday. Last night she required an increase in her FiO2.  She has been complaining of feeling tired and seems a bit sleepier than usual.\u201d\n\n<\/div>\n
\n\n \n\nGladys looks down at Miki, who is propped up with a few pillows at 45 degrees.\n\n<\/div>\n
\n\n \n\n\u201cTracie, would you have a few minutes to help me reposition Ms. Huang? I think I can help improve her saturations with better position for expansion and maybe lead her to do some deep breathing exercises and coughing exercises to help move her secretions out.\u201d\n\n<\/div>\n
\n\n \n\n\u201cI can help.\u201d\n\n<\/div>\n
\n\n \n\n\u201cOkay, I am just going to get a bolster. Can you find a couple more pillows for me?\u201d\n\n<\/div>\n
\n\n \n\n\u201cYes, I think so. There is always a shortage of pillows. Most are like placemats, and patients are always hoarding them as one is never fluffy enough.\u201d\n\n<\/div>\n
\n\n \n\nGladys smiles and moves out the door to the storeroom to find a bolster.\n\n<\/div>\n
\n\n \n\nA few minutes later, both Gladys and Tracie are standing together at the end of the bed looking at Miki, who stares back cautious.\n\n<\/div>\n
\n\n \n\n\u201cOkay Gladys, what are we going to do?\u201d\n\n<\/div>\n
\n\n \n\n\u201cI would like to position Ms. Huang more upright in bed with her arms resting on pillows on the overbed table. I am not familiar with these beds, but I believe we can move the foot of the bed, so Ms. Huang is in more of a sitting position?\u201d\n\n<\/div>\n
\n\n \n\n\u201cSounds good; let\u2019s get started.\u201d\n\n<\/div>\n
\n\n \n\nThroughout this exchange, Linda is not present, and Miki is growing increasingly anxious. As much as she hates admitting it, she is reliant on her daughter now more than ever. Sure, at home Linda took care of Miki\u2019s physical needs, but ever since they got to the hospital, Linda also took over anything related to communication. \u201cIf only I had tried harder to learn English in the past,\u201d Miki thinks to herself wistfully, and not for the first time since she arrived either.\n\n<\/div>\n
\n\n \n\nNow, in bed, she feels completely in the dark about what the doctors want to do with her. What if it hurt? What if something went wrong? Where was Linda when she needed her most? Miki notices Gladys gesturing towards her, seemingly trying to demonstrate what they wanted to do. Miki only grips the bed railing tighter.\n\n<\/div>\n
\n\n \n\nBoth Gladys and Tracie work together to move Miki into a chair-like position while in bed. They place the bolster at Miki\u2019s back to ensure correct body alignment. After positioning Miki, both step back to admire their work, but Miki\u2019s heart is pounding rapidly. Was that it? Did they only need to adjust her position?\n\n<\/div>\n
\n\n[caption id=\"attachment_5796\" align=\"aligncenter\" width=\"2560\"]\"Miki Day 3 - While wearing a breathing mask, Miki is placed in a position by the respiratory therapist and nurse. Image created by Sarah Pinault under a CC-BY-NC license<\/span>[\/caption]\n\nJust then, Linda returns from the bathroom. \u201cOh, hi there. What\u2019s happening?\u201d\n\n<\/div>\n
\n\n \n\n\u201cI\u2019m going to check Ms. Huang\u2019s vitals again to see if this movement helped. I\u2019ll go get the machine to do that.\u201d\n\n<\/div>\n
\n\n \n\n\u201cI am going to see if I can get her to deep-breathe and cough. Maybe moving or clearing those secretions will help.\u201d\n\n<\/div>\n
\n\n \n\nGladys moves closer to Miki. \u201cOkay, Ms. Huang, I want you to take a deep breath.\u201d\n\n<\/div>\n
\n\n \n\n\u201cTake a deep breath, Mom,\u201d Linda instructed.\n\n<\/div>\n
\n\n \n\nMiki takes a week breath in through her mouth. \u201cThat\u2019s great. And now breathe out.\u201d Miki coughs weakly.\n\n<\/div>\n
\n\n \n\n\u201cThat is very good Ms. Huang. I want you to take a slow deep breath to the count of three, then breathe out to the count of three.\u201d Gladys demonstrates what she is asking.\n\n<\/div>\n
\n\n \n\nMiki understands that she\u2019s imitating what she wants and nods her head. \u201cOkay, breathe in, 1, 2, 3. Hold. Breathe out 1, 2, 3. Very good.\u201d Miki begins coughing and makes frantic motions with her hands to remove the O2 mask. Gladys removes the mask and hands a tissue to Miki. Miki coughs a moderate amount of green sputum into the tissue.\n\n<\/div>\n
\n\n \n\nBehind them, Linda winces, but Gladys is happy. \u201cThis is exactly what we want to see! Let\u2019s do the breathing and coughing exercises some more and see if we can clear your lungs a bit.\u201d Gladys then leads Miki through five more deep breathing and coughing exercises with Linda\u2019s assistance. At the end of each deep breath, Miki coughs out more greenish\/yellow sputum.\n\n<\/div>\n
\n\n \n\nAt the end of the fifth attempt, Tracie walks into the room with the vital sign machine. \u201cSorry, I had to answer Bed 6\u2019s call bell. Did I miss anything?\u201d Tracie walks to Miki and attaches the machine to her arm and finger.\n\n<\/div>\n
\n\n \n\nGladys smiles, \u201cDo we need a sputum sample? Ms. Huang has coughed out quite a bit of stuff.\u201d\n\n<\/div>\n
\n\n \n\n\u201cNo, I don\u2019t think so. One was sent from Emergency that we are still waiting on. If she is coughing now, we can always have you come back and assist us to get another specimen.\u201d\n\n<\/div>\n
\n\n \n\nThe vital sign machine beeps and displays the vital signs on the screen. Saturations are up quite a bit and HR and BP are back to normal for Miki. Temperature is still low-grade fever. Tracie records the vital signs.\n\n \n\n\n\n\n
Day: 3<\/strong><\/td>\nPulse Rate<\/strong><\/td>\nBlood Pressure<\/strong><\/td>\nRespiratory Rate<\/strong><\/td>\nTemperature<\/strong><\/td>\nO2 Saturation<\/strong><\/td>\n<\/tr>\n
Time: 09h00<\/strong><\/td>\n86<\/td>\n150\/85<\/td>\n18<\/td>\n36.5\u00b0C<\/td>\n95% on FM<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n
\n\n \n\n\u201cWow, great improvement Ms. Huang. Getting you up in bed and breathing better has certainly helped.\u201d Miki smiles weakly at the encouraging tones.\n\n<\/div>\n
