Pullman Regional Hospital - Wednesday April 7, 2021

 These entries will be a bit odd as I (Jess) will be transcribing text messages from Dusty of the events as they happened and he had time to reach out to myself and the family. I will have him come back and edit/add more when he can. 

8:49 a.m. Dusty:  Dusty back on site at PRH, ICU staff busy in two different rooms with patients, update forthcoming once they realize Dusty has snuck in.

8:50 a.m. Dusty:  Joyce awake and watching television,  stretched out in recliner.

8:55 a.m. Dusty:  Dietician (also named Joyce, calling her Joy going forward  to differentiate) arrived to visit with Dusty. Joy have been tracking Joyce's food intake and noticed decline in food being consumed. Reviewed health log family has been keeping.

8:56 a.m. Dusty:  Dusty informed Joy that mom eats slow and if she takes too long eating one meal it will throw off her appetite for other meals. Joy acknowledged that as she has time stamps for mom's meal deliveries and tray abandonment.

8:57 a.m. Dusty: Joy began sending Joyce milkshakes yesterday and will continue sending them and smoothies to try and help get nutrients and protein into her. Joyce appears to appreciate the milkshakes and smoothies. 

8:58 a.m. Dusty:  Joy concurred with Kindred nurse assessment a few months ago, give Joyce foods she wants to eat or eats readily/agreeably.

9:06 a.m. Dusty:  Carol (respiratory tech) stopped by to check on Joyce. Had orders from doc to do evaluation on Joyce for home oxygen order. Dusty confirmed Joyce already using oxygen concentrator at home at 2 liter flow rate and uses portable oxygen for outside of home travel. Carol will update doc home O2 orders ready in place and actively used.

9:21 a.m. Dusty:  Kim (day nurse) said chest x-ray showed no pneumonia, 24 hour urine test results still pending processing results, Joyce refused to keep BiPAP on last night. Results from ultrasound of heart still showing as pending in her nurse's station report in computer. Morning meds administered - losartan, carvedilol, aspirin, torvastatin (cholesterol control), Spironolactone (blood pressure).

9:24 a.m. Dusty:  Kim knows Christy. Informed Joyce she just saw her this past weekend at a barrel race. 

9:25 a.m. Carol: Good morning, what is Kim's last name?

9:25 a.m. Dusty:  Joyce remembered Christy was her grand daughter with a prompt from Dusty after Kim departed. Kim going to see if she can get an update on ultrasound of Joyce's heart.

9:26 a.m. Dusty:  I didn't ask but will ask when she returns.

9:41 a.m. Dusty:  Kim Mcgann (sp?). Room service delivered smoothie to Joyce.

10:11 Dusty to Jess : She is napping off and on, I think she likes the smoothie when she remembers it is there. She finally told me she was not in the mood for "sour" (citrus) smoothie.

10:12 a.m. Jess to Dusty: She likes sweet ones. 

10:23 a.m. Dusty:  Joyce summoned nurse for bathroom use, got her transferred off of recliner and onto commode. Nurses forgot to let respiratory know, oxygen alarm went off because they forgot to turn off  sensors prior to removal,  caused rush of response team into room because they thought Joyce stopped breathing..

10:48 a.m. Dusty:  Joyce constipated, still struggling with passing stool. Dusty attempting to help with coaching her, Joyce forgetting how to pass stool when constipated. Nurses seeing if Miralax can be given with doc's approval.

10:49 a.m. Dusty:  Bringing in squatty potty device to see if it helps align Joyce's bowel to pass bowel movement.

11:17 a.m. Dusty:  Toileting abandoned, Joyce taking too long, falling asleep on commode. Fecal material still lodged in sphincter, unable to be passed by Joyce. Diaper pulled up to collect it in case it passes, nursing aide will see if Kim can work on getting it passed with application of lubricant and physical manipulation. Joyce not happy she isn't allowed to attempt manually removing type 1 fecal material herself with her bare hands.

11:31 a.m. Dusty:  Nurse assistant arrived. Joyce declined lunch, negotiated order to be placed at noon "for something." Joyce consented. Vitals collected on Joyce. Temperature normal, BP 111/62 (good).

11:42 a.m. Dusty:  Miley (PT) arrived to check on Joyce .

11:44 a.m. Dusty:  Miley attempting to take Joyce for walk, Joyce very concerned about fecal material still lodged in sphincter and not yet passed, Miley knows and hope is walk will help Joyce work it loose.

11:46 a.m. Dusty:  Joyce unhappy they are not letting her sit on toilet, feels like she will soil herself. Miley and Dusty assured Joyce that would be fine as then fecal material would pass. Joyce concerned about leaking, not understanding she is still wearing diaper.

11:49 a.m. Dusty:  Joyce returned to room and temporarily placed into bed  by Kim and Miley. Kim prepping Joyce for bowel impactor tool use. Joyce mad she was not taken to bathroom, resisting being assisted by Kim and Miley.

11:57 a.m. Dusty:  First attempt with bowel impactor tool ineffective. Dr. Mark arrived to assist. 

12:00 p.m. Dusty:  Doc is struggling with using the impactor tool on Joyce, they are now going to attempt to irrigate/enema in addition to lube.

12:01 p.m. Dusty:  Joyce having difficulty in following directions.

