fish out of water

Got pulled briefly the other night to go "help" out in peds. It was a nightmare come true, I swear! I always do everything possible to get out of going to that unit. Sick little kids and babies are definitely not my cup of tea. Anyhow, they were getting 3 admits all at once, and since we were empty, guess who had to go on over? We had to move one patient to a different room, clean that room top to bottom, and then assist with the admissions.

Not to bad, but man did we ever work our tails off. We were praying for anyone to become critical in the ER. We prayed for an overhead code blue. Anything to get us out of peds. None it happened. So we were stuck until the peds nurse was caught up.

If it were me, I would have called in their unit manager and told her to get in there and help out. At least she knows what she is doing? Understands all that stuff that goes along with peds: special IV tubing, weights, etc and so on. No matter what people say, kids are not little adults.
Anyhow, it didn't take too awfully long to help them get caught up and we got the hell out of dodge, never to return we hope for a long long time. I found something else to do to occupy my time -- got to go start a few IV's out on the floor. Now that made me feel better!

Off to work I go. Thank god we got some patients again :)

CPR

This is why everyone needs to have a basic knowledge of CPR. I realize this is old news to many, but it does not matter that this story is old. What matters is that the people who were with this woman did not perform or did not know how to perform basic life saving skills. Ultimately, would it have saved her life? That is unknown, but it may have remarkably increased her chances of survival.

Happy Holidays!

Hope that the holidays find everyone safe, enjoying the time spent with your families. I also hope that you don't have to go to the stores tomorrow to return any gifts, surely the lines will be horribly long with loads of impatient post-Christmas shoppers, not to mention those returning gifts as well.

Lucky for me, I got CasH $$ so no need to return here :)
Have a wonderful holiday!

Accidents happen to Good people

Not that they don't happen to bad people, either. But in this case, it was a freak accident. Older gentleman, in his 70s, who lead a very active lifestyle and in really good health... strange I know for those that age right? lol. Anyhow, he was at home trimming the trees outside, when a branch that had been cut swung around the wrong way and knocked him off of the ladder onto the ground. About a 20 foot fall. Most people of this generation fall on rugs at home, or in the bathroom, or many other simpler ways. But this man fell from a good height and was taken to the hospital, where he was released with the diagnosis of a concussion.

Later on in the evening, at home, neuro status begins to change. He is slurring his words, barely able to talk, and is having weakness on one side of his body. Wife calls rescue, per instructions, and back to the hospital he goes. One thing inevitably leads to another, and patient is transferred to a higher level trauma center. Intubated. To neurosurgery stat.

A 4" section of the skull is removed to allow for the increased ICP. Body temp is lowered in hopes to preserve brain function. Obviously still intubated, with paralytics on board. Mannitol infusing. Family at bedside. Waiting for any change in condition, whether he makes it or not. It is touch and go for days.

One doctor says this is the best that it is going to get. All previous levels of function will be lost, and this patient will need to go to a nursing home for the rest of his life. Another doctor says that the other doctor is nuts, that there is always hope. ICP has come down now, and paralytics have been weaned. Patient remains intubated. He is able to follow some simple commands, and this gives the family all of the hope in the world. They refuse to believe that this is the best it will get. They have been researching and looking into rehab centers for him to go to soon.

This happened to a family member, and as one who does not live near where they live, we get a lot of second hand information from the wife and children and others who live nearer. As a nurse, it is killing me inside to not know what they might not be telling the family, or perhaps even what they are telling them that they do not understand. I wish I could be there to translate all of the medical information that has been thrust at them over the past week. But I am not able. All I can hope is that they are getting the information, the prognosis, and everything that they need to understand everything that is happening.

It is tough to be on the other side of the fence.

To Be Old and Alone, Drunk in the Cold

We have all heard this story before. Elderly person lives alone, something happens, no one finds them until finally someone goes to check on them.

According to family, this particular elderly patient lives alone. Spouse died about 7 years ago. Patient likes to drink... about a "6 pack a day" [which in medical terms usually means about a 12 pack a day or so]. Family brings over the booze. Aren't they swell? Can't bother to stay, but may as well get em drunk so they don't remember?

Meals on Wheels brings the food 3 days a week. Not sure if they just bring 1 meal, or what. Not important at this time. But this time, they showed up to find the patient unresponsive. Called rescue. Brought to ER.

Somehow, the patient got into a shut room in the house that has no heat. Yes, no heat. Body temp upon arrival at ER: 87.5; thus the unresponsiveness. Hard to say what exactly has happened or for how long the patient was in the room. Patient is not talking much at this point in time. Patient is sent to the unit.

FF to the next morning. I am lucky enough to say hi to my new regular body temp patient. Temp is now 98 degrees. Bair huggers do wonders, I say! But this is no longer the problem. Toes will be lost as they are getting darker as the day goes on. Started with just a couple of spots of purple on 2 toes and by the end of the shift, all the toes on both feet were purple and spreading to the balls of the feet. Fingers on both hands are purple down to the middle knuckle. Not a pretty picture, really. I figure this person who was once able to hold a can of beer in one hand and smoke a cigarette in the other will no longer be able to do it exactly as before. Talk about stolen quality of life of their own accord, or was it?

But this is not all of the problem. BNP is 2900. EF is 25%. Significant systemic edema to include JVD. Apneic for 30-45 seconds with compensatory respirations lasting 90 seconds. Did I mention full code? Flipping between a fib and sinus with a whole lot of frequent multifocal pvc's. Heart is getting just a tad bit irritated. Luckily BP is holding steady at around 100/70. HR 70s-80s. Mental status is caput. Barely alert, mostly restless and increasingly so. Came up with 2 PIV sites, one leaking and discontinued. The other is going good until the restlessness includes pulling off the gown and subsequently pulling out the IV. PLT are 60, so it takes awhile to stop the bleeding. A colleague and I then secure another site in each arm. One for fluids, one for 'just in case.' DT's are in the infancy stage.

Doc questions whether to start the nutrition or address the apnea. ABC's of course, and CPAP is started. Will this eventually matter though? Glucose on arrival was less than 25. The brain does not live without glucose. Is the mental status a reflection of hypoxia, low glucose, etoh withdrawal, or just a combination of the three?

All I can do is take care of each small thing as it presents and think big picture. Follow md orders. Hope like hell this patient doesn't suddenly crash unexpectedly. Will the apneic period suddenly overcome? Will we have to code this patient? Will they stop breathing or go into an unfavorable rhythm? My eyes are on the patient at all times.

Luckily, they survived to the end of my shift. For the most part, patient is stable but critical. It could go any direction at any time. Sometimes I hate the days when you just have to hope beyond all hope that they make until you leave.

But my biggest gripe out of all of this is WHY for god's sake do people not check on their elderly relatives/neighbors? Especially the ones that live alone. You know they live alone. Anything could happen at any time. Especially when you, as a family member, bring them alcohol every other day or so and then not check on them daily!! A simple phone call might suffice? If they don't answer.... Check on them! [Another case in point: eldery man lives alone, drinks. Falls on space heater but is so intoxicated, is unable to move off of the heater in time and suffers 2nd-3rd degree burns on both legs.]

Luckily this patient (above) had their meals delivered, but is this enough? It simply is not the responsibility of these volunteers to ensure the safety of another person. Sure, they do many things when they deliver food, but it is just not enough. It just makes me sad inside, because deep down I know this is not an isolated incident. It happens all of the time. ALL of the time. Sometimes it is difficult in this 'me' type society that we live in now to address all of these issues that really may or may not pertain to our own family or our lives. But something has to be done to address this problem. I wish I knew the answer as to how.

christmas shopping woes

Every year I think that I am going to get started early. Never happens. As of today, I have 0 things bought for Christmas, which is just over 1 week away. Why didn't I start earlier? Why? I do this every year. I know what happens. I guess I am just a procrastinator of the supreme kind.

Now, there is no way I am going to find any of the white/silver psp's. One child wants the white one and one wants the silver one. Now, I could potentially find the white one online, but the silver is to be found.... nowhere. So, can't get one for one child and not the other. I could order the nfl/nba jerseys they want from online, but now will they get here by Christmas? Doubt it. Sigh. (smacks self for waiting).

Not to mention, even going to the store for simple household items is a chore because of all the damn people out there shopping. Waiting in line for at least 30 minutes just to check out. I hate being in large crowds of people, especially the Christmas crowd. It sure does bring out the ugly in people. I've experienced it in the worst possible way.

Now I am going to go wallow in my misery a little more until I find something else to do. Like laundry. :)

welcome back

and yes, they will be admitted yet again. why? because they have one or more of the problems identified in this post. It is a never ending cycle of admissions until they inevitably meet Dr. G. or someone like her. Maybe even the embalmer will get them instead. Hard to say. But when they start coming in like this, you can be sure that one day soon, they just won't make it in to the hospital in time or that their family won't find them unresponsive in time. More possible even is that the disease process finally takes hold for good and won't let go until everything on the inside is ravished and gone. At least their suffering is over.


