Since coming off orientation I seem to be caring for a disproportionate amount of liver failure patients. At first I saw this as a bad thing, but now I’ve come to think of it as an opportunity to learn all I can about hepatic encephalopathy. Which isn’t much.
This is what normally happens: You body digests proteins, and ammonia is left as a byproduct. The liver gets rid of the ammonia and that’s that. When the liver fails to function, the ammonia particles hang around the body like so many unwanted guests at a party that’s been long over. This ammonia is toxic to the central nervous system. And this is as far as I got. No one seems to know why or how it’s toxic – just that it is. And the treatment for this ammonia overload? The dreaded lactulose enema.
So caring for the liver failure patient means dealing with his crumbling neuro status, while trying to make him poop out as much ammonia as possible. Your patient ranges from being slightly confused, to acting somewhat psychotic, to eventually landing in a hepatic coma.
The first patient was 27. I’ll call him Tommy. Suspected alcoholic liver failure, but this could not be confirmed. He was past the mildly confused stage and heading towards psychosis. Where I went wrong was that I was fresh from orientation and so I was nervous, scared and somewhat hesitant in my care. He sensed this, and so viewed me as a threat. When his family came to visit him I went in to draw my noon labs and he started thrashing in the bed and trying to kick me. His dad asked him what’s wrong and he pointed at me and said, “She’s trying to hurt me!”
My heart started racing. I left the room, got the charge nurse to draw the labs and watch over him for the next hour or so.
I went to lunch and this was what I was thinking:
My patient wants to kill me.
This nursing thing just isn’t for me.
But more importantly: How in the Hell am I going to give him his lactulose enema when a. he already thinks I’m trying to hurt him, and b. I’ve never given an enema before.
Thank God for co-workers. They listened to my story, gave me assorted pep talks, and all promised to help with the enema. I was ready to go back for Round Two with Tommy.
I will spare the details and just share with you what I learned. When a patient is liver-confused, they will take cues from you as to how they should feel. Tommy saw that as I was scared and nervous and he mirrored this back to me. I started to convince myself that Tommy was harmless. He was a scared little boy that needed my help. I was his nurse and I was there to help him. I started changing my vocal tone to sound more soothing. For every moment that he did not get threatening or agitated with me I praised him in a sing-songy voice. I felt funny doing this but the bottom line is that it was working. By the end of the shift he actually let me start an IV on him!
Later it occurred to me that I was using things I had learned from obedience training for my dog: Praise when being good. The dog takes his cues from you, so don’t show fear.