\n\n \n\nTracie stares at Miki for a moment longer and thinks, \u201cShe looks more alert, eyes are open, better eye contact...overall she looks much better than when I first came on shift.\u201d\n\n<\/div>\n
\n\n \n\nThe RT, Herman, arrives in the room and looks at Ms. Huang, Linda, Gladys, and Tracie. \u201cHi, I\u2019m Herman. You paged me earlier to come and see Ms. Huang.\u201d\n\n<\/div>\n
\n\n \n\n\u201cHi Herman. I\u2019m Tracie and this is Gladys, a physiotherapist. And this here is Linda, Ms. Huang\u2019s daughter. Since Ms. Huang cannot speak English, she\u2019s helping out as a translator.\u201d\n\n<\/div>\n
\n\n \n\n\u201cHappy to meet you all. So, what can I do to help Ms. Huang here?\u201d Herman moves closer to Miki, checks her mask, and then works his way back to the humidifier and checks the flow meter on the wall. He nods his head, thinking, \u201cExactly like I was told. No real changes in therapy.\u201d\n\n<\/div>\n
\n\n \n\nTracie then gives a quick report including changes overnight and what happened thus far this morning.\n\n<\/div>\n
\n\n \n\nHerman rubs his chin. \u201cOkay, she has improved with physio but is still on high flow. We know she is a CO2 retainer which may explain her being sleepy this morning, and she has not had an ABG since being in Emergency. Doctor orders give me some leeway on taking an ABG. I would like to do an ABG and see where we are and if there are really any changes since Emergency. From her saturations here it looks like we could drop her FiO2 a bit. So, let\u2019s do this: I will drop her FiO2 a bit to bring her sats to 93% and then go gather the stuff for an ABG radial stab. We will let her rest for a few more minutes and then I will do a gas.\u201d Herman adjusts the FiO2 while keeping an eye on the saturations displayed on the vital sign machine. He makes a couple of more adjustments and sees the sats stabilize at 93%. He gives the FiO2 to Tracie who records it in the nurses\u2019 notes and flow sheet.\n\n<\/div>\n
\n\n \n\nHerman leans closer in. \u201cLinda, can you please ask your mother how that feels with the oxygen decreased a little?\u201d\n\n<\/div>\n
\n\n \n\nLinda smiles. \u201cShe says she\u2019s a little better than earlier, although still short of breath.\u201d\n\n<\/div>\n
\n\n \n\n\u201cOkay, that may not change very quickly. I\u2019m going to listen to her lungs now. Is that okay?\u201d\n\n<\/div>\n
\n\n \n\nLinda starts to nod, then remembers. \u201cWait a minute, let me ask. Mom, is it okay if the doctor listens to your lungs?\u201d\n\n<\/div>\n
\n\n \n\nMiki rolls her eyes and answers, \u201cYes, of course. Isn\u2019t that what he\u2019s here for?\u201d Secretly, though, she's glad Linda confirmed with her first before consenting on her behalf.\n\n<\/div>\n
\n\n \n\nHerman pulls his stethoscope out and systematically auscultates Ms. Huang\u2019s chest. \u201cNot too bad. A bit decreased to the bases with coarse sounds and no wheezes.\u201d\n\n<\/div>\n
\n\n \n\nTraci smiles at Gladys. \u201cThat does sound better than what I heard this morning.\u201d\n\n<\/div>\n
\n\n \n\nHerman says, \u201cOkay, she seems okay right now. I am going to get my stuff to do the ABG and will be back in about 10 minutes.\u201d\n\n<\/div>\n
\n\n \n\nBoth Tracie and Gladys nods. Tracie nods towards Miki. \u201cLinda, does your mother need anything right now?\u201d\n\n<\/div>\n
\n\n \n\n\u201cNo, we\u2019ll probably just keep watching TV to be honest.\u201d\n\n<\/div>\n
\n\n \n\nGladys pats her hand. \u201cI will come back in about 30 minutes and see if she needs to be repositioned or feels strong enough to get into a chair then.\u201d\n\n<\/div>\n
\n\n \n\nLinda and Miki wave to both of them before focusing their attention on the TV.\n\n<\/div>\n
\n\n \n\nTracie and Gladys move out of the room.\n\n<\/div>\n
\n\n \n\n\u201cThank you, Gladys, for your help. You did a great job in there.\u201d\n\n<\/div>\n
\n\n \n\n\u201cThanks Tracie. It was really nice to see that I made a difference. I\u2019m going to talk with my preceptor about what I did and see another patient. I will come back in about 30 minutes to see how Ms. Huang is doing.\u201d\n\n<\/div>\n
\n\n \n\n\u201cAwesome. Let me know if you need my help. I am going to see my other patients and hand out my 10am meds and antibiotics.\u201d\n\n<\/div>\n
\n\n \n\nBack in the room, both mother and daughter\u2019s eyes are still fixed on the television, but Miki speaks up.\n\n<\/div>\n
\n\n \n\n\u201cWhen you were in the bathroom, and they came in to move me I was a little scared.\u201d\n\n<\/div>\n
\n\n \n\n\u201cI\u2019m sorry, but you really cannot expect me to be here 24\/7. That\u2019s just not possible.\u201d\n\n<\/div>\n
\n\n \n\n\u201cI know, I\u2019m not blaming you. I just wish I could have known what was going on and what they wanted to do to me.\u201d\n\n<\/div>\n
\n\n \n\nLinda sighs, \u201cI\u2019m sorry Mom. I don\u2019t know what to say. You\u2019ll be better soon enough, and we can get out of this place.\u201d\n\n<\/div>\n
\n\n \n\nMiki finds it hard to express her frustration; as kind and sympathetic as her daughter tried to be, there was just know way to truly know how frightening it was to be so physically vulnerable in an environment where you also could not understand a single word.\n\n<\/div>\n
\n\n \n\nAcross the room in her chair, all Linda wants to do is lock herself in her room and sob. It pains her to see her mother so on edge and anxious, but ever since her mother got sick Linda has constantly been feeling suffocating pressure. Besides constantly being by her mother\u2019s side and acting as the primary liaison, she also hasn\u2019t slept well in days and is worried about all the work she\u2019s missing. Deep in her heart, she knows that this is not a sustainable arrangement and wonders if she made the wrong call in turning down the designated translator. Although there are so many things happening at once, the only thing Linda can\u2019t stop obsessing over is the fact that she is almost out of allotted sick days for her job.\n\n<\/div>\n