[ Yes there are really, truly sick people that have truly no reason for their disease. Yes, they too can come into the hospital over and over again. There are also people who are completely noncompliant and visit us far more often, giving them the status of "frequent flyer".]

chest pain, you said?

There once was a patient of a notorious past who came to the ER. CC is chest pain. Admit to telemetry for monitoring. Because of the chest pain complaint, orders include morphine 2 mg q4 hours, for chest pain. Enter nurse on duty. Asks patient if they are having any pain. Patient replies, not all the time, but my left arm hurts right now. Patient points to left forearm. Nurse asks the standard, on a scale of 0-10, how do you rate that pain? Patient replies with a 4. Nurse asks patient if they are having any chest pain at the moment. Patient states no. Nurse tells patient that they will get some Tylenol for the pain this time because when they go back to their 'home', they will not get morphine there. Patient receives tylenol. Nurse charts tylenol administration and documents the pain to arm and absence of chest pain.

Because pain with medication adminstration must be followed up, the nurse goes back into the patient's room to find out how effective the tylenol was. Patient states that it has not helped at all. Patient goes on to state that they said they were having chest pain the whole time that went from the heart all the way to the left arm. Nurse asks patient if they are having chest pain right now. Patient states that it is always present, that they have a 75% blockage of such and such artery. Patient states that when they were a patient at the awesome hospital, they got morphine every hour. Patient then begins to writhe around in the bed. Nurse has no choice but to go and get the morphine for the patient, who states that they are having chest pain. It is ordered. Has been more than 4 hours since the last administration. Patient is given the 2 mg morphine IV. Meanwhile, VS of T 98.7, HR 77, RR 20, BP 118/68.


Heart rhythm looks like this:

No ST elevation. Not even ST depression, as might be expected with ischemic pain. Patient is s/p cardiac cath x 8 weeks. MD is informed that patient is continuing to have chest pain. MD decides to ship patient out to hospital that performed the cath. Nurse hugs MD (not really, but she wanted to).

Fast forward two weeks.
Above patient arrives in er with seizures. Admitted to telemetry unit for observation. Has ordered tests, such as EEG, etc. Tests are negative. Neurologist tells patient that it is probable that they will be sent back 'home' today. Patient begins to have seizures again. This nurse was called in by 'friend watching over the patient' for a seizure that lasted for 15 seconds. Charge nurse then comes into room and patient begins 'seizing' episode again, in a tonic-clonic fashion involving mostly only the legs. Episode lasts 20 seconds. Immediately after episode, patient is awake and alert. No post-ictal confusion/sleepiness/nothing. Charge nurse calls neuro, gives ativan as ordered, and prepares to transfer patient to higher level facility per order. No further seizing episodes are noted after that point.

How come every time the patient was about to be sent back 'home', their problems suddenly got worse and also these problems required subsequent narcotic medications for relief? It is just frustrating to be manipulated by the system. Not saying that this patient did not actually have chest pain or that this patient did not actually have seizures. But I have yet to see a tonic-clonic seizure without some form of a post-ictal phase, even if it is just a short period of confusion. Maybe it happens? I don't know. The chest pain incident was just a ploy to get morphine. Yes, I believe that. But on the floor, we are required to treat to patient stated pain. Not too many chest pains, especially chronic as stated by this patient, have a beautifully normal sinus rhythm without any ectopy.

But there are 2 things that will get you sent to the hospital from this patient's 'home', and that would be chest pain and seizures. Sigh.

on the subject of emergencies

If your heart is showing any of the following on an ekg or a monitor.. you will receive immediate treatment.

These are life-threatening emergencies.

If you come in, and your leg looks like this:

There will be no waiting, I am sure of it. This will get you a lot of pain medication. And surgery.

If your chest xray looks like this, you won't be waiting long either.

Because you can't breathe. And you could even end up like the person in the previous post.

Ok, off rant now. Going to bed.

venting

Got sucked into the conundrum over here which makes me appreciate the type of patients I get to see. They don't walk, don't talk, and certainly get all the pain and amnesia medication they need for comfort.

If you end up like this... that was an emergency.

(btw, i have no idea who those people in the picture are).

Change of Shift..

.. is up at Emergiblog. Kim has a terrific edition up now for your reading pleasure.

ice. blech.

I love my brother. I do. But I am so glad not to be where he is right now. cold as hell. maybe have electricity. trees on your house. all is a nightmare that is the the midwest right now.

thank god i moved east. shoot, this would shut down the whole entire state here for like a month.

Clinicals

Clinicals were very stressful. It was like living in your own little world for about 2-3 days a week because you have all of this information to write down and put in your head for quick retrieval. It gave me horrible hand cramps from all the writing. In fact, our first year, we had to literally write out each drug card. Not typed, not pre-printed, but hand-written. It sucked, especially when I had a patient like patient 1 below. We prayed for the patients with only like 5 medications. But I also learned those medications very well because of it. In our second year, which is exampled below, we were allowed to type up the drug cards or use the pre-printed ones if we had them. Most of us didn’t, we just typed and printed them ourselves. One day, in our first year, I had a patient with anemia. Instructor wants me to write up ALL the anemias. I could have died. Do you know how many there are??? My hand cramped for like 3 days after that because we had to hand write those too. She was a tough one, but I respect her for it, even today. Ok, so you want to know what it was like in my clinical experience? Read below.
---------
Here is an example excerpt from my clinical experience:
Day 1: Attend lecture. Get patient assignment for the next day, which will be 2 patients.
Patient 1:
Diagnosis: Pneumonia. Patient history includes: HTN, DM, COPD, CHF, Hypothyroidism, AFib, GERD, CAD, CABG (2005), Bilateral Fem-Pop (2003, 2006), Smoker.
Med List: Protonix 40 mg, Atenolol 25 mg, Lisinopril 40 mg, Diovan 80 mg, Reglan 10 mg, Digoxin 0.125 mg, ASA 81 mg, Glucophage 1000 mg, Glucotrol 5 mg, Levothyroxine 100 mcg, Pravachol 20 mg, Lasix 20 mg, Aldactone 25 mg, Coumadin 2 mg, Novolog Sliding Scale, Lantus 40 units, Multivitamin, Zosyn 3.35 grams, Solumedrol 60 mg, Levaquin 500 mg, Xopenex/Atrovent nebs, Advair, Spiriva, Nitropaste ½ inch, Nicotine patch 21 mg, Ativan 0.25 mg, Gabapentin 600 mg, Hydrocodone 5/500 mg prn moderate to severe pain, Tylenol 650 mg prn mild pain, temp > 101.
Treatments: Blood sugar glucometers AC/HS, O2@3L per NC, Nebs q6 hours, Daily PT/INR, daily weight
Patient 2:
Diagnosis: Acute Pancreatitis. Patient history includes: GERD, ETOH abuse, Smoker, Cholecystectomy (2000), Appendectomy
Med List: Protonix drip 8 mg/hr, Demerol 50 mg, NS with MVI, Thiamine and Folic Acid to each liter @ 80 cc/hr, TPN @ 60 cc/hr, Lipids @ 10 cc/hr [total 150 cc/hr IVF], Nicotine patch 21 mg, Novolog Sliding Scale, Ativan 1 mg prn, Librium 50 mg prn.
Treatments: Blood sugar glucometers q 6 hours, Central line, Neuro checks q shift and prn, NGT to LIS with 30 cc irrigation q shift, bilateral soft wrist restraints

With assignments in hand, off to the facility (45 min away) for chart information to include: H&P, lab data, and any other information pertinent to the preparation tool and treatments scheduled. This takes 2 hours of writing stuff down and then 1 hour to drive home.
Get home. Make sure uniform is clean and ironed, if not , throw it in washer stat. Order pizza. Kids love you for ordering pizza. Send kids in other room to watch whatever they want. Kids love you more because they can watch Spongebob, Sportscenter, videos all evening as long as they get their homework done. Hole yourself up at computer or desk or kitchen table with all your Med-Surg, Drug, Lab, and Care Plan books. Write up the main medical diagnosis and one additional diagnosis for each patient – complete disease pathology plus anything else the book has in it so nothing is missed. Make a list of nursing diagnoses and care plan interventions expected for each patient. List all abnormal and pertinent normal laboratory data with explanations of each and why abnormal. Write or type up each medication listed on index cards to include: name, action, dose and route, contraindications, administration information, side effects, and nursing implications. Make sure kids are bathed and tucked in by 10 pm. You finally get to bed at 1 am.

