Sunday, 17 November 2013


13th October (Sunday)

Two nurses hoisted Rachael to change her pad and clean her with I's help.  Rachael reported that she felt dehydrated at 4.30pm.  The nurse made a note of this and said that she will also inform the doctor.  The nurse came back to say that a doctor will be coming to see Rachael re being dehydrated.  He may need to put a IV line in to hydrate her.  Rachael wants to make sure that the TPN team are made aware of what happens.  The H8 nurse came at 6.30 to change Rachael’s feed.  She will make sure that something is done about Rachael’s dehydration.  Rachael’s syringe driver was changed at 6.50.

Blood thinners..

12th October (Saturday)
Rachael finally received her Citalopram liquid and took 0.25ml.  The nurse was asked to check if it was ok to take the Citalopram at the same time as Lorazepam and whether there would be any interaction between the two drugs.  She was told that it was fine to use both and that there should be no side affects.  Rachael has been having problems with her catheter again.  Nurse L gave Rachael a bladder wash but it doesn’t appear to have improved Rachael’s discomfort.

Nurse L also informed Rachael that, as her blood base line readings are as they should be if she were at home she no longer is being prescribed “Blood thinners”. Rachael however thought Dr A had said that she should continue with the medication.  This will obviously need clarifying with Dr A.

11th October - hospital stay continues - preparations for going home...

DM rang saying she works in partnership with DF.  DM said she will ring and inform the hospital of what can be put on Rachael’s nose to ease the pressure when she is using the Bipap.  She also said she would get a doctor to have a look in Rachael’s mouth as she believes Rachael may have mouth thrush.

E arrived at 8.15am.  Nurse L came in to discuss Citalopram dosage.  L said she would get the pharmacist to visit this afternoon to answer any queries that Rachael had to ask.  The Doctor saw Rachael on the ward rounds at 1.15pm.  He looked in Rachael’s mouth but could not see any abnormality.  He did point out Rachael’s lips were a bit chapped but stressed this could be remedied with lip balm.  Rachael explained how much her shoulder was hurting her.  Rachael asked if it was possible to have an injection to dull the pain in her shoulder.  The doctor said he would look into it.  Rachael then asked when she could go home.  The doctor said Rachael needed to wait 4 -5 days whilst everything was readied for her to go home.  Rachael got very upset and said she wanted to spend as much time at home with her daughter as possible.  The doctor said he would double check with Dr A.

J, nurse came to take blood from Rachael’s Picc Line.  Rachael stressed that H8 have been adamant about being the only department to deal with the line to prevent infection and clotting.  J said she would have to get somebody to take blood via normal methods.

Dr S, Palliative Care Team visited Rachael to see how she was doing.  Rachael initially discussed how painful her shoulder was.  Her PA asked about injections to numb the pain directly at the site.  Dr S said this was a very difficult procedure and had to be handled by the pain team.  She stressed it would not be impossible for Rachael, just very difficult to numb the right nerve.  Dr S received a phone call from Dr A.  When Dr S returned, Rachael told her that she had been prescribed Citalopram to try and combat her emotional ability.  Rachael also explained that the oxycodone seemed to be reducing the pain in her shoulder, when positioning of a physio hadn’t.  Dr S then explained what Dr A had told her.  He had said that Rachael needs to stay in hospital a few more days so they can see if Rachael tolerates feed and the rate of feed through the PICC line.  He said they need to arrange delivery of a fridge to Rachael’s home, have the correct feed made up and organise when BUPA nurses will be calling.  Rachael was less upset once she knew what needed to be done to get her home.   She asked DR S to inform all the nurses that the PICC line must only be dealt with from people from ward H8.  She said that if Rachael ever gets frustrated or needs someone to talk to ring her on her hospital extension at anytime.  At 3pm the pharmacist visited to discuss the Citalopram.  Rachael explained that she was concerned about the imprecise measurements given by the dropper.  The pharmacist said she would look into whether tablets could be crushed and dissolved.  At 3.30 pm a student doctor came and asked to take Rachael’s bloods.  He looked at the mark on the back of Rachael’s hand and asked if people struggle to take blood from her.  She said the mark was from a canulla and requested blood be taken from the back of the wrist.  He said he would get a nurse to come back.
D, nurse came in to stop machine from beeping.  PA stressed it must only be touched by H8.  D said he will continue feed by another 50 ml, meaning Rachael had had an extra 150ml today.  He said H8 will be up shortly to change bag over.  Pharmacist came back to see if Rachael would feel better about mixing drops with water.  Rachael said she would be happier if she could get a specific volume so the measures are constant.  The pharmacist said she would measure out the 4 drops and get a specific volume.  A few moments later the pharmacist expressed difficulty getting a consistent drop of Citaloprom.  She said she would discuss with colleagues and get back to Racahel with a definite action plan.
The pharmacist rang at 4.45 to say that Rachael’s prescription of 10mg actually equates to 0.25ml.  She said she would try and speak to Dr E over the weekend about upping Rachael’s dose to 2.0mg/0.5ml as they definitely have a syringe to measure that amount.  She also advised Rachael to try the 0.25l in the morning mixed with water and flushed.  Rachael said she would try this.
K from Ward H8 came at 5.10pm to change Rachael’s TPN.  She said the feed would be on over the next 24 hour period and stressed a nurse from her department would change the feed over at roughly the same time everyday.