Time: 10h00<\/h3>\n
\n\nHerman comes up to the desk and sees Tracie charting. \u201cHi Tracie, I\u2019ve done the ABG on Ms. Huang and have sent it to the lab. We should be getting the results in about 30 minutes or less. I\u2019m going to see a patient on the tenth floor. I will check the system for the results, and I may come back and make additional changes to her FiO2.\u201d\n\n<\/div>\n
\n\n \n\n\u201cThank you, Herman. I really appreciate your help.\u201d\n\n<\/div>\n

Time: 11h00<\/h3>\n
\n\nTracie logs into the clinical system in the hallway outside Miki\u2019s room. \u201cOkay, let\u2019s find the ABG result. Wow, that ABG result looks much better, O2 and sats better, CO2 is high but looks normal for her. Nice. Looks like Herman can bring her FiO2 down.\u201d Next Tracie checks to see if the culture and sensitivity is back. \u201cC&S is still pending. Gram stain shows gram positive cocci. Okay, not sure what that means; I will have to ask Dr. Hunicutt.\u201d\n\n<\/div>\n
\n\n \n\nTracie signs off the system, turns around, and runs directly into Herman. \u201cOh, I am so sorry!\u201d\n\n<\/div>\n
\n\n \n\n\u201cNo problem. Did you see the ABG result?\u201d\n\n<\/div>\n
\n\n \n\n\u201cYes, it looks better than it did even in Emergency.\u201d\n\n<\/div>\n
\n\n \n\n\u201cYes, it is, but you have to remember she is on a higher amount of O2.\u201d\n\n<\/div>\n
\n\n \n\n\u201cYes, I never considered that. Good point.\u201d\n\n<\/div>\n
\n\n \n\n\u201cI am going to go in and adjust her FiO2 down a bit more. If she continues to improve, we can probably move her later today or tomorrow to Optiflow again.\u201d\n\n<\/div>\n
\n\n \n\n\u201cExcellent. I will come in with you and do a focus assessment.\u201d\n\n<\/div>\n
\n\n \n\n\u201cSure, no problem.\u201d\n\n<\/div>\n
\n\n \n\nBoth Herman and Tracie enter Miki\u2019s room to find her and Linda still watching TV intently.\n\n<\/div>\n
\n\n \n\nMiki notices the two of them entering her room out of the corner of her eye and groans inwardly. \u201cUgh, they literally just left. What do these two want again? Will I never get peace and quiet?\u201d\n\n<\/div>\n
\n\n \n\n\u201cHi, Ms. Huang. Herman here is going to make some adjustments to your oxygen level. And with the test we did earlier, we may be able to move you to a more comfortable type of mask.\u201d\n\n<\/div>\n
\n\n \n\nTracie moves the vital sign machine to Miki\u2019s bedside and attaches it to her left arm and right finger.\n\n<\/div>\n
\n\n \n\nHerman checks the pulse ox saturation and then begins to adjust the FiO2. He thinks, \u201cIt\u2019s not below the toxic level of oxygen, which should help.\u201d\n\n<\/div>\n
\n\n \n\nThe oxygen saturation stays stable. Tracie listens to Miki\u2019s chest and finds that the air entry is decreased to her bases, with a few crackles, and no wheezes noted. Vital signs are unchanged from the morning.\n\n<\/div>\n
\n\n \n\n\u201cYou are looking pretty good, Ms. Huang.\u201d\n\n<\/div>\n
\n\n \n\nLinda jabs her mom excitedly, \u201cHey, they said you\u2019re looking pretty good!\u201d\n\n<\/div>\n
\n\n \n\nMiki rolled her eyes. \u201cThen why am I still here? Tell them not to waste their time lying to me and heal me instead.\u201d\n\n<\/div>\n
\n\n \n\nLinda smiles at the doctors, \u201cUm, my mom said thanks.\u201d\n\n<\/div>\n
\n\n \n\nHerman smiles back. \u201cDr. Hunicutt will also be coming by today to update you>\u201d\n\n<\/div>\n
\n\n \n\n\u201cOkay Tracie, I have decreased the FiO2 below .50 and she looks to be holding her saturations really well at 93%. I will come by towards the end of the shift and if things are good, move to Optiflow.\u201d\n\n<\/div>\n
\n\n \n\n\u201cThanks, Herman.\u201d\n\n<\/div>\n
\n\n \n\nJust then, Gladys enters the room. \u201cHi Tracie. Hi Ms. Huang and Linda! Would you like to sit in a chair or move to a different position?\u201d\n\n<\/div>\n
\n\n \n\nLinda translates, then turns to Gladys, \u201cShe said a chair sounds much better.\u201d\n\n<\/div>\n
\n\n \n\nGladys then directs both Tracie and Herman to assist her to move Miki to a bedside chair. Miki transfers easily and feels much more comfortable.\n\n<\/div>\n
\n\n \n\nGladys explains, \u201cWe need to be careful that you do not get any bed sores. Plus, moving around helps your lungs out. Tomorrow I will come by and get you walking the hallways.\u201d\n\n<\/div>\n
\n\n \n\nSuddenly more cheerful, Linda is pleased with the progress and the prospect of her mother moving around. She thinks that perhaps she should run home later and grab her laptop so she can get some work done when her mom\u2019s walking tomorrow.\n\n<\/div>\n
\n\n \n\nTracie leans forward and adjusts the blanket on Miki. \u201cAll good. Need anything right now?\u201d\n\n<\/div>\n
\n\n \n\nLinda asks her mom, who shakes her head. Tracie heads to the nursing station to complete her charting, and Gladys heads off to find her preceptor.\n\n<\/div>\n