Day 2: Alarm goes off at 4 am. Shower. Iron uniform if not already done. Pack bag with all needed nursing supplies, paperwork, and whatnots. Leave house by 5:15 am. Get to facility at 6:20 am and on the floor by 6:30 am for pre-conference. Discuss expectations of patients and their diagnoses. Get report from floor nurses. And off to the floor to begin your patient care. You are selected to give medications today on both patients. You have to do all patient care to include toileting, baths, linen changes, meals, etc. Also reviewing drug cards so that when quizzed by the instructor, you know these medications and why they are being given. You also have to find time to write your notes and assessments for review by the instructor. She would like to have these by 10 am. Continue throughout day until 3:30 pm when you break for post-conference. Leave facility by 4:30 pm. Get home by 5:45 pm. Plop on couch. Nap for 30 minutes until kids wake you up. Take youngest child to basketball practice. Bring sandwiches to eat on the way for dinner. Get home at 9 pm. Put uniform in washer again. Review paperwork for tomorrow and make any needed changes. Iron uniform tonight. All in bed by 11 pm.
Day 3: Alarm goes off at 4 am again. Get up at 4:30 and shower. Bag still packed from yesterday. Enjoy extra 15 minutes of coffee. Get to facility by 6:15 am and repeat yesterday all over again. Leave facility by 3:30 pm today as instructor will do post-conference in class tomorrow after the test. Get home and finish up clinical paperwork due tomorrow. Fix a real dinner tonight and get kids to help with clean up. Gather books and notes to study for test tomorrow. Get to bed by midnight.
----------
How the day went in the hospital depended largely on the patient. If you had a lot of extensive things going on, like above, it would be so hard to get everything done, but you did it. You knew your drugs. You knew their medical diagnoses in and out and could spew off tidbits of information at the drop of a hat. When the instructor asked you about the most obscure medication on the list and you didn’t know it, she would let you look it up and then tell her about it. One thing about clinical is that your fellow students were usually there to help if needed. And your instructor was always available. It was a team work environment. But I am so glad it is over :)

er trip

oldest son 'partially subluxated' his right shoulder joint this evening playing basketball. supposedly, he 'packed' a shot, felt the shoulder "slip out" and couldn't move his arm. so being the tough dude that he is [he is almost 15 now], he decided he would try to put it back in himself. then he calls me at work because he is in a lot of pain. oh yeah, he was in pain. but he got the joint pretty much back in place, so the er doc had very little manipulation to do. for me, the mom and not the nurse, this made me pretty happy because i would hate for him to have to endure anymore pain than he has to. although i have to say, that my son is pretty stoic when it comes to pain.

now he has to wear a sling for the rest of the week and got a note to get out of PE. he was ok with that, but he really wanted a slip to get out of homework for the week because he is right handed and said he won't be able to write. KIDS. :)

i wish i could say that this was one of the few er trips that we have had to do. well for my oldest, this is one of the few. he doesn't get hurt often. he has broken a toe before, and that is about it, really. oh yes, once he broke out in hives but never did figure out why.

my youngest has been to the er as a baby for influenza, hydrocele blocking urine output (several times) until that resolved, rolling down the stairs (hangs head -- who knew he would roll over to the stairs?? lol), falling down the stairs in the walker (yes, those warnings were heeded, and yes we had a gate, but oldest son left gate open!). One of the sounds you will never forget is the 'thump, thump, thump' of your child going down the stairs. Oh and he has had broken a finger too.

now, those are about the only reasons that they have been to the er. tonight a whole family with 5 kids running around the er waiting room, jumping, laughing, having fun, acting like normal wild toddlers all came in for an 'overdose'. Must have been benadryl with paroxysmal effects or something. they were seen before my child with the dislocated shoulder. good thing it wasn't serious on either accounts.

ok off for the night. gotta work in the morning. sigh.

where have i been?

I would love to say where I have been today, but it's a little to close to home. Just let me say that it involves something famous. :) once in a lifetime.

It was fantastic, really. But that is all I can say.

orientation

monday began my official orientation to the icu. started with the standard critical care classes, and orientation on the unit. not that i needed to be shown around much, after all, i did work in there as an extern for almost a year.



i just wanted to say how happy i am to get up in the mornings and show up for work. what a difference a change makes, especially a change to an area of your career that really pushes your buttons in the right way.

Continuing Education

Is it just me.. or shouldn't all states require nurses to keep current with the nursing practice? After short research, I have found that approximately only 30/50 states require the nurses to have a certain number of CEU's per required time period. In fact, I live in a state that does not require nurses to fulfill any of these requirements. Is that a good thing.. or a bad thing?

Sure, I think that we should all attempt to remain current after our graduation. But on the other hand, some of these continuing education units are damn expensive. Who wants to pay 30 bucks for each test that is sent in? I don't! I don't understand why it is so expensive, and just where does that money go? For instance, if your state requires 30 units/hours over a course of 3 years, and let's say for the sake of it, each article in your favorite journal that has these continuing education articles/tests for $29.95 each and worth 1.2 contact hours each.. that means that you will spend approximately: $750 to continue your education if you only go that route. That's a good little chunk of money for some people.

But, does this also mean that nurses who live in a state that requires these units are considered to be more 'up to date' than those who live in states that do not require these units? Does the responsibility then fall upon the facilities to keep nursing practice updated on new standards? Who is responsible for teaching these 'old' graduated nurses the new tricks of the trade? Graduate students? Staff education? I don't know! I guess if your state doesn't require these ceu's, then the responsible thing to do as a professional would be to subscribe to a journal or two or so to keep yourself updated. I know I do.

change of shift

Change of Shift is up at Dr. Anonymous. I am pleased to be included in this week's edition.

Go on.. have a read :)

10 things I can't live without

No particular order here...
1. DVR/Tivo
2. My car/My job/My paycheck (ok that is 3 things but they are all related)
3. Diet Mountain Dew
4. Coffee with Hazelnut or French Vanilla creamer
5. Ben & Jerry's Chocolate Fudge Brownie
6. XM
7. Netflix
8. Laptop/Internet
9. Cell phone
10. My kids... of course.

TV

What am I going to do this January when I have no new shows to watch? Other than American Idol. I loooove American Idol, but no 24???? No Lost????? and so on??? Do they not know that the only tv show my step-father watches religiously is 24? Do they not know how miserable that is making my mother, having to listen to him gripe about nothing to watch this winter since 24 is suspended indefinitely? All of this over royalties for web content, if I understand what I am reading.

I urge the studios to give these people what they want. Without them, you have nothing, as you will soon see. People love to watch tv. Love it. Especially in the winter. There is nothing else to do! But on a high point, I am taking 2 classes for the spring semester, and this will allow me to concentrate on my classes instead of being disrupted by tv. Shoot, maybe even families will start spending more time together. Maybe even people will get up off of the couch and start exercising???? (I doubt it.. luckily, cable provides mucho entertainment, even if they are reruns).

Anyhow.. I will probably have a boring winter with nothing to look forward to on the tv. Boring. I guess I can up my netflix and watch a load of movies. What other option will I have? Other than American Idol and all of its cheesiness.

Fatal

It was a simple case of clostridium difficile. Or so it was thought. But in reality, it was much, much worse. Thanksgiving day, the patient was in good spirits, mad as hell that there was no turkey to be ate or the day spent with the family. Mad as hell because the doctor said that the patient was full of stool and what was escaping was also positive for c. diff. The patient is on isolation. Lots of handwashing going on in the room by the staff, and family had been told to be sure to wash well too. But did they? They were reminded time and again, but can we monitor their every move? Anyhow, the patient was ordered a laxative to get the stool out overnight, which did not work until the next day. Samples sent to the lab continued to come back positive. Patient is in fairly good spirits, no distress, just upset because the laxative seems to have been working overtime now.

I did not have this patient the next few days. But fast forward 2 days, come into work and the patient is being transferred to ICU. WBC count suddenly up to 48. Is it an acute abdomen? I will never know. Once that patient was out of my care, then I had to worry about my new patients and their problems. But this patient just looked bad.

Fast forward 2 more days. WBC count suddenly up to 120. Pt dies. From C. diff resistant to antibiotics. Gone. Coincidentally, patient had a family member that had passed very recently from complications associated with the same disease. Hmph.

This is scary to me for several reasons. Did I wash my hands enough? I think so, god, I hope so! What about the family that had visited him on the holiday? Did they wash good enough when I wasn't there? Did the other nurses remind them to be diligent on handwashing? Did the other nurses wash good enough and often enough as well? Did the housekeepers clean the room good enough so that the next person doesn't get this disease?

