WNA has so many incredible members making a lasting impression in nursing. We think it’s about time that everyone else knows about our incredible members, too. That is why we have a Member Spotlight series on our website. This is the space to showcase your talent. Tell us about your remarkable research, your touching stories, the obstacles you’ve overcome. Show us—and the world—what it really means to be a Wisconsin Nurse. Fill out your form to be spotlighted! WNA Member Spotlight Questionnaire
What is your name (and credentials)?
Alex Hetzer, BSN, RN-BC
What have been your roles at WNA / how long have you been a member?
I have been a member since October 2014 and served as the Staff Nurse Representative since that time.
Where do you work?
Aurora St. Luke’s Medical Center in the Neuro ICU
What is your job title?
Staff Registered Nurse
What do you do in your job?
I care for critically ill, neurologically compromised patients with multiple comorbidities in a comprehensive stroke center. I manage complex cases such as patients with extraventricular drains, post-TPA patients, and subarachnoid hemorrhages. I perform the nursing process including assessment and recognition of significant changes in patient conditions, implementing a nursing plan of care, and evaluating clinical outcomes. My job duties include monitoring patients on the unit; assisting physicians with bedside procedures; and collaborating with teams to determine patient readiness for transfer or discharge. I maintain close communication with physicians, respiratory therapists, patients, families, and other members of the health care team. Additionally, I participate in discussions of ethics and end-of-life-issues with the critical care and palliative care teams.
Tell us a story from your job (or a past one).
When I worked in a respiratory ICU, I had a patient who I admitted into the ICU from the ED. We can call this patient Mr. B. Mr. B had come to the ED that day from an assisted living facility with respiratory distress. He was 78 years old and had a history of COPD, HTN, malignant throat CA, PVD/PAD, neuropathy, falls, forgetfulness, and prostate atrophy. He also admitted that he smoked his pipe every day and drank one beer per day. In the ED, he had an ABG drawn that showed a pH of 7.25, PaCO2 62, PaO2 101, and HCO3 27. Since the ABG showed respiratory acidosis, he had been placed on 50% FiO2 BIPAP, got a stat chest xray that showed RLL infiltrates (possible PNA; acute on chronic respiratory failure), was started on an IV antibiotic, and placed in droplet precautions. He had recently been admitted (less than 2 weeks prior) for weakness and COPD exacerbation. His code status was DNR/DNI.
When Mr. B. came up to the ICU, he was awake and alert, disoriented to place and time, calm, and pleasant. He was answering questions appropriately and cooperating with cares. He appeared quite malnourished and had a BMI of 14.38. His vital signs were stable. His lactic acid was slightly elevated at 1.4, WBC count 29. His blood glucose was 193, BNP elevated at 475, and creatinine slightly elevated at 2.0. The patient mentioned that he had two sons that lived in Wisconsin but they were out of town.
Shortly after the patient was settled into his room, he started to become agitated and pull off his BIPAP mask. When this happened, his SpO2 dropped to the mid-80’s. The patient told me that he did not want to wear the mask anymore because it was uncomfortable. I calmly but firmly explained to him the reason why he needed the BIPAP mask. I told him that the doctor believes he has pneumonia; His lungs are weak from the infection. so the BIPAP is helping him breathe while his lungs heal. I also informed him that he is receiving IV antibiotics to help fight the infection as well. The information seemed to settle him for a few minutes, but then he went right back to pulling off the mask again. Since the patient had a history of “forgetfulness” I believed this agitation to be related to dementia. When he first came up, he had already been disoriented to place and time, so he may have forgotten where he was here or why he needed to wear the BIPAP. He may just need more redirecting. I already knew that he was hypercapnic based on the ABG’s that were drawn in the ED, and confusion/restlessness are an early sign of this. However, he had an order for DNR/DNI (do not intubate) so I didn’t think it was necessary to draw another ABG at this time. In addition, a lot of patients get agitated when they have to wear a BIPAP for an extended period of time because it is uncomfortable. In order to make sure there wasn’t anything else bothering him, I attempted to probe the patient for answers, but he was not in the mood for talking. I asked him what was wrong and if there was anything I could do to make him more comfortable. He just kept saying “I want this mask off.”
After several attempts to calm Mr. B. to that he would wear his mask, I called the respiratory therapist to collaborate with me and see if we could figure something out to help him feel more comfortable. I explained to her that Mr. B. didn’t find the BIPAP comfortable and was refusing to wear it. I knew the patient was already hypercapnic, but since he was not lethargic (a late sign of increasing respiratory acidosis)– he was awake and alert at this time– the RT and I both thought it would be safe to try a simple mask at 10 L flow on him. My hope was that with the BIPAP off, Mr. B. would finally be able to rest. However, this was not the case. The patient continued to be agitated and was now quite irritable. At times he even took off the simple mask.
I asked him why he wouldn’t wear the simple mask. Surely, the simple mask had to be more comfortable than the BIPAP. He told me that he was upset because his mouth was dry and he wanted to drink water. The flow of the oxygen was making his dry mouth worse. I told him that the doctor had ordered nothing by mouth except medications. Mr. B. responded that he didn’t care what the doctor ordered. I explained to him that the doctor is concerned about his breathing right now, and that giving him a lot of water might cause him to aspirate or choke. I offered the patient a mouth swab at this time, which he declined. Since the patient had a few medications due in a few minutes, I told the patient that he could take a small sip of water with his meds. This seemed to temporarily appease Mr. B, but I knew it was going to take more than just a sip of water to calm him down. He seemed really upset; my intuition was telling me there was more to the story than what he was telling me. I left the room to get the medications.
Before I came back to Mr. B’s room, I called the doctor to give him an update on the patient’s condition. I told him that the patient was refusing to wear the BIPAP and now on 10 L simple mask, was agitated, and was quite upset about being NPO. The doctor told me I could give him a clear liquid diet. In my mind, I thought: “Great! Now I don’t have to fight with the patient over his diet anymore.” However, I was also still weary because I know that just because I have a diet order doesn’t mean I should stop using my nursing judgement. I hadn’t given the patient any liquids yet, and I had no idea what his swallow was like. I decided it was better to see how Mr. B did with his meds first, and then see if I felt it was safe to give him additional liquids.
Next, I went into the room with the patient’s scheduled medications. I gave the patient his pills, one at a time, with a small sip of water. Immediately, the patient started coughing and gagging. He couldn’t get the pill down. He ended up having to spit it back up, so I decided to hold all the rest of the pills. He then asked for another sip of water. Since I wasn’t sure how he would do with the water alone (no pills), I agreed to give him one more sip. He did the same thing—coughing, gagging, and this time desaturating. Needless to say, he wasn’t going to be getting that clear liquid diet. He was clearly having difficulty swallowing. I wasn’t sure if the respiratory issues were causing the swallowing issues, or vice versa. I was thinking more than likely, he probably had aspiration pneumonia. I made a mental note to ask for a speech therapy order for tomorrow.
I explained to the patient that I couldn’t give him any more water. His oxygen level had dropped the last time I gave him a sip, and some of the water went into his lungs. He told me that he didn’t care if his oxygen dropped and he didn’t even care if he died. It was at that moment that I realized this is what had been bothering him all along. He didn’t want to be here. I now remembered reading in the doctor’s note earlier that there had been a discussion about palliative care with the patient and his son during his previous admission, but no decisions had been made. The patient appeared very emotional at this time. I needed to know more about his wishes and if he seemed decisional to me. “Does the doctor or your sons know that you want to die, Mr. B?” “Well…no.” “Mr. B., the reason why you have to wear oxygen and why I can’t give you water right now is because this is the medical treatment that is most appropriate for somebody who wants everything done. If you don’t want those things, then a discussion between you, your sons, and the doctor needs to take place to change the goals of your care. Right now, it’s late at night and the doctor and your sons are asleep. For tonight, we will keep your care goals as they are. But tomorrow, we can work on changing them.”
The patient began to cry. He told me that he had wanted to die a long time ago, but he stayed around because his sons wanted him to. I felt my heart breaking for Mr. B. But I also knew that he needed somebody to advocate for him. I stayed with Mr. B. and held his hand, I wanted him to know I was there for him. He seemed decisional to me because his reasoning was sound and his story was matching up with what I had read in the doctor’s note. However, since I had suspected dementia, it was important to get a palliative care consult in order to decide what his care goals should be and if he is truly able to make those decisions on his own. I was sure that his sons would be involved with the decision regardless. “I will make sure that you get help in order to receive the care that you desire, Mr. B.” I made another mental note to ask for a palliative care consult.
Before the end of my shift, I verbally reported to the next nurse to ask for a speech therapy order in the morning. He seemed like he had been aspirating quite a bit and was unable to even swallow his medications. I also told her about the conversation I had with Mr. B about his wishes, and that he needed a palliative care consult. I was glad that I was able to advocate for my patient and listen to what he really needed while collaborating with other members of the healthcare team and setting care goals. When I returned the next day, another nurse had this patient, but they were awaiting a family meeting with the patient, his two sons, and the palliative care team. Within the following two days, he was discharged to hospice care. I felt like I really made a difference by advocating for the patient and helping him get the care he wanted at the end of his life.
What do you do in your free time?
travel, bike, go to concerts, play with my cats, ride motorcycles
What are you passionate about?
I am passionate about end-of-life care and helping patients die with dignity and on their own terms. There is much opportunity for patient/family education in the critical care area regarding end-of-life. My dream job would be a palliative care nurse practitioner.
Brag to us about one thing (or 2, or 5, or 10) you’ve done in your career.
I got ANCC certified in pain management this past winter!
What does being a nurse mean to you?
Being a nurse means a tremendous opportunity to touch lives in many different ways. Whether it be something small like inspiring an elderly cancer patient to dye her hair pink because she liked my blue hair, or something big like helping a grieving family cope with the loss of a loved one. I also try to learn from my patients, and I feel that nursing makes me a better person every day.
What’s one thing you wish we asked you?
What’s my educational background? (Graduated from UW-Eau Claire traditional BSN program)