Time: 19h00-shift change<\/h3>\n
\n\n\u201cHi Jim, how are you this lovely evening?\u201d\n\n<\/div>\n
\n\n \n\n\u201cHi Tracie, I am doing well. I had a great sleep.\u201d\n\n<\/div>\n
\n\n \n\n\u201cAwesome. You should have the same patients as last night.\u201d\n\n<\/div>\n
\n\n \n\n\u201cCool. Should be a quick report.\u201d\n\n<\/div>\n
\n\n \n\nTracie then describes the status of each of the patients. Coming to Miki\u2019s chart, Tracie explains, \u201cMs. Huang is doing much better, up in a chair today. Deep breathing exercises cleared a lot of sputum. FiO2 less than .5 gram stain came back gram positive, but Dr. Hunicutt says it is not too helpful for adjusting her antibiotics. C&S should be available tomorrow. The RT did not want to move quite yet to Optiflow and they may do so tomorrow. She is still comfortable on the mask, and the humidity may help clear secretions.\u201d Tracie then goes through the rest of the assessment.\n\n<\/div>\n
\n\n \n\n\u201cLooks good, thanks, Tracie. I guess tomorrow is your last day shift?\u201d\n\n<\/div>\n
\n\n \n\n\u201cYes, see you in the morning.\u201d\n\n<\/div>\n

Adaptations<\/h1>\nThis section has been from Health Case Studies<\/a> by Glynda Rees, Rob Kruger, and Janet Morrison.\n","rendered":"
\n

Day 3<\/h2>\n<\/div>\n
\n

Time: 07h00<\/h3>\n<\/div>\n
\n

Place: Medical Unit<\/h3>\n<\/div>\n
\n

Tracie walks slowly up the walkway behind a patient in a walker entering the hospital. She remarks to herself, \u201cWow. My third dayshift. I didn\u2019t think I would miss the changeover time to nights.\u201d<\/span><\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cHere, let me get the door for you,\u201d Tracie says as she opens the door for an elderly patient who then asks directions to the Ultrasound Department. Tracie points him in the direction of the Diagnostics Department and explains that he can follow the blue line right to the check-in desk.<\/p>\n<\/div>\n

\n

 <\/p>\n

Tracie turns in the opposite direction and enters the elevator that takes her to the seventh floor. The doors open, and she is greeted with the familiar disinfectant smells. Walking quickly to the staff room, she shrugs out of her coat and puts on her duty clogs. Looking in the mirror, she moves errant strands of hair behind her ears and runs her hands over her uniform. \u201cI guess I\u2019m ready. Let\u2019s go see if anything has changed overnight.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

Walking out of the staff room to the main nursing station, Tracie finds Jim finishing off his night\u2019s charting.<\/p>\n<\/div>\n

\n

 <\/p>\n

Jim looks up. \u201cWow, I am glad to see you.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cOkay, that answers my first question. I have the same assignment as yesterday?\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

Jim smiles. \u201cYes, you do. I asked specifically to keep you with the same group of patients as you know then and it will provide some consistency.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cAre you ready to hand over to me?\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cJust give me a minute to finish this last note and chart my meds that I just gave to Room 5. It has been very busy, and I have not really had a chance to sit down all night.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cOk, I am going to grab a glass of water. I\u2019ll be right back.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

A few minutes later, Tracie sits down beside an obviously exhausted Jim to get the handover report.<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cWhere to start? Let\u2019s start with Ms. Miki Huang if that is okay?\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cSure. I am hoping she had a quiet night.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cYes, she had a better night than her roommate and some of the other patients on the floor. Last night we needed to adjust her oxygen up as her sats went to 90% and even dropped further with movement. The RTs saw her a number of times but elected not to do an ABG at this time.\u201d Jim points at the vital signs flow sheet. \u201cHer heart rate, temp, and BP are up slightly from what you recorded yesterday. Ins and outs are even balance. She is due for lab work this morning, a CXR and potentially an ABG, especially if you can\u2019t decrease her oxygen.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cIf I remember correctly, the Physio will also assess her. Is she still on IV antibiotics?\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cYes, it\u2019s only day two and we have no results from the sputum sample in the system. We could be changing them tomorrow if we get the culture\/sensitivities then. Her next antibiotic is due at 10h00 and she has some other meds at 08h00.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cGreat, who is next?\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

Jim then goes through the rest of the patient assignment.<\/p>\n<\/div>\n

\n

 <\/p>\n

Leaning back in his chair, Jim rubs his hair through his closely cropped hair. \u201cThat\u2019s it for me. I\u2019m going to change into my gear and cycle home in time to take the kids to school. Any questions?\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cNope. Have a good sleep.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cSee you tonight. I\u2019m scheduled to come in.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cAwesome.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

