April, 1977 – Midwest, USA
After one week of vacation visiting friends, I began orientation on the diabetes unit on day shift. The nurses have been very friendly and encouraging as they teach me about diabetes and how to care for the patients. This new hospital is a circular tower with 10 floors of 30 private patient rooms on each floor. It was designed with nurses in mind since the nurse’s station and elevators are in the center. This way, each patient room is equally close to the nurse’s station. Since no one has a roommate, it also eliminates roommate problems, and it is easy to put someone in isolation when they have an infection.
I quickly learned the day shift routine. After clocking in with our badge, we began by listening to the cassette taped report from the night shift nurse in the conference room. Then we made walking rounds with the night shift nurse and checked how much fluid was remaining in each IV (intravenous) glass bottle and marked the tape on the side of the bottle with the hour. Next we counted narcotics with the night shift nurse, both signed the book, and she handed me the keys. Then I mixed all my IV antibiotics for my shift in 50 cc bottles of normal saline. This could be quite time consuming if I had to mix 10 to 15 bottles. First I wrote out all the labels with the patient’s name, medication, time, date, and my initials. Then I gathered the glass bottles of dry medication from their tray in the medication cart and enough 10 cc syringes from the supply cart. Next I withdrew 10 cc of saline, injected it into the bottle with powdered medication, rolled it between my hands until it dissolved, withdrew it from the small bottle, injected it into the 50 cc bottle of normal saline, and pasted on the label.
By that time it was breakfast. The aides checked each patient’s urine sample for sugar and handed us the list of results: negative, trace, 1+, 2+, 3+, or 4+. Then I checked he patient’s insulin dose, drew up NPH or Lente, and added enough Regular Insulin (short acting insulin) to cover the amount of sugar the patient spilled in his urine. Then I went to the patient’s room and watched him inject himself while giving him further instruction.
After the patients finished breakfast, the aides started baths and bed changes while the nurses passed the 9 a.m. meds. After meds, we did treatments such as dressing changes. In between all this, we made rounds with the chart rack whenever the doctors appeared, and then processed the orders. After the MD wrote the orders on carbon paper, the unit clerk tore off the extra copies and sent them in the pneumatic tube to the correct department (lab, pharmacy, dietary, etc.) Then the nurse cosigned the order after checking their work for accuracy.
On day shift, there are 3 nurses, so each cares for 10 patients and there is one nursing assistant for each block of patients. On evenings, there are only 2 nurses so each cares for 15 patients with 1 nursing assistant on each block. On night shift, there is usually only 1 RN and 1 nursing assistant for the entire floor. This is really challenging trying to manage 15-20 IVs alone with antibiotics, hypoglycemia, etc. It is quite a shock to me to take care of so many patients after only having 2 patients in nursing school! Probably my best preparation was the summer I worked as a nursing assistant on night shift in the nursing home and was in charge of 50 patients at night. But the nursing home patients only needed custodial care; they were not acutely ill such as these complex diabetic patients.
All patients who are diagnosed with diabetes come to our floor whether they have a medical or surgical problem. We can closely monitor their blood sugars and adjust their insulin or tablets appropriately. We also are taught to quickly recognize and treat low blood sugar with 50 cc intravenous injection of glucose if they are unconscious.
When a patient is newly diagnosed with diabetes, they are admitted to the hospital for an entire week of classes. We have a new diabetes classroom and have class every day after lunch. On Monday, we teach them about diabetes in general by showing a short 8 track film and using posters. On Tuesdays, the dietician teaches them about the diabetic diet and counting exchanges of the different food groups. Wednesdays, we teach them about the 3 different oral medications (Diabenese, Orinase, Tolinase) and the 4 types on insulin (Regular, NPH, Lente, Ultralente) and they learn how to inject insulin into a sponge for practice. Thursdays we review exercise and how to travel with diabetes. Fridays we teach them about foot care and skin care since they are prone to ulcers on their feet, and what to do when they become sick. We also encourage them to walk around the unit to get their exercise. I really enjoy teaching the classes!
I have completed 4 weeks of orientation on day shift. Next week I go to evening shift for 2 more weeks of orientation, and then I’m in charge of the whole unit. I have to admit, it sounds rather scary… Every day before I go to work, I ask the Lord to give me wisdom in making the right decision and to help me learn all this new information. I am definitely on information overload!
If any of you lack wisdom, let him ask of God, who giveth to all men liberally, and upbraideth not, and it shall be given him. James 1:5
Reflection – 2014
As I think back over the workload on that very busy diabetes unit, I can recall so vividly my feelings of inadequacy and struggles with time management and making the right decisions, especially in emergencies as a new graduate. I quickly became much more comfortable with patients with diabetes which had been a weak area for me in nursing school. There are now so many medications available to treat diabetes, that it is hard to keep up with them!
I am so thankful we now have plastic IV bags and that the antibiotics are mixed in pharmacy before they are delivered to the floor. I recall dropping a glass bottle on occasion which shattered and made a big mess!
The advent of the blood glucometer so each patient can check their own blood sugar numerous times daily has made patient management much easier. As a result, the urine dipsticks for sugar have become obsolete. Our unit piloted one of the first glucometers which cost $500, needed to be plugged into an electrical outlet, and was about 4 inches by 6 inches in size. But it was much better than calling the lab for a stat blood sugar before giving the patient orange juice loaded with 3 packets of sugar while we waited for the results.