12:26 p.m. Dusty:  Joyce transferred back to commode.

12:49 p.m. Dusty:  Joyce giving up on toileting. Nurse summoned. Joyce attempting to remove wireless sensors. Kim and Abby (nurse's aid) working on cleaning up Joyce and moving her back to recliner. Some bowel movement passed. Bandaging over pressure sores replaced.

12:53 p.m. Dusty:  Joyce receptive for lunch, ordered tea, salmon, mashed potatoes with Abby's help.

12:56 p.m. Dusty:  ER director (Stephanie) stopped in to verify it was all right to bring in med students (new doctors) to review Joyce's health history tomorrow. Dusty confirmed he would be present.

1:01 p.m. Dusty:  Joyce calmed/exhausted, slipping into "idle" mode while sitting in recliner.

1:31 p.m. Dusty:  Kim arrived to check blood sugar and reattach sensors Joyce removed.

1:33 p.m. Dusty:  Blood glucose @ 165

1:43 p.m. Dusty:  Insulin administered per "sliding chart" for Joyce.

2:47 p.m. Dusty:  Joyce has been working on her lunch since 1:45 p.m., eating slow. Upset with Dusty that they don't agree - the thing Joyce wants Dusty to agree with her on is that he needs to eat the other half of her salmon and then go get to give his speech he is late for giving.

3:09 p.m. Dusty:  Room service delivered milkshake dietician ordered for her to ingest. Joyce resistant to milkshake, trying to have Dusty consume it for her.

3:35 p.m. Dusty:  Joyce attempted to remove sensors, wanted Dusty to take them off and put the system in his backpack. Joyce not focusing, trying to get out of eating her lunch.

3:50 p.m. Dusty:  Doc Geheb arrived to provide update. Calcium levels are high, Hyperparthyroid condition, can lead to weakness and confusion. Doc will call Craig shortly. Plan to discharge Joyce tomorrow. Will place Joyce back on Metformin. 

3:52 p.m. Dusty:  Recommendation is Joyce has overnight caregiver present going forward in addition to day time caregiver being present to ensure she keeps her oxygen line in place, is available if Joyce needs help/support/calls out.

3:53 p.m. Dusty:  Abby arrived to take vitals.

3:55 p.m. Dusty:  Joyce told Abby she was done with dinner - did not drink tea at all, finished salmon and potatoes. 1/3 of milkshake left. Abby leaving milkshake to see if Dusty can work with Joyce on finishing.

3:57 p.m. Dusty:  BP 126/70    Pulse 80. (Good)

4:04 p.m. Dusty:  Joyce removed her sensors, ignoring Dustys attempts to stop her. 

4:18 p.m. Dusty:  Joyce latched onto Dr Greheb saying she could go home (tomorrow) and believes that means she can go right now. Kim arrived, will ask doc if Joyce can be off sensors as she is back to continually removing them after they get reapplied. Joyce irritated that Dusty not getting her clothes and taking her home.

4:32 p.m. Joyce calmed, fighting sleeping in recliner. 

5:15 p.m. Joyce woke suddenly from napping, declared she wanted to go to bed (but not at hospital) then that she had to go to the bathroom. Kim summoned, helped transition Joyce to commode.

5:17 p.m. Joyce apologizing to Dusty for "stealing your help" (mom thinks Kim was stopped from taking Dusty to the bathroom to take Joyce to bathroom)

5:25 p.m. Joyce thinking she is at farmhouse, asked Dusty to prepare guest rooms for Abby and Kim, thinking it was late and they shouldn't drive home.

5:29 p.m. Blood sugar levels checked, 192. Joyce concerned about the empty bed in the room next to her, thinks she is taking it from someone (as Abby took the blankets and pillows from it to resituate Joyce in recliner). Blood thinner/anticoagulant administered. Miralax and metformjn to be administered in a few minutes.

5:34 p.m. Insulin administered. Metformin administered.

5:37 p.m. Joyce refused to make dinner order, Kim will stop by to see if Joyce changes her mind before shift change and closure of kitchen for the night.

7:04 p.m. High protein milkshake delivered to Joyce, Joyce attempting to resist drinking. Dusty working on getting her to drink it as she declined dinner.

7:41 p.m. ICU team got busy just after shift change, surgery patients brought in for them to deal with. 

8:09 p.m. Nurse's aide arrived to take vitals, check blood glucose,  and assist with incontinence clean up.

8:18 p.m. Toileting completed. Joyce setup in recliner. Nurse's aide believes bipap will be tried tonight for Joyce.

8:22 p.m. Peggy (nurse) informed Dusty Joyce did not sleep much last night, she hated the bipap and after it was removed she just sat awake most of the night in the recliner, taking small naps but snapping awake constantly - possibly due to discomfort of being in foreign environment and hearing foreign sounds she isn't used to at home.

8:24 p.m. Dusty packing up to depart,  Peggy and her aide will attempt to settle Joyce down with bipap after administering miralax and evening meds. Hope is Joyce will be hit with exhaustion and sleep. Peggy doubts Joyce will allow them to keep bipap on her due to discomfort or claustrophobia Joyce experienced last night from it.

8:27 p.m. Dusty returning to PRH tomorrow morning.

8:38 p.m. Blood glucose @ 156 Dusty loitering a few mins to grab this before heading home.