Jim walks quickly to the staff room and then disappears through the door. Meanwhile, Tracie takes a quick look through her patient chart to plan her priorities for the day.<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cBed 5 is ready for discharge, so should be okay for the next little bit. Beds 6 and 7 had a rough night. I will see them and then be off to check on Ms. Huang.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

Sighing a little as she stands, Tracie heads off to Bed 6.<\/p>\n<\/div>\n

\n

Time: 08h15<\/h3>\n<\/div>\n
\n

\u201cGood morning Ms. Huang, how are you doing? Good to see you too, Linda.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

Tracie looks towards Miki and sees a very sleepy elderly woman. \u201cWow, she looks like she has aged even more since yesterday,\u201d she thinks to herself.<\/p>\n<\/div>\n

\n

 <\/p>\n

Miki looks up and attempts to say something, but it comes out as \u201cArgg argg.\u201d Her voice is muffled by the mask and the sound of the bubbling from the humidifier.<\/p>\n<\/div>\n

\n

 <\/p>\n

Linda frowns, \u201cWhat\u2019s that, Mom?\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

Tracie also furrows her brow. \u201cHmm, that doesn\u2019t sound right,\u201d she mutters to herself.<\/p>\n<\/div>\n

\n

 <\/p>\n

She pulls the vital sign machine up to the bedside and hooks Miki up. Immediately, she notes that Miki\u2019s oxygen saturation is down again to 90%, then thinks to herself, \u201cOkay, I am going to have to call the RT. May need to adjust her FiO2.\u201d About a minute later, the machine beeps and the vitals are displayed on the small screen. Tracie records them on the vital sign flow sheet.<\/p>\n

 <\/p>\n\n\n\n\n
Day: 3<\/strong><\/td>\nPulse Rate<\/strong><\/td>\nBlood Pressure<\/strong><\/td>\nRespiratory Rate<\/strong><\/td>\nTemperature<\/strong><\/td>\nO2 Saturation<\/strong><\/td>\n<\/tr>\n
Time: 08h00<\/strong><\/td>\n96<\/td>\n170\/90<\/td>\n22<\/td>\n36.5\u00b0C<\/td>\n90% on FM<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n
\n

 <\/p>\n

\u201cMs. Huang, I am going to listen to your lungs and heart.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cMom, she\u2019s just going to check your lungs and heart, okay?\u201d Linda translates.<\/p>\n<\/div>\n

\n

 <\/p>\n

Miki nods her head, \u201cI do feel really tired though.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

Tracie places the stethoscope in her ears and bell against Miki\u2019s chest. She quickly moves the bell around her chest in a systematic manner. Standing up straight and stretching her arms out after leaning over the bed, she thinks, \u201cThere seems to be slightly coarser sounds mid to lower field bilaterally. A few wheezes on expiration. Heart sounds are normal.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cMs. Huang, I am going to give you some Ventolin and ask the RT to come and see you to make sure you are on the right oxygen setting.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

Miki doesn\u2019t react to this, but Linda nods worriedly and tells Tracie that her mother is very tired.<\/p>\n<\/div>\n

\n

 <\/p>\n

Tracie heads over to the nursing station and asks the unit coordinator to page the RT for her.<\/p>\n<\/div>\n

\n

 <\/p>\n

A few minutes later, the RT, Herman, calls back.<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cHey, this is Herman; I am the RT covering the floors today.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cThank you for calling back so quickly. Did you get the report on Ms. Miki Huang?\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cShe\u2019s the lady on the seventh floor with pneumonia and COPD, and on high flow face mask?\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cYes, that is Ms. Huang. This morning when I assessed her, she mentioned being pretty tired. Sats are around 90%, RR is up slightly along with HR and blood pressure (BP). Breath sounds are a bit coarser in the lower fields with wheezes on expiration in the upper. I have just started her on some Ventolin. I am not sure about adjusting her FiO2 further or whether her COPD is getting worse which is causing her to feel tired. There is an order for an ABG if there is a change in patient\u2019s condition. I would like you to come and see her.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cSounds like I should pop up there. I am seeing a patient on the fourth floor right now and titrating his oxygen. Can you wait about 10 minutes?\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cI can. I am pretty sure Ms. Huang will be okay as well. I will recheck her saturations after the Ventolin treatment.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cThat\u2019s an excellent idea, I will be up as soon as I can.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cThanks.\u201d Tracie hangs up the phone. Pushing back the loose strands of hair behind her ears, she stands up and heads down the hallway again to Ms. Huang\u2019s room. Entering the room, she finds a very tall, fit, woman leaning over the bedside of Ms. Huang.<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cCan I help you?\u201d Tracie asks.<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cHi, my name is Gladys. I am a Physio student doing a preceptorship, and Ms. Huang\u2019s name is on our list of patients to see today. I thought I would come by and see Ms. Huang to see what physio she needs and then plan a time to come back to do physio with her.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cOh, okay. Sorry, I didn\u2019t see your name tag. My name is Tracie, and I am the nurse caring for her. I don’t think this morning is a good time. Ms. Huang\u2019s oxygen saturations are down a bit and her breath sounds are a bit coarser than yesterday. Last night she required an increase in her FiO2.  She has been complaining of feeling tired and seems a bit sleepier than usual.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

Gladys looks down at Miki, who is propped up with a few pillows at 45 degrees.<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cTracie, would you have a few minutes to help me reposition Ms. Huang? I think I can help improve her saturations with better position for expansion and maybe lead her to do some deep breathing exercises and coughing exercises to help move her secretions out.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cI can help.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cOkay, I am just going to get a bolster. Can you find a couple more pillows for me?\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cYes, I think so. There is always a shortage of pillows. Most are like placemats, and patients are always hoarding them as one is never fluffy enough.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

