A couple years ago, I took care of a patient who had been readmitted for pneumonia that they had been treated for a week prior with IV antibiotics. This patient was middle aged and a relatively healthy person person. Im going to use the name Jack for HIPPA purposes (names, details, and situation may have been changed as well for privacy, but all are real life accurate occurrences)….yall catch my drift ;). Jack and his family members were clearly well educated and not the type of people that would be readmitted for noncompliance. Jack was taking the prescribed oral antibiotics that he was discharged on from a previous admission, and things just seemed to be getting worse. When Jack was directly admitted to the hospital again, he was assigned to me.
As I assessed him that morning and got to know the family….it became clear to me that with my prior knowledge of pneumonia and experience taking care of patients with it, something else was going on with him. He was complaining of really bad abdominal pain and shortness of breath. Upon accessing Jack, I realized that he had really bad abdominal ascites. Something was up. I asked the patient and family how long his stomach had been like this, and if the SOB had gotten worse, as the stomach had gotten bigger. They said to me, “well now that you mentioned it, yes!” Let me now explain that the doctor had already been in that morning and assessed the patient. For all you new nurses out there, the first thing you should always do before calling a doctor about an issue or new finding is to read their notes! They don’t always touch base with the nurses, but will document that they are aware of X, Y, or Z, and either mention that they are getting a consult with the appropriate practice, or what the plan of action for the issue is. That way you don’t waste your time and a slap on the hand from them for calling about something that has already been noted! A doctors time is precious. I read through the Doctors progress notes, and there was no mention of abdominal ascites or worsening SOB. Everything was related to PNA (pneumonia) treatment and basically stated that the last treatment was unsuccessful and we will continue IV antibiotics, fluids, and oxygen.
The patient continued to complain about abdominal pain and worsening SOB. I paged the doctor to let him know what I assessed, and an update of my patients condition. I asked him kindly if he had assessed the patient’s abdomen this morning. He sarcastically said “yes, I assessed my patient, did you read my notes?” I explained that I did, but there was no mention of abdominal pain and ascites. He then explained to me that the patient had not complained of that when he saw him this morning. I knew deep down that he did not fully assess the abdominal area because the ascites was bad! (Ascites is a fancy medical term for an accumulation of fluid, specifically in the abdominal area.) I suggested that he come back to the floor and see the patient again, and possibly consider getting a CT of the abdomen, because my nursing instinct told me PNA was the least of this patients issues! Not only could they not breathe because of the PNA, but I was thinking all of the pressure in the abdomen could be pushing upward, causing the shortness of breath. The MD sounded frustrated, but said he’d be up shortly. I went and updated my patient and the family.
After a “second” assessment by the doctor, he agreed that there was definitely ascites and would order a routine Cat Scan (CT). It was a Friday, and the CT department was backed up as usual. I was really frustrated because my patients breathing and pain were getting worse. When you’ve worked the floor long enough, you will learn that you don’t typically get these “acute issues” from the get go. They SHOULD be relatively stable before coming to the floor directly. If the patient isn’t doing well at all on admission, they’ll typically go to an Intermediate unit or ICU. I was a 1 to 1 with this patient the minute he got to my floor. I think the bottom line was that this patient was a general PNA admit, and they thought that’s all it was.
To make a long story a little shorter, it took a lot of pushing down at the CT department, and negotiating with the doctor to put the CT in as stat and not for THE NEXT DAY ( ughhhh I was going to go crazy! “PLEASE LISTEN TO ME” were my thoughts) !!! I could see the fear on the family’s face as their loved one got worse. I knew instinctively that something wasn’t right and it wasn’t just bad PNA. They ended up finding a huge mass. I found this all out on the next shift, when I came into work. They ended up getting transferred to an intermediate unit and the patient went home on HOSPICE because the prognosis was that bad. My heart just sunk when I found all of this out!
That day I will never forget because I fought so hard to get the doctors attention. To negotiate with the CT department about getting my patient in that night, and not first thing the next morning. I had a friend on the floor watch my patients and I personally wheeled Jack down to CT. Leaving the floor with a patient is never convenient, but Jack was my priority. It got done, and we made progress that night in the patients plan of care. When I left from that shift, the family thanked me with fear (not tears) in their eyes. I reassured them that we made progress and would have answers later tonight. I fought hard for Jack that day!
Being a patient advocate isn’t just passing medications on time, and catering to their every little need. It is WAY more than that. Being a patient advocate is staying on top of your patient’s plan of care the minute you get on the floor and receive report. If a patient has been NPO after midnight and scheduled for a test in the morning, calling down to that test department and getting an ETA makes all of the differnece. Trying your hardest to be in the room when the doctors come in to see the patient. Asking questions on behalf of the patient with your knowledge of their condition. Collaborating with the doctor outside of the room, discussing issues that have presented themselves. Calling the family member of an elderly patient to update them that their loved one just went down for a procedure, whether they truly care or not (you will get that, but SOMEONE needs to know, even if it guilt trips them). Holding their hand when they break down crying, feeling overwhelmed about an update or diagnosis. Calling the chaplin to come be a support. Having a meal/diet ordered for that patient when they get back from their procedure. Putting a Pandora station on your phone in your confused patients room, set to their favorite type of music. BEING AVAILABLE. Listening. Laughing with your patients. Smiling. Thinking outside of the nursing box to solve situations. Advocating for your patient can take on many roles.
I can honestly say I have been a chaplin, a social worker, a dietary service member, taxi reserver….the list goes on. To be an advocate for your patient takes effort. It’s not easy. Some people are never pleased. That’s healthcare for you. But I can honestly say, 90% of the time, I have a really great relationship with my patients, and I leave work feeling exhausted….but ultimately fulfilled. Which is why I come back with a smile on my face.
When I think about that time with Jack, I know that I did everything to get the ball rolling on what needed to happen. I can’t change the diagnosis. I can’t change the prognosis. But what I CAN do is be assured that I did everything in my power to be a strong patient advocate, and made a difference in that family’s stay. They didn’t feel guilty that something didn’t get done that day, because I pushed. They didn’t feel they had to go to the manager because their loved one was suffering and nothing was being done, because I called and communicated. They weren’t on the call light all day long asking for help, because I was available, and checked in frequently. I’m not trying to toot my own horn. I’m trying to make a point. If this was my dad/mom in this situation, I would have wanted that!
Be an advocate. You may butt heads with Doctors. They may snap at you because you called. Remember, YOU are with these patients for 12 hours! You see their progression/regression throughout the day. You are the one to catch that change in mental status and condition. Don’t ever doubt your instinct. Thats part of being an advocate and a good nurse! Even if the doctors aren’t concerned about what you’ve observed, who cares!?! You are advocating for you patient, and feel confident in your decision to let someone else know! It’s safe and wise. Never feel afraid to ask for opinions before calling. Ultimately, they are YOUR patient and your responsibility. There have been plenty of times I’ve asked opinions and was told that it didn’t seem concerning, but I still called! You are your own nurse and advocate. Stand firm on your instincts and decisions. It’s not easy. And you won’t always feel appreciated. But you will leave knowing you did everything you could do for your patients. And most of the time, you will get that sincere “goodnight, and thank you so much” from your patients for the care you gave! It’s because I gave my all, that I keep coming back. Because it’s worth it! Your heart is mine!
Disclaimer: I REALLY LOVE DOCTORS! I have worked with some really AWESOME ones and difficult ones. This is not attempt to degrade or tear MD’s down. Just story telling. Thank you MD’s for your intelligence and commitment to healthcare…. be kind to your nurses! We’re just trying to help!