At 6.00pm Citalopram tablets arrived from the pharmacy.  Rachael spoke to the nurse and said she will wait for drops as she now has a volume o.25ml.  The nurse said she would speak to pharmacy and get back to her in the morning.  This can be administered using a 2.5ml enteral syringe.

PICC Line procedure was a success..

10th October
Nurse came to take bloods at 11.30 wanted blood from right arm so results would be correct.  Rachael wasn’t happy about this so nurse went to speak to doctor and decided they would just take them from the PICC line.  S arrived to come down with E and Rachael to have the Picc line.  Everything went smoothly apart from the fact that they couldn’t x-ray Rachael in her chair.  She had to go in the bed but was kept elevated as much as possible.  Rachael’s arm is quite sore but the actual Picc line is fine.  We have been advised not to touch the Picc line and to leave it to the professionals.  Brother and B visited, so put a smile on Rachael’s face.   When giving Rachael her bedtime drugs the rig kept getting jammed – only solution at the time was to force back then try again.  This was successful! Citalopram has been prescribed to start on 11th October says 4 drops on bottle but nurse advised 10 ml.  Double checked and on their system it says pills so as liquid has been given, nurse advised wait for later on to get correct dosage.

Visit from Dr E - hospital rounds (9th October)

Doctor – morning rounds.  After telling and showing the doctor how swollen Rachael’s feet are he said there wasn’t a lot he could do,  adding that water tablets wouldn’t help as the swelling is due to positioning.  I explained that R had been put on water tablets and asked if they could be stopped – he was happy for that to happen.  The Doctor reassured us that Rachael is on the licat for a new PICC line tomorrow (10th October).  We asked if he had had any joy finding out what time the procedure will be taking place – he said he had phoned but couldn’t give a time.  I asked if he would try and find out if it would be am or pm at least.  We explained that R was still having problems with R’s catheter as it doesn’t appear to be draining properly.  He said he would try and get someone from urology to come and have a look.  Just as they left R was in pain with her stomach.  I had tried to release some air with no joy so Rachael asked me to ask the DR to come and have a look, he had a fell and reassured us that it was just air after a few more attempts to release the air it worked.

Dr E and S H S (MND Nurse) came to see Rachael following S's chat with Rachael yesterday.  S ran over what her and Rachael had talked about yesterday (8th October) with Dr E and S trying to find solutions.
Dr E wasn’t sure what to suggest regarding Rachael’s shoulder pain so said he would speak to physio.  He ran over what would happen tomorrow when Rachael has a new PICC line put in to make sure Rachael was happy.  We asked if he was able to find out what time it may happen but he had had no joy.
Both Dr E and S were keen to try and help Rachael control her emotions.  They strongly recommended trying an anti depressant drops.  Rachael has tried in the past and wasn’t keen but is willing to try again.
The physio from the MND clinic came to see R regarding her shoulder after taking a look she asked R if she would consider an injection in her shoulder to stop any pain.  R said yes so she said someone would do it soon, she also asked if Rachael would mind if she rang wheelchair people to see if there is a better back cushion that would have less pressure.  R was happy for her to do this.  I asked if she would have a look at Rachael’s swollen feet.  She confirmed that the swelling was water, she said the best thing we can do is massage the feet pushing the water up R’s leg.  This seemed to work using a little cream to stop any friction.

I have tried to phone D F re Rachael’s mask on bipap causing Rachael to have some cuts in Rachael’s mouth (inner lip) there was no answer so I will take her number and phone again tomorrow.

Cold feet..(8th October)

E arrived at 8am greeted by S who explained procedures.  R was hoisted at around 10am due to by passing fluid onto pad rather than through catheter.  E spoke to nurses P and A who have requested someone from urology department to come and look at the catheter to see why Rachael is bypassing.  Macmillan nurse came to see Rachael to check about discomfort.  Told her she was still having trouble with her left shoulder.  She advised she will speak to someone regarding physio.  3 doctors came in to explain about Rachael having an x ray and pick line done on Thrusday.  Rachael requested a specific time as she wants S to be present.  Doctors said would ring and find out.  Rachael was hoisted again, this time with much less messing about by E and P (nurse) at around 2pm as pad was wet again.  S the MND nurse spoke with R regarding 3 main topics – shoulder pain, emotions and the procedure with the pic line.  R got very emotional explaining she can’t stop crying.  Brother visited at 7.30pm R has been complaining about her cold feet especially her right one.  Brother spoke to the nurse to see if any other way of keeping feet warm.  They said to keep feet raised and they will inform doctor in the morning.  Also bipap starting to cut into R’s nose.  R requested to ask Z to speak to D F about it.  We then resorted to battery socks but due to swollen ankles socks were causing discomfort.  Sister saved the day by handing over the ones she was wearing when visited with B.  Before bed checked leg bag and was empty and Rachael was bursting for a week.  I rubbed tube and could feel it blocked.  Spoke to nurse who came to syringe the catheter but was no joy as it was blocked up so the nurse put an urgent call out to the doctor.  By then Rachael had already relieved herself.  Rachael was hoisted. Still no sign of doctor by 11.15pm.  Doctor came at 11.30pm and put a new catheter on.

6th October

M arrived at 8am.  Racahel was in pain with her shoulder, arm, bottom and neck.  She had pain relief throughout the day.  Rachael was hoisted and repositioned at 12pm.  Rachael asked again for the IV nurse to look at her PICC site as it is still aching.  The nurses were unable to contact her and will try again tomorrow.  S and E visited Rachael in the morning and R visited later on in the afternoon.