Gladys smiles and moves out the door to the storeroom to find a bolster.<\/p>\n<\/div>\n

\n

 <\/p>\n

A few minutes later, both Gladys and Tracie are standing together at the end of the bed looking at Miki, who stares back cautious.<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cOkay Gladys, what are we going to do?\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cI would like to position Ms. Huang more upright in bed with her arms resting on pillows on the overbed table. I am not familiar with these beds, but I believe we can move the foot of the bed, so Ms. Huang is in more of a sitting position?\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cSounds good; let\u2019s get started.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

Throughout this exchange, Linda is not present, and Miki is growing increasingly anxious. As much as she hates admitting it, she is reliant on her daughter now more than ever. Sure, at home Linda took care of Miki\u2019s physical needs, but ever since they got to the hospital, Linda also took over anything related to communication. \u201cIf only I had tried harder to learn English in the past,\u201d Miki thinks to herself wistfully, and not for the first time since she arrived either.<\/p>\n<\/div>\n

\n

 <\/p>\n

Now, in bed, she feels completely in the dark about what the doctors want to do with her. What if it hurt? What if something went wrong? Where was Linda when she needed her most? Miki notices Gladys gesturing towards her, seemingly trying to demonstrate what they wanted to do. Miki only grips the bed railing tighter.<\/p>\n<\/div>\n

\n

 <\/p>\n

Both Gladys and Tracie work together to move Miki into a chair-like position while in bed. They place the bolster at Miki\u2019s back to ensure correct body alignment. After positioning Miki, both step back to admire their work, but Miki\u2019s heart is pounding rapidly. Was that it? Did they only need to adjust her position?<\/p>\n<\/div>\n

\n
\"Miki
Day 3 – While wearing a breathing mask, Miki is placed in a position by the respiratory therapist and nurse. Image created by Sarah Pinault under a CC-BY-NC license<\/span><\/figcaption><\/figure>\n

Just then, Linda returns from the bathroom. \u201cOh, hi there. What\u2019s happening?\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cI\u2019m going to check Ms. Huang\u2019s vitals again to see if this movement helped. I\u2019ll go get the machine to do that.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cI am going to see if I can get her to deep-breathe and cough. Maybe moving or clearing those secretions will help.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

Gladys moves closer to Miki. \u201cOkay, Ms. Huang, I want you to take a deep breath.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cTake a deep breath, Mom,\u201d Linda instructed.<\/p>\n<\/div>\n

\n

 <\/p>\n

Miki takes a week breath in through her mouth. \u201cThat\u2019s great. And now breathe out.\u201d Miki coughs weakly.<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cThat is very good Ms. Huang. I want you to take a slow deep breath to the count of three, then breathe out to the count of three.\u201d Gladys demonstrates what she is asking.<\/p>\n<\/div>\n

\n

 <\/p>\n

Miki understands that she\u2019s imitating what she wants and nods her head. \u201cOkay, breathe in, 1, 2, 3. Hold. Breathe out 1, 2, 3. Very good.\u201d Miki begins coughing and makes frantic motions with her hands to remove the O2 mask. Gladys removes the mask and hands a tissue to Miki. Miki coughs a moderate amount of green sputum into the tissue.<\/p>\n<\/div>\n

\n

 <\/p>\n

Behind them, Linda winces, but Gladys is happy. \u201cThis is exactly what we want to see! Let\u2019s do the breathing and coughing exercises some more and see if we can clear your lungs a bit.\u201d Gladys then leads Miki through five more deep breathing and coughing exercises with Linda\u2019s assistance. At the end of each deep breath, Miki coughs out more greenish\/yellow sputum.<\/p>\n<\/div>\n

\n

 <\/p>\n

At the end of the fifth attempt, Tracie walks into the room with the vital sign machine. \u201cSorry, I had to answer Bed 6\u2019s call bell. Did I miss anything?\u201d Tracie walks to Miki and attaches the machine to her arm and finger.<\/p>\n<\/div>\n

\n

 <\/p>\n

Gladys smiles, \u201cDo we need a sputum sample? Ms. Huang has coughed out quite a bit of stuff.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cNo, I don\u2019t think so. One was sent from Emergency that we are still waiting on. If she is coughing now, we can always have you come back and assist us to get another specimen.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

The vital sign machine beeps and displays the vital signs on the screen. Saturations are up quite a bit and HR and BP are back to normal for Miki. Temperature is still low-grade fever. Tracie records the vital signs.<\/p>\n

 <\/p>\n\n\n\n\n
Day: 3<\/strong><\/td>\nPulse Rate<\/strong><\/td>\nBlood Pressure<\/strong><\/td>\nRespiratory Rate<\/strong><\/td>\nTemperature<\/strong><\/td>\nO2 Saturation<\/strong><\/td>\n<\/tr>\n
Time: 09h00<\/strong><\/td>\n86<\/td>\n150\/85<\/td>\n18<\/td>\n36.5\u00b0C<\/td>\n95% on FM<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n
\n

 <\/p>\n

\u201cWow, great improvement Ms. Huang. Getting you up in bed and breathing better has certainly helped.\u201d Miki smiles weakly at the encouraging tones.<\/p>\n<\/div>\n

\n

 <\/p>\n

Tracie stares at Miki for a moment longer and thinks, \u201cShe looks more alert, eyes are open, better eye contact…overall she looks much better than when I first came on shift.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

The RT, Herman, arrives in the room and looks at Ms. Huang, Linda, Gladys, and Tracie. \u201cHi, I\u2019m Herman. You paged me earlier to come and see Ms. Huang.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cHi Herman. I\u2019m Tracie and this is Gladys, a physiotherapist. And this here is Linda, Ms. Huang\u2019s daughter. Since Ms. Huang cannot speak English, she\u2019s helping out as a translator.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cHappy to meet you all. So, what can I do to help Ms. Huang here?\u201d Herman moves closer to Miki, checks her mask, and then works his way back to the humidifier and checks the flow meter on the wall. He nods his head, thinking, \u201cExactly like I was told. No real changes in therapy.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

Tracie then gives a quick report including changes overnight and what happened thus far this morning.<\/p>\n<\/div>\n

\n

 <\/p>\n

Herman rubs his chin. \u201cOkay, she has improved with physio but is still on high flow. We know she is a CO2 retainer which may explain her being sleepy this morning, and she has not had an ABG since being in Emergency. Doctor orders give me some leeway on taking an ABG. I would like to do an ABG and see where we are and if there are really any changes since Emergency. From her saturations here it looks like we could drop her FiO2 a bit. So, let\u2019s do this: I will drop her FiO2 a bit to bring her sats to 93% and then go gather the stuff for an ABG radial stab. We will let her rest for a few more minutes and then I will do a gas.\u201d Herman adjusts the FiO2 while keeping an eye on the saturations displayed on the vital sign machine. He makes a couple of more adjustments and sees the sats stabilize at 93%. He gives the FiO2 to Tracie who records it in the nurses\u2019 notes and flow sheet.<\/p>\n<\/div>\n

\n

 <\/p>\n

Herman leans closer in. \u201cLinda, can you please ask your mother how that feels with the oxygen decreased a little?\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

Linda smiles. \u201cShe says she\u2019s a little better than earlier, although still short of breath.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cOkay, that may not change very quickly. I\u2019m going to listen to her lungs now. Is that okay?\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

Linda starts to nod, then remembers. \u201cWait a minute, let me ask. Mom, is it okay if the doctor listens to your lungs?\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

Miki rolls her eyes and answers, \u201cYes, of course. Isn\u2019t that what he\u2019s here for?\u201d Secretly, though, she’s glad Linda confirmed with her first before consenting on her behalf.<\/p>\n<\/div>\n

\n

 <\/p>\n

Herman pulls his stethoscope out and systematically auscultates Ms. Huang\u2019s chest. \u201cNot too bad. A bit decreased to the bases with coarse sounds and no wheezes.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

Traci smiles at Gladys. \u201cThat does sound better than what I heard this morning.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

Herman says, \u201cOkay, she seems okay right now. I am going to get my stuff to do the ABG and will be back in about 10 minutes.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

Both Tracie and Gladys nods. Tracie nods towards Miki. \u201cLinda, does your mother need anything right now?\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cNo, we\u2019ll probably just keep watching TV to be honest.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

Gladys pats her hand. \u201cI will come back in about 30 minutes and see if she needs to be repositioned or feels strong enough to get into a chair then.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

Linda and Miki wave to both of them before focusing their attention on the TV.<\/p>\n<\/div>\n

\n

 <\/p>\n

Tracie and Gladys move out of the room.<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cThank you, Gladys, for your help. You did a great job in there.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cThanks Tracie. It was really nice to see that I made a difference. I\u2019m going to talk with my preceptor about what I did and see another patient. I will come back in about 30 minutes to see how Ms. Huang is doing.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cAwesome. Let me know if you need my help. I am going to see my other patients and hand out my 10am meds and antibiotics.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

Back in the room, both mother and daughter\u2019s eyes are still fixed on the television, but Miki speaks up.<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cWhen you were in the bathroom, and they came in to move me I was a little scared.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cI\u2019m sorry, but you really cannot expect me to be here 24\/7. That\u2019s just not possible.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cI know, I\u2019m not blaming you. I just wish I could have known what was going on and what they wanted to do to me.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

Linda sighs, \u201cI\u2019m sorry Mom. I don\u2019t know what to say. You\u2019ll be better soon enough, and we can get out of this place.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

Miki finds it hard to express her frustration; as kind and sympathetic as her daughter tried to be, there was just know way to truly know how frightening it was to be so physically vulnerable in an environment where you also could not understand a single word.<\/p>\n<\/div>\n

\n

 <\/p>\n

Across the room in her chair, all Linda wants to do is lock herself in her room and sob. It pains her to see her mother so on edge and anxious, but ever since her mother got sick Linda has constantly been feeling suffocating pressure. Besides constantly being by her mother\u2019s side and acting as the primary liaison, she also hasn\u2019t slept well in days and is worried about all the work she\u2019s missing. Deep in her heart, she knows that this is not a sustainable arrangement and wonders if she made the wrong call in turning down the designated translator. Although there are so many things happening at once, the only thing Linda can\u2019t stop obsessing over is the fact that she is almost out of allotted sick days for her job.<\/p>\n<\/div>\n

Time: 10h00<\/h3>\n
\n

Herman comes up to the desk and sees Tracie charting. \u201cHi Tracie, I\u2019ve done the ABG on Ms. Huang and have sent it to the lab. We should be getting the results in about 30 minutes or less. I\u2019m going to see a patient on the tenth floor. I will check the system for the results, and I may come back and make additional changes to her FiO2.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cThank you, Herman. I really appreciate your help.\u201d<\/p>\n<\/div>\n

Time: 11h00<\/h3>\n
\n

Tracie logs into the clinical system in the hallway outside Miki\u2019s room. \u201cOkay, let\u2019s find the ABG result. Wow, that ABG result looks much better, O2 and sats better, CO2 is high but looks normal for her. Nice. Looks like Herman can bring her FiO2 down.\u201d Next Tracie checks to see if the culture and sensitivity is back. \u201cC&S is still pending. Gram stain shows gram positive cocci. Okay, not sure what that means; I will have to ask Dr. Hunicutt.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

Tracie signs off the system, turns around, and runs directly into Herman. \u201cOh, I am so sorry!\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cNo problem. Did you see the ABG result?\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cYes, it looks better than it did even in Emergency.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cYes, it is, but you have to remember she is on a higher amount of O2.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cYes, I never considered that. Good point.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cI am going to go in and adjust her FiO2 down a bit more. If she continues to improve, we can probably move her later today or tomorrow to Optiflow again.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cExcellent. I will come in with you and do a focus assessment.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cSure, no problem.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

Both Herman and Tracie enter Miki\u2019s room to find her and Linda still watching TV intently.<\/p>\n<\/div>\n

\n

 <\/p>\n

Miki notices the two of them entering her room out of the corner of her eye and groans inwardly. \u201cUgh, they literally just left. What do these two want again? Will I never get peace and quiet?\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cHi, Ms. Huang. Herman here is going to make some adjustments to your oxygen level. And with the test we did earlier, we may be able to move you to a more comfortable type of mask.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

Tracie moves the vital sign machine to Miki\u2019s bedside and attaches it to her left arm and right finger.<\/p>\n<\/div>\n

\n

 <\/p>\n

Herman checks the pulse ox saturation and then begins to adjust the FiO2. He thinks, \u201cIt\u2019s not below the toxic level of oxygen, which should help.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

The oxygen saturation stays stable. Tracie listens to Miki\u2019s chest and finds that the air entry is decreased to her bases, with a few crackles, and no wheezes noted. Vital signs are unchanged from the morning.<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cYou are looking pretty good, Ms. Huang.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

Linda jabs her mom excitedly, \u201cHey, they said you\u2019re looking pretty good!\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

Miki rolled her eyes. \u201cThen why am I still here? Tell them not to waste their time lying to me and heal me instead.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

Linda smiles at the doctors, \u201cUm, my mom said thanks.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

Herman smiles back. \u201cDr. Hunicutt will also be coming by today to update you>\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cOkay Tracie, I have decreased the FiO2 below .50 and she looks to be holding her saturations really well at 93%. I will come by towards the end of the shift and if things are good, move to Optiflow.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cThanks, Herman.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

Just then, Gladys enters the room. \u201cHi Tracie. Hi Ms. Huang and Linda! Would you like to sit in a chair or move to a different position?\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

Linda translates, then turns to Gladys, \u201cShe said a chair sounds much better.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

Gladys then directs both Tracie and Herman to assist her to move Miki to a bedside chair. Miki transfers easily and feels much more comfortable.<\/p>\n<\/div>\n

\n

 <\/p>\n

Gladys explains, \u201cWe need to be careful that you do not get any bed sores. Plus, moving around helps your lungs out. Tomorrow I will come by and get you walking the hallways.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

Suddenly more cheerful, Linda is pleased with the progress and the prospect of her mother moving around. She thinks that perhaps she should run home later and grab her laptop so she can get some work done when her mom\u2019s walking tomorrow.<\/p>\n<\/div>\n

\n

 <\/p>\n

Tracie leans forward and adjusts the blanket on Miki. \u201cAll good. Need anything right now?\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

Linda asks her mom, who shakes her head. Tracie heads to the nursing station to complete her charting, and Gladys heads off to find her preceptor.<\/p>\n<\/div>\n

Time: 19h00-shift change<\/h3>\n
\n

\u201cHi Jim, how are you this lovely evening?\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cHi Tracie, I am doing well. I had a great sleep.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cAwesome. You should have the same patients as last night.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cCool. Should be a quick report.\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

Tracie then describes the status of each of the patients. Coming to Miki\u2019s chart, Tracie explains, \u201cMs. Huang is doing much better, up in a chair today. Deep breathing exercises cleared a lot of sputum. FiO2 less than .5 gram stain came back gram positive, but Dr. Hunicutt says it is not too helpful for adjusting her antibiotics. C&S should be available tomorrow. The RT did not want to move quite yet to Optiflow and they may do so tomorrow. She is still comfortable on the mask, and the humidity may help clear secretions.\u201d Tracie then goes through the rest of the assessment.<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cLooks good, thanks, Tracie. I guess tomorrow is your last day shift?\u201d<\/p>\n<\/div>\n

\n

 <\/p>\n

\u201cYes, see you in the morning.\u201d<\/p>\n<\/div>\n

Adaptations<\/h1>\n

This section has been from Health Case Studies<\/a> by Glynda Rees, Rob Kruger, and Janet Morrison.<\/p>\n","protected":false},"author":103,"menu_order":7,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":["aliao01"],"pb_section_license":""},"chapter-type":[],"contributor":[68],"license":[],"class_list":["post-644","chapter","type-chapter","status-publish","hentry","contributor-aliao01"],"part":631,"_links":{"self":[{"href":"https:\/\/pressbooks.bccampus.ca\/dcbiol2200\/wp-json\/pressbooks\/v2\/chapters\/644","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pressbooks.bccampus.ca\/dcbiol2200\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/pressbooks.bccampus.ca\/dcbiol2200\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/dcbiol2200\/wp-json\/wp\/v2\/users\/103"}],"version-history":[{"count":0,"href":"https:\/\/pressbooks.bccampus.ca\/dcbiol2200\/wp-json\/pressbooks\/v2\/chapters\/644\/revisions"}],"part":[{"href":"https:\/\/pressbooks.bccampus.ca\/dcbiol2200\/wp-json\/pressbooks\/v2\/parts\/631"}],"metadata":[{"href":"https:\/\/pressbooks.bccampus.ca\/dcbiol2200\/wp-json\/pressbooks\/v2\/chapters\/644\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/pressbooks.bccampus.ca\/dcbiol2200\/wp-json\/wp\/v2\/media?parent=644"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/dcbiol2200\/wp-json\/pressbooks\/v2\/chapter-type?post=644"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/dcbiol2200\/wp-json\/wp\/v2\/contributor?post=644"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/dcbiol2200\/wp-json\/wp\/v2\/license?post=644"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}