I have had a lot of patients who have had C. diff. A lot. It can become so common at times (they seem to all be in the hospital at the same time) that it just becomes a nuisance. The constant stools. The smell. But never had anyone died from it here recently in the last few years anyhow. Now, I know I will learn from this. I am sorry this patient had to suffer that fate. Truly sorry. But now I will be super diligent in handwashing and all the precautions that come with this disease. Not that I wasn't following the guidelines before. Not that I didn't wash when entering and leaving the room. I always had on gloves, always. But the idea that somehow I may contact this highly trasmissible disease is just simply scary.

And for all the nurses out there, hopefully this will serve as a reminder of the true seriousness that C. diff can present. Be diligent.

Pt satisfaction rules, hospitals drool

Perhaps I am a bit jaded. I don’t know. I cannot for the life of me remembering being taught that the patient is always right. Now, I know that the “customer is always right” is an old adage passed down in customer service to keep those customers coming back. But when did patients suddenly begin to apply to these same standards? More often than not, the patient isn’t always right, otherwise why else are they in the hospital? Most don’t choose to be admitted, although granted there are those people out there who enjoy nothing more than being in the hospital.

I also understand making that stay in the hospital as pleasant as possible. Sick people are miserable and have the capability of making everyone else around them miserable as well. This misery feeds on the environment and trickles down to all levels of employees. But with the implement of all the muriad of information about patient satisfaction, I think it is high time that health care professionals take it back.

Being in the hospital is not about what you want, it is about what you need. Staying in the Hilton on vacation, for example, is what you want. But you don’t necessarily need it. The hospital is definitely not the Hilton. I mean, I would much rather be in the Hilton, but they probably are not going to be able to give me IVF. You will pay lots of money to stay in either, but only in the hospital do the employees also potentially pay for your stay, especially if you are on Medicare or Medicaid. Medicare or Medicaid certainly will not pay for your stay in the Hilton. Since many hospital earnings come primarily from these two sources, why can’t the health care professionals have a say in the care of the patients? Why do we have to bend over backward because the administration says so? Between all of the taxes paid from our paychecks, we probably send the government enough money to pay for that hospital visit. Why do we have to heed to the complaints of the people who didn’t get what they wanted out of their hospital stay?

Not all patients are like this. Many are very gracious about the care and information that we give them. But it is the few worm infested apples of the bunch who take the time to send in those surveys who ruin it for everyone. I don’t know if some people think that there is no need to send it in if you had exceptional care. It seems it is only the ones who had a “problem.” Is that really reflective of the care we provide as professionals? We are admonished like school children if we are not doing everything possible to ensure the stay in the hospital is not like the stay in the Hilton.

Some examples of things that will never be like the Hilton in the hospital:

* Your food will never taste like it does at the hotel. In fact, it won’t even taste like the food at home, let alone McDonald’s. But because of the food you eat in those places, you are in here with a blood sugar of 600. Please don’t be upset with us when your food tastes like cardboard. We are trying to make you better, and that food will most likely have very little sugar and salt. Sorry. And we will probably see you again in a few weeks because you didn’t follow the instructions that we left with you at discharge on your diet or medications.

* You will get woken up at all hours of the day and night. We do not have a wake up service. We need to monitor your vitals and all sorts of things, even at night. Unlike in the hotel, you are not here for rest and relaxation. You are here to get healthy, and if that means waking you up in the middle of the night because your heart rate suddenly dropped to 30, then we will do so. Sorry.

* You can call for room service in the hotel. They are happy to bring you whatever you want whenever they can. Shoot, you even tip them for their services. At the hospital, we cannot accept tips, even though we may bring you many things you want throughout your stay. But just because you want something, doesn’t mean you can have it. For instance, the person above with the cardboard tasting food, please don’t have your family bring you a bucket of chicken in. It will only make your stay that much longer because we will not be able to get your blood sugar under control.

* In the hospital, all rooms are pretty much created equal. [Unless you are in the OB ward, but that is different.] Please don’t complain about the furniture or comfort of the bed. In the hotel, you can have a nice, soft, pillowed mattress. But in the hospital, those types of things are difficult to clean and breed germs that we may even be unaware of. Yes, we understand that it is not like sleeping in your bed at home or at the hotel. There is nothing that we can do about that. Really.

Well, those are just a few things that I can think of anyhow. All I want is to take care of my patients in a safe environment. I cannot help it if the MD orders something not to the patient’s liking. Like actually getting out of the bed and sitting in the chair for a few minutes a day. Or being on a fluid restriction because your kidneys cannot handle it, and the extra fluid will send you into pulmonary edema, but every drop of fluid you can get your hands on you suck down in a blink. Gone are the days of patient responsibility. It has become an all hospital responsibility to ensure that everything is done to the patient’s satisfaction, regardless of outcome.

things they don't teach you in nursing school...

Going against the pack mentality of some of the more experienced nurses. Sure, in school, we are taught to embrace change and learn all kinds of new things that may or may not be beneficial to the area in which you finally work. Just good luck in getting some of the more experienced nurses to care. Many times, it is very hard to get them to see beyond the way things are always done. It is a slippery slope to fall into; sometimes you are even pushed in order to conform and not upset the balance that is established.

How to deal with difficult families. Only experience gives you this inside trick. Sure could have used it lately too. It is difficult to get frustrated at your new job and then have that compounded by families who are now empowered with a plethora of information from the internet or keen eavesdropping skills. It is also as if the families can smell new meat and feast accordingly.

Ways to incorporate your newly learned skills and knowledge into your job. You are new and so people tend to not take you seriously. Often times, things you say or do will be discounted because, well, you are new. You have no experience. You need to learn the “real world” of nursing, or so they say. Also, this is frustrating because you need to develop your own skills along the way… and it is also used to get you to conform to the “old, better way” of doing things. May as well hang the sign that says “Change not welcome here” above the entrance on some days. If you are lucky, you can work in a progressive environment that is willing to accept that a new grad may actually know something :) In some ways, I am lucky to have a portion of that environment. I know that administration (believe it or not) is working to make our lives as nurses better, it will just take awhile to for it to be accepted.

Dealing with the stress of the job. Sure, you learn to cope and manage in school and how to deal with that stress. Often times, those same coping skills do not assimilate well into the job. When working with no new people, it is difficult to get them to remember what it actually feels like to be a new graduate. Things were done much differently back then, weren’t they? But they forget what it is like to be unsure of yourself, and building your confidence in your new job can take a good amount of time. Are your co-workers enablers or disablers? Will they give you a good environment to encourage your skills and build that confidence or will they disable you completely, make you feel burned out within 6 months because you are never able to make that step forward? Will you go home and cry because you feel that it is just too difficult to manage some days? Maybe you might even cry on the job. Is that a sign of weakness or just simply poor coping skills. Maybe it is just learning when to take a step back for a moment to gather composure without interfering eyes that refuse to encourage you or give you advice on what to do. You may need to figure it out on your own, and it shouldn’t be that way.

No situation is perfect. In school, you deal with textbook situations. More times than not, you will be confronted with cases [patients] who are not textbook. You have to rely on the experience of others to guide you through, and this can be difficult in so many ways. Not only for you as the new nurse, but also as you the former student not long out of school. You want to rely on the textbook, but it can fail you. It gives you the guidelines and the basics in which to follow, and then you need to adapt those guidelines to each patient. Much like how you adapt your care plans, but in the real hands on setting. If you aren’t able to rely on your co-workers to assist you through these situations, you can remain completely lost. Someone you work with is a good mentor. Seeking that person out can be a long process, and I hope that you find that one person.

Utilizing resources. As a new grad, you are a blank slate. Of course you learned a lot in school. You learned exactly what you need to learn in order to pass boards. You learned a lot in clinical that gives you some hands on experience. But what they don’t teach you, or really can’t teach you, is how to use the resources at your new job. The instructors don’t know where you will go once you leave their nest. You have to actually sit back and watch others, see where they go to find answers. And if in doubt, you can always pull out the policy and procedure manual. It is full of answers specific to your facility.

I am sure there are more…

alert and oriented guidelines

There have been a lot of posts lately weighing in on patient satisfaction surveys. I agree in the fact that it seems we as nurses are treated more like room service than well, nurses. I believe in participating in your own care if you are able. So you get the survey and are asked if the nurses were helpful or attended to your needs. You may score them low because they didn’t let you go outside to smoke or bring you something to eat in the middle of the night knowing that there isn’t any food on the floor other than graham crackers or unsalted saltines or because you simply cannot eat anything right now. You may even choose to score them low because when you rang your call bell your nurses were in another room cleaning up an incontinent episode, and they didn’t get you in your allotted ‘me now want something’ time. So here are a few guidelines for alert and oriented patients in the hospitals. Please abide by them carefully.

- Assuming that you do not have some debilitating injury, you were able to do many things for yourself at home. We encourage you to continue doing them here at the hospital as well. Please feel free to bathe or wash up anytime you feel like. We will be happy to bring you the supplies you need. Want to walk down the hall? Go for it. Docs love to see ambulating patients. So do nurses, for it means you will be going home soon.

- Please don’t use the call bell for trivial matters. While you are spending time lying around in the bed, think of things you will need as the day goes on. That way when the nurse makes rounds, you can tell her what you need so she can get it at one time instead of being interrupted all day long to get you a drink or ice or whatever else it is that you need. Unfortunately, there are other patients on the floor too that need to feel just as special as you do, only they aren’t able to control many of their own body functions, including their own minds. And then when you do ring, we know that you really do need something that is important and will attend to it as soon as possible.

- Bored? Need something to read? We have a ton of patient education materials at the nurse’s station. You could always ask for materials about your diagnosis to read in your downtime. Also, while you are reading and learning about your illness, you could write down questions to ask the doctor when he makes rounds. This saves a lot of time at discharge.

- Speaking of discharges. So the doc said he is going to send you home today. Great! Now remember that we cannot just unhook all that tubing and iv’s and stuff before we get the definite orders for you to leave. You have to remember that typing up discharges can take a good amount of time depending on what medications you were on and what the doc has ordered for you at home. Instead of standing at your door giving us the evil eye because you have been waiting for an hour, pack up your stuff and wait patiently. Oh and remember that patient education? We need to go over it again, so if you had been reading the information from when we gave it to you earlier, whether you asked for it or not, it could make the discharge time go by much faster.

- Don’t be a complainer or a whiner. As a patient, you have a reputation with nursing staff. Those patients who fall into this category are the ones that the nurses dread going to see. Why? Because we are doing our job as required by the hospital, by the state licensing board, by your medical diagnosis and all you ever do is find something wrong or something that just isn’t quite right according to your personal wants. You have to remember that being in the hospital isn’t about what you want, it is about what you need. And often, you need to rest so that you can heal.

- When we are firm with you, don’t take it as that we are being hateful or just mean. We are being firm because you aren’t paying attention to us. Remember when we told you not to mess with your IV? Well you didn’t listen and now the site is leaking, and so we have to stick you yet again, causing pain. We aren’t being mean. We don’t like to cause pain. We tried to warn you. Now see the point about complainers and whiners.

So the next time you get that survey in the mail, put it all in perspective. As stated above, it isn’t about your wants in the hospital, it is about your needs. Did you have everything you needed? If you did, then score it high. Were the nurses caring? If we were firm with you, was it for your own good? We also understand that not everyone has a great bedside manner, so you have to judge how you acted and how the nurses acted in response to that. If they took care of your needs no matter how ugly you acted, then score them high. Did the nurses answer your call bell in a timely manner? Ask yourself how many times you hit the call bell and what exactly were the things you needed? And then answer this question, did the nurses respond and bring you what you need? If so, score it appropriately. Oh and if you cannot remember the names of all of the nurses who took care of you, don’t single out one person who may have only had you for one shift. We all share in your care, so we all should be rewarded accordingly. This includes not writing down only the name of the discharge nurse because she was the last one you talked to, even if it was me.

Now, starting with that next admission, should you ever be admitted as an alert and oriented patient, remember these couple of guidelines. Your experience is likely to be much improved. :)

I am sure there a few more I forgot to add..

Sick :(

Left work early last night (our census was down) but have yet to hit the sack. Believe me, I tried to sleep in the bed, tried to sleep in the chair in front of the tv, but alas, no sleep. You see, I got the sniffles. Hell of a cold coming on and I am miserable. Thankfully, I am not on the schedule for tomorrow... well today, now. Go to wally world at 3 am to get some medicine. Waiting for it to work. Had to wait to take it because I took some medicine that I had here at home, that didn't work, and had to wait for the time to be up to take something else. So here I sit, bored, tired, miserable, mouth breathing, lips chapped, just in a plain sorry state. All I want to do is lay down but as soon as I do, congestion city. I hate a snotty nose more than anything in the world almost. But might as well stay up now and get the kiddos up for school. Then sleep it off hopefully during the day. If I feel this horrible tomorrow night, guess I will have to use some of my sick time for Tues. No way would I want a nurse coming into my room as bad as I am sure that I look at this moment. No way. Sigh.

It was a slow one...

So last night was pretty uneventful as far as the evening shift goes.
So I come back to the floor from eating dinner, and the na who is assigned the other half of the floor tells me that she emptied the bsc for one of my patients. She said that she did a hemoccult because the stool was visually quite bloody before she realized that the pt was in for a lower GIB. She laughs at herself.. but I ask her.. well was it positive?? :)

One of my pts was transferred to hospice care before coming out from the unit as a transfer. This pt was quite young by our standards (age < 50). End stage cardiac failure. EF less than 10%. Respirations cyclic with 20-30 sec periods of apnea. All we can do is make the pt comfortable. It is sad though that the family wasn't quite ready to accept the prognosis, and it seemed that they were quite unsure about the care hospice provides. I did a good bit of educating with the family on heart failure. Not a lot on hospice because I don't know much about their program other than the comfort care and support that they provide to the pt, families and loved ones coping with a terminal prognosis. I wish it were easier to tell a family that their loved one was certainly going to die. I know that the doctors have discussed it with them at length, and they know what is going to happen, but it seems that they are starved for information about what is happening. The disease process, how much time does the pt have? things like that. How can I give definitive answers? I know that is what they are looking for, but no one has that answer. The pt could live a couple of days to a couple of months? I had no answers. All I could tell them about was heart failure and what it does to the body. I did the best I could to provide support, veracity, and caring to this family. It's all I could do.

Other than that.. nothing else really happened all shift. All of my patients lived for those 8 hours :) Always a good thing! Had some stable pts and a couple of really sickly ones. One pt has a creatinine of 11. No dialysis access because 2 days ago, coags were non-existent. Now, after multiple vit k injections, the inr is down to 3.5 but still too high to risk catheter placement. I am afraid though that if it isn't placed soon, the pt is going to take a turn for the worse. Mostly because the pt has stated how much better they have been feeling and has been more alert than about a week or so ago. They always seem to be getting better before it turns. And worse is when the family notices and gets false hope. I try to remind the family that even though the pt seems to feel better, the pt is still very ill. All I can do... after all, I don't predict the future.

Now here is crossing fingers that tonight goes much the same.... uneventful. But we tend to have a lot of admissions on Sunday, usually after church. Crossing fingers :)

thinking out loud

there were a couple of things i was worried about once i graduated and passed boards.
first thing was accepting the position in the unit where i currently work and how the people there would treat me and see me in this 'new' role.

having worked as an extern on the floor for awhile and then in the icu for even longer (which i love the icu, no secret there), i saw things and took note to things that happened between people, how nurses were, and such. i didn't forget these things. and i TRY my best to have kept my self promise to never do these things. but for me, the treatment hasn't always been the best. for those to whom i was basically an equal for a good amount of time, it seems that they have a hard time accepting me in the role of rn. for some reason, they expect me to do all of my job and some of theirs too. i don't get it. when i clock in, i do my job. i do what it is expected of me. why can't these people do their job? maybe it is just the dayshift people.. i don't know? one thing i do know is that there is so much more teamwork on nights. period. days.. not so much. people are so afraid they might have to do more than someone else. it's crazy. is it so hard to do your job? as a dayshift nurse, i have a hundred meds to pass out at 9 am, along with doing assessments and hopefully finding time to chart. is it necessary for me to also feed a patient or change a bed while you sit on your ass at the nurse's station, talking? it's so frustrating. mostly because patient care comes first for me. i wish i had the time to sit down and chit chat. and then if i ask you to please help.. don't give me the evil eye. sure, i did your job for almost 2 years, and yes, i can still do it, but unfortunately at this moment you cannot do my job. and it is now my job to make sure you do your job. if you did your job, i wouldn't have to ask you to do it.

which leads me to the other problem. three months in and the burn out is beginning. many, many days i so wish i would have just taken the nights position. people on nightshift are just a different breed of people. they are more laid back. you can actually joke with them without them taking anything personal. life goes on. sure you may get frustrated and mad at times, but you are still a team. period. on days, it is sink or swim. sometimes i feel as though i just tread water all day long. just the other day, have to work 12 hours. come 3 pm, we have 3 nurses for 20 patients. i am told that in addition to my 5 existing patients, one who will be arriving any minute from the ed, and potentially 3 discharges in that group, that i need to pick up 2 more patients, one of which is a potential discharge. md's haven't yet made rounds. i told the charge nurse that i 'can't' do 7 patients. note i said can't, not won't. i have 3 months experience, but she thinks that i can take care of all of this shit. are any of the dc orders done? hell no. when another nurse stands up for me, the charge nurse states that i should be able to take care of all of these patients. then she promptly runs into the manager's office to "tell on me." in the meantime, i get report on these 2 extra patients, only to find out a few minutes later, the manager suddenly decides she will come out and be charge for the next 4 hours, freeing up the oncoming charge nurse to take a group. leaving charge nurse seems pissed, tells me i don't have to take the new patients, and goes home. essentially, i finish the 3 discharges as timely as i could [meaning waiting for md rounds and orders] all the while with a family member staring at me, giving me their own version of the evil eye for 2 hours! as if i can control when the md makes rounds, writes orders, and then prioritizing the discharges and other stuff i have to do to make sure my patients get safe care. staring at me does not make me work faster. it just makes me mad. to top that off, the patient storms down the hall, and yells at me for not getting that dc done fast enough. oops, there went the press-ganey score for that patient. hope the manager doesn't call that one tomorrow. in all, we completed 9 discharges for the floor and 5 admissions in those 4 hours of hell. but damn, it's days like that that really make me regret the fact that i didn't shop around other hospitals for a job. i am not saying that it is any better anywhere else, but i didn't even look, and that makes me sad inside.

is it too soon to need a vacation already? well, i try not to take the job home with me. and not all days are like this, but many days are. unfortunately, in a tele unit, we have a high turnover of patients. that's just standard. 99% of chest pains are admitted, whether it is real chest pain or not. many are sent home the next day with negative work ups and negative rhythm changes. but once those rooms are empty, the er typically has another to fill its spot. and this time of year is supposed to be our 'lull' time. hasn't happened this summer. we have been rocking and rolling all summer long. makes for good paychecks and ot opportunities. doesn't help with the day to day doldrums though.

on that note, i am off to bed so that i can do it all over again tomorrow. wonder who i can make mad? oh and my biggest gripe of all... taking care out of our hands and turning the hospitals into hotels. all to look good on a survey which asks questions about matters completely out of our control. can i control how old the furniture in the room is? nope. can i control how the food tastes? nope. can i control the fact that the walls aren't thick enough to block out the noise of the confused patient next door who hollers all night long because they don't know any better? nope. that, however, is a different topic for a different time.

less carbon, more oxygen please

chalk it up to my inexperience, but as i am in the room with the pt attempting to get a urine sample for drug screen, i was much too distracted to look at his nose to see if the nc was correctly in place. story goes like this....


patient has arrived back to his room from getting an eeg. nurse goes into room to reconnect the telemetry after being informed said pt is back. ask pt to pull shirt up over his head so that said electrodes can be reapplied to chest. pt complies. good, he follows commands. tele is intact. knowing that i need to get a urine sample...
..........
-nurse: do you have to pee?
-pt: yes.
-nurse: ok. i need you to pee in this little cup. do you think you can do that?
-pt: yes. yes, i need to pee. i need to pee.
nurse hands pt the little cup, expecting pt to comply and pee.
pt fiddles with cup, then holds it in his hand to side of bed, over the edge.
-pt: i need to put this right here.
pt fiddles with cup some more. nurse takes cup away from pt.
-nurse: if you have to pee, you can pee in the urinal. i will pour it into the cup. can you do that?
-pt: yes, need to pee. hand me my piss bucket.
nurse complies and hands the pt the urinal.
-pt: i have to pee. this is very important for something, but i am not sure what. (pt holds urinal in hand at end of extended arm for me to see.)
-nurse: yes, you need to pee in it.
-pt: no it has another function. i know it does. [sighs] i can't think of it at the moment.
nurse, expecting him to urinate at any moment in time, stares at pt who begins to grab the top that goes on the urinal and takes it off of the handle.
-pt: this is it, i have to get this just right.
pt begins to take the top of the urinal and put it on the handle, twist it around so that it comes back off of the handle. over. and over. and over. for at least 5 good minutes.
nurse attempts to grab urinal.
-pt snatches urinal and exlaims: this is important!
-nurse: let me have the urinal.
-pt: no, let me finish. i have to get it right.
pt once again begins fidgeting with the lid to the urinal, doing exactly the same things as before.
-nurse: give. me. the. urinal.

..........
at this point in time, i am ready to throw the damn thing across the room.
pt complies and hands me the urinal with the look of a 2 year old whose mom just took away his cookies.
-exasperated, nurse: i will just come back later for this.
pt pulls on his shirt.
-pt: i know there is something important to do with my shirt.
-nurse: no, we already put the monitor back on. put your shirt back down.

..........
i step out of the room and ask cna if she can obtain urine specimen. please????
i sit down to chart, thinking 'this pt did not act like this before he went for his eeg.' i wonder what in the world they did to him in there... and then like some epiphany in my head, i immediately hop right out of the chair and hurry back to room.
observe cna having same difficulty with pt.
this time however, i look directly at pt and see that he does not have his oxygen on. instead, it is tossed to the side on his pillow.

..........
UGH.
immediately get oxygen back on, attempt pulse ox. pt will not comply and begins to yank on finger probe, saying it has to be on another finger, not that finger, and so i firmly hold his arm to keep it still waiting for sat to show up. sat bleeps on for 2 secs.. sat is 84%. ask another cna to please go get me a peds sticky finger probe asap. crank oxygen up to 4L. wait for cna.
ask other cna to call rt for breathing tx. other cna comes back with finger probe. sats are now 94% on 4L. rt comes in, i ask her to turn oxygen to 3L.. we wait. sats stay steady at 94%, so i ask her to cut it down to 2L. again, sats stay steady. i tell her to go ahead and do the tx and then we will see where he is.
after tx, pt is alert but confused, his baseline. doesn't recall episode. sats are still steady. pt is stablized and moved closer to nurse's station.


and my eyes on that o2 tubing the rest of the shift.

vacation from hell

So yesterday.. I got my vacation from hell. Away from it, that is. I got floated to the unit. My future home. It was such a nice break! After my day last Friday on the floor.. I welcomed the change, even if it was to be only for 8 hours. But this mission just reaffirmed my desire to work in there.
At first, I was to have only 1 patient. Then one of the other nurses in there (the only one in the hospital who puts in PICC lines at the moment got called away to put in a PICC line early that morning). So I inherited her patients. That gave me 3 patients. Grand! I was the second nurse in there. It is a small ICU.. only 6 beds. But I have to say that they rarely ever let the floated nurse have much responsibility... the unit coordinator in there even told me that they must trust me in order to give me that responsibility. (And I have to say, for the first time since I started nursing... I felt like a real nurse.) It was just a welcome change, and I have missed that place so much since I have passed boards. I cannot wait until my time is up so that I can transfer in there.
So, yesterday ended up being a good day. I needed that vaction from hell... hell being the floor in which I work. Today, however, I go back in to be overworked and overstressed. Hopefully it ends up being a good day too. I don't know how many more bad days I can take. Seriously.

Mandatory....

I just wanted to say that mandatory meetings on days off just plain and outright... SUCK. Period. WHO the hell cares about radiation? I don't work in radiology!! I am not exposed to it. UGH. Gotta go.. it's mandatory, ya know.

Just Plain... Mean.

You see, there are just some people out there in this world who are never, ever pleased no matter what you do. Just so happens that I had a patient like this.. we will call (name and identifying information has been changed) her, B. I had heard the horror stories from the nurses who had previously been involved in her care. "She's a witch in the worst sense" they would claim. I didn't doubt them in the least. Patients like these carry these reputations across units.

So my day began with report. I was told that this woman had refused all of her early morning medications, all of her early morning care, to include turning. You also must understand that this was no small woman by any means. And so when I went in to do my assessment first thing.. the darling was sleeping. I took the opportunity to attempt waking her, and telling her what I was going to do, but she just mumbled and kept on sleeping. I got to listen to her heart, her stomach and such. Take a peek at the IV site, looked at her legs which were wrapped in kling. Thought I would come back in a bit to finish up the rest of the assessment when we was more alert. Didn't take long for her to wake up though.. breakfast soon arrived.

And she awoke. And the complaining began. Since I was told she had refused her 0600 meds, I didn't open a single one until I got into the room. Of course, she didn't want to take any of them. Why take vit C? She doesn't need that, she said. I don't want it, she continued, I know you all are trying to just dope me up. I shook my head. I explained each and every single medication to her at that time that I would be giving her. All of the vitamins, the anticoagulants, etc. She mumbled and grumbled... no way was she taking this many pills. She couldn't do it, unless she had applesauce of course. So applesauce she got. And all those pills disappeared down her esophagus. :) Took some maneuvering but it was done. Phew!

It was a never ending battle with this woman. All day long, either she wasn't sitting right or the food wasn't right or the light was too bright. It was on and on and on. It wears your patience down, but I killed her with kindness. I politely explained every aspect of her nursing care when I was involved. But it didn't stop her endless insults to everything and everyone around her. I don't know if she was just miserable or just plain, well, mean.

In the early afternoon, I had queried the cna assigned to her if she had even attempted to give this woman a bath. (of course these are to be done in the mornings.. but this cna.. well she lacks the drive and initiative to do her work). She told me that this woman had refused her bath. (After my many encounters with this patient, I didn't doubt this was the case.. however) I told the cna that this patient could not do for herself, but if she refused her bath, fine. BUT she absolutely must have foley care done no matter what. She had to have it and please go do it. Even if she refuses, just get the stuff ready and do it anyway. She will comply. (see I had this feeling that all the cna had to do was get the bath water and stuff ready and the woman would allow her to wash her up... and guess what? she did!)

Nevertheless, it was a trying day with this woman. Luckily, she took a good afternoon nap after her bath and some scheduled xanax. And that allowed me to focus entirely on another patient of mine... who didn't make a complaint all day long. In fact, this patient was expected to pass at any moment in time. It put the complainer in perspective.. she was lucky that she could talk and tell me how she felt... about everything in the world. My other patient couldn't even tell me she if she was having any pain at all. The only voice she had that day was the "death rattle" and the longer the day went, the louder that voice got. No matter what I did, that voice never faltered. You try to make your patients comfortable, even in their last few hours, but it isn't always possible. Whether because they are miserable humans or unable to tell you what it is they need. All we can do is our best in every situation.. and move on from there.

when the moon is full....

so i was put on call this morning. (yes, i did the happy dance at 5 am lol). this is only because i was off this weekend and am off the next 2 days as well. BUT i had to go in to work at 3 pm. it was the middle of the day... but i could already tell the moon was going to be full tonight. as i am sure that most people understand, the full moon brings out the best in people. right?? :)

first off, the first patient i go to see has like an airway obstruction. sats are 82% on 3L. yay! HR 155. beautiful! temp 102.2. getting better? ng tube with tube feeding. so in the middle of all of this... i put him up to 4L.. sats only go up to 86% even after he coughs up some of the yummiest sputum out there. seriously. the respiratory tech and i argue about whether or not it was tube feeding. i stand my ground.. it was much too yellow to be tube feeding. yes, tube feeding is a shade of yellow/brown, but this just looked purulent and not like any other aspirated tube feeding that i have ever seen. his lungs were full of rhonchi down to the bases.. which is another reason i didn't think it was aspiration. anyhow.. sats weren't better, so i preoxygenated him with 6L of O2 and then suctioned the mess out of him. sats instantly to the mid 90s (yay!) and put him back down on 3.5L where he stayed well oxygenated. Now the doozy.. during this time, the man is calm, has some chills, but is alert and oriented and not a problem. once i got the sats up.. he was plain nutty! usually, it is the other way around! not today :) gotta be the moon.

so once he is fixed.. emergency in the dialysis room. pt is bleeding out of the graft site. plts are 18. doesn't take a neurosurgeon to figure out that one. but the surgeon that responded to sew up the graft site wasn't too thrilled about it. luckily i got to monitor the rhythms and the phones during all of that. i have already seen one person bleed out in real life.. i really prefer not to see anymore. this person in dialysis was stablized but she is a dnr and probably won't make it through the night or much longer than that if she does. because i know her well as a patient.. she will really be in a much better place than where she is right now. because right now she is miserable and there is nothing that we can do to prevent it. not even treat it.

and i cannot forget about my country patient. alcoholic.. lethargic... just a plain mess. he was actually better back on friday when i had him. he had woken up some then.. was more alert. today.. hallucinating, lethargic, weak, speech so slurred that you couldn't understand a word he said. hardly a response to pain unless you count that evil glare he gave me with deep nail bed pressure. he sure didn't move his leg back in response to it. i can't imagine that he is going to pull out of this anytime soon. he must certainly be visiting liver land or something to that effect because he is well past the time to go through dt's. either that or it's just the moon. heh.

and now i am off for a couple more days. hopefully by the time i get back to work.. the moon will wax or wane itself away, and we on the floor can get back to the normalcy of our pleasantly confused patients without the added effect of the moon.

Much Ado about Nothing at all.

Well my 2 whole days off have flown by and again, I didn't get too much done around the house. I had to go out to my mother's house and fix their computer. I tried to charge them $50 for technical support, but all I got was a breakfast that you can't even get at the Waldorf (inside joke in the family lol).

My oldest son is very.. lucky.. to be alive. Got the cell phone bill and voila... he sent 775 text messages last month. I hadn't put him on the unlimited plan yet but you bet your ass that next month he will be on it. So he is grounded from his cell phone until then. I would so much rather pay the extra $10 a month than $100. Geez.

My last few days of work have been fairly uneventful. Nothing much to even write about at all really lately. I guess I need to get a real life. 'nuff said.

etoh... cause and effect

they show the teenagers the shock value of drinking and driving.. what can happen in those horrible wrecks to shock them out of the idea of drinking and driving. in my experience as a nurse, even though it may be limited compared to others out there.. what these kids need to see is what happens when you drink.. and keep drinking.. and keep drinking. sure, it won't make a dent, because teens believe that they are untouchable. we need a way to reach these people when they are bit more mature and able to comprehend that life doesn't go on forever.

a case in point would be the pt that i cared for last week. a male, just 7 or 8 years my senior. came in with pneumonia, but through his history, found out that he was a drinker. and he drank a lot. so 48 hours later, when the behavior changed and the tremors came, so did also a myriad of problems. i spent 3 days of hell with this man. he was acutely confused, had difficulty swallowing anything at all.. so that his liquids had to be thickened so that he wouldn't aspirate them. how do you continually reorient someone who cannot comprehend at the time what is going on? and then when his abdomen became distended after a few hours of vomiting feces, and having to put in the ng tube that was replaced time upon time again, because as i said, how do you reorient someone who cannot comprehend what the hell is happening here? he would go through spells in which the librium would work for him, but other times, it wouldn't touch him. as a person, i felt for the man because he was truly ill and he may not even make it out of this hospital stay alive because he was just that sick. was it all to drinking? i believe so. i can understand that from the problems in which i encountered with him that his pneumonia was most likely due to aspiration. i cannot confirm it, it is just the gut feeling that i have. he was eventually transferred to icu because his condition deteriorated over the weekend and he was a full code. they would be able to give him more attention in that unit than those on floor were able to do. personally, i think it was a wise decision to transfer him. part of me wishes the md would have done it sooner but it is not a decision that we take lightly either. i was able to care for him when we was in my charge. that is not saying that he did not frustrate me, because he wore out just about every bit of patience that i had as a person, but he got very good care with me. i do also believe that if people were to see this aspect of alcohol that they might be more inclined to just leave it alone or touch it in moderation before it becomes a problem. then again, i could very well be wrong, too. unfortunately people never believe it will happen to them.

On the Issue of Hospital Staffing

I can't proclaim to note how all the other hospitals in the USA or world, for that matter, choose to handle the staffing for the floors; I can only comment on how the hospital in which I work handles staffing on my floor. That being said.....

I have just finished reading several posts in other blogs about nursing ratios in the ED. At my hospital, I do not know what the ratio is down in our ED. I do know that on the floor, we are assigned staff based upon the number of patients on the unit. Whether these people are all walkie-talkie or total care people, easily done or complex patients, we get the same number of people for whatever the census is. Included in our staffing concerns are the assistants, nurse manager, unit secretaries, LPN's and RN's. When it comes to a low census day, the first people called off are the non-essential personnel... thus the assistants and unit secretary (which if we were lucky enough to have one, would be called off. we do not have a unit secretary on our unit, do not know why. instead the charge nurse has to handle putting in all of the orders and doing all of the paperwork if the other nurses are not available to do so because the doctors give all of their orders to the charge nurse!). By non-essential, it means those not needed for essential pt care, such as giving meds, etc. Sure sometimes the nurses are called off, but if they need all of the nurses to cover all of the patients, then the nurses will not be called off.

I would love to know why the nurse manager is included in our staffing. She doesn't often work the floor. She might fill in a few minutes now and then if they are in a bind and they need her help right quick, but for the most part, she is in her office or in meetings. She also doesn't count in the staffing for the other departments that she is over either... I don't get that myself. For one thing, she surely isn't ever "called off."

I understand that they have to set limits in order to save money. "They" being the administration. But sometimes these limits are so hindering that the nurses are forced to take 6-7 patients because of circumstances and census control. Maybe you think, well 6-7 patients isn't that bad... what if 5/6 patients ... each have about 30 meds due at 0900, maybe even one has a peg tube and all their meds need to be crushed and put through said peg... one has to go to dialysis and needs weights and other specialized care... heck one is on isolation because they have c diff, and they are stooling every 30 minutes and need extra bottom care so that the stool doesn't eat right through the skin. Surely then another patient on tele monitoring is having an acute episode of afib with rvr, possibly needing transfer to the ICU to get a cardizem drip if the dig doesn't take care of it. The COPD patient is having difficulty breathing and has a hard time remembering to purse-lip breath because... well because they are hypoxic and cannot think of anything but not being able to breath. Oh and that last patient? Came in with chest pain, but tmc's are negative and tele monitoring shows nsr.. all they need is the dr to make rounds and d/c them, and ask you every hour when is the doc getting there because they would really like to go outside and smoke or just go on home.

Of course, these are just examples, but in truth, it really does happen. Prioritizing & time management do have to take place when seeing pt's like this. My question is this... wouldn't it have just been safer to allow the extra staff to come in that day so that we can perform safe pt care? After all, safety is number 1 when caring for patients. People wonder why nurses get burned out so quickly.. have a few days like the above over and over again, and it is obvious. We do the best that we can with what we have. I don't know of a simple solution to the problem unless they somehow came up with staffing quotas for pt problems, much like a drg -- but tailored to the patient and nursing care received.

Now, one thing that I really think should happen in the future is that patients are also billed for specific nursing duties, sure they already getting billed for the supplies, right? I don't know how much it costs to receive that duoderm.. but what about the time it takes for the nurse to cut it to the right size, stand there and hold it against the wound so that it will attach, and monitor it each day to see if 1) it is still intact or 2) it has been a week and needs to be changed, and etc. Doctors get to bill for procedures, why can't nurses? Why can't the patient be billed for insertion of a foley, or insertion of an NG tube? especially the ones who pull out that ng tube several times a shift? I understand that we are not doctors and do not diagnose problems or write orders. We follow the doctors orders and critical pathways for a diagnosis in order to treat the patient and hopefully send them home in the allotted amount of time. All I am saying is that there is the opportunity for nurses to also be money-makers in this profession as well. Just need some good political action on the healthcare forum? Perhaps that could allow nurses to be paid a bit more for the hard work they do and even allow for enough staff to care for patients who might need a little bit more 1:1 attention. May even attract more people into nursing.. who knows?

Finally.. after reading a comment on this topic from a non-medical person who thinks that nursing is well... non-essential. "people come to the hospital to see the doctor" GREAT! just remember that while you are the hospital, it is the nurses who carry out the doctor's orders, give you your medications (for the most part), write up the discharges so you can go home... get you your water in the middle of the night because you are really thirsty etc. It is the nurses who are the eyes and ears of the doctors, so just in case you go into vtach in the middle of the night -- when the doctor's aren't there! -- they can just possibly get in there and save your life. Next time this person goes to the hospital.. I wonder what they would do if the nurse wasn't there to take care of all of their needs.. sure won't be the doctor there giving the meds and wiping their butts if the pt isn't able to do it or watching the cardiac monitor to make sure that ST depression doesn't suddenly flip into an elevation. ok off rant :)

Just rambling....

yesterday was a hellacious day at work. good things that come from it? i finished my iv therapy class - required by my employer before i can even look at someone's veins; finished my first admission mostly by myself with a few cues from my preceptor... which i thought was a pretty good accomplishment really, considering this little elderly person TALKED my ear off LOL :) she sure didn't want to be in the hospital at all.. but she was the one who called the rescue squad? go figure on that one.

now something ironic... i just said that i finished my iv class.. now my preceptor does not start IV's, so i am wondering who will sign me off? ha. ask how a nurse on a unit doesn't start an iv.. because i do not know that answer. i guess there are just more people willing to start them for her so that she doesn't have to.

when i first accepted this position... it was because it was all that was open at the hospital at the time. i am on days for orientation right now, but will move to nights soon. it will be a bittersweet move because i enjoy the pace of day shift, but man, i really, really hate getting up early in the mornings. i set my alarm for this morning so i didn't not want to go to bed tonight... of course the puppy woke me up much earlier to let me know it was time for him to potty whether or not i was ready to crawl out of the bed. anyhow... i find myself not hating the job like i thought i would. but then again, i think it is the pace of days that has kept my interest. i am not sure what will happen when i go to nights and it is much slower. guess i will see when the time comes.

today i have to go get a thank you card for my coworkers who got me some flowers, gave me some chocolates and a little bit of spending cash for passing boards. it was so nice of them! i didn't expect anything at all from them.

sorry for all of the misc ramblings.. i think i just need more coffee!

Being Alone....

One of my patient's today told me a story of great sadness. The spouse had died just a few months earlier. A past drinking problem resurfaced with this death... and got to a point in which he passed out and laid on the floor for days before someone found him. Bleeding internally from a varices. He was lucky to have been found when he did. Although this near brush of his own death has made him realize that drinking will not alleviate the search he had been on. He understands that he damage that he has done to himself will not be undone. He also understands that he can try to do the best that he can to live the rest of his life as full as he can. I tried my best to be therapeutic... I listened very well to his story indeed. My concern was that when he returns home... will he be able to follow his own advice and discontinue the drinking? Does he have someone who can check on him every day?? I asked him about that one!

This patient isn't the only patient who I have met in my time working at the hospital who has had problems being at home alone with no one to check on them regularly. I realized that something could potentially happen to anyone who lives alone. Isn't there something we could do to help these people who are alone and not in the best of health? Just even to have someone do something as simple as check on them. I just wish I knew the answer. All I could do is ask my patient, and luckily he has someone in which he has made arrangements to have this done. It made the rest of my day go by much easier just knowing this.

Pity party of sorts

Now that school is over, nclex is finished... I wonder what I plan to do to occupy my time. Other than cleaning my house, of course. That is never ending, with a teenager and tween and all. These boys can really, really make a mess. Of course, neither of them claim the mess.. so the blame goes to my invisible child... often called, "wasn't me", or "i dunno who did it". i know every family with children also has this invisible child as well, right?

Once upon a time, I used to be really, really good at working with computer graphics. I am not sure if I want to get into that again?? I used to know how to a lot of things that would occupy my free time for hours... but I am so just not interested in that stuff anymore like I once was. I guess I just need to find a new hobby.. hell maybe even a boyfriend after all of these years of being the single mom. I dunno??? Kinda confused. I am sure this is all part of the after-school let down phase that I was told I would go through. Kinda sucks, huh, if you have been through it.

I miss the internet friends that I haven't been too attentive of over the past couple of years. I am sure that a few friendships have just dissipated because of a lack of communication. It was difficult to manage school, work, and the kids as well as maintaining friendships with barely any free time at all for myself. Now I have this time, and well, I just don't seem to have the same things in common with these people anymore. A few I will always be able to talk with, etc, but others.... may as well just delete them from my messengers.

Ok enough poor, pity me stuff.. I must get in the bed so I do not oversleep in the morning. That would be.. well.... BAD. g'nite :)

Baseball & Committment

Today is my last day of a wonderful 4 day weekend. I have a few errands that I need to do.. like go pick up my OFFICIAL new badge that has my new title on it :) Also have to go to the grocery store :( I hate going to the store with a passion. My youngest is at baseball practice at the moment, and he will have to go again tonight. That is the committment of being an All-Star.. practices every day for 2 weeks, sometimes 2 times a day. Now he wants to play AAU baseball, which if you are not familiar with it... well it costs a lot of money, requires a lot of travel, and also is a huge committment, even moreso than what we are going through right now with the youth league & all-stars. Then my oldest informs me that he would also like to try out of an AAU team. I am one person.. how can I even make that kind of committment between working nights (which will come about probably mid next month) and being a single parent? I suppose if I had to do anything, I would allow the oldest to try out first, well because he is the oldest. He really enjoys playing baseball, but he doesn't seem to have the passion that my youngest has for the game. It really puts a person in a predicament.

It's not that he doesn't love the game, but I just wonder about his committment to that type of team. AAU is serious about it, and I guess all I could do is give him the opportunity to try out. If he doesn't make the team, then all of the worrying would be for nothing. Problem is: if he didn't make the team and the youngest did, then a part of him would most likely begrudge the youngest for getting to do something that he didn't get the opportunity to do. I honestly just do not know what to do? I suppose I will just start thinking about it a little more and then make a decision later on this summer. After all, most teams will not be having tryouts until after this all-star stuff is completed and nationals, for the teams that are good enough or lucky enough to make it there. Gives me a couple of months to think. Now I am off to get cleaned up so I can run my errands!

yeah.. it's official!!

so i took the leap and took the nclex this past tuesday. never before have i ever been to the almost panic level of anxiety, but i was almost there on monday night! i couldn't even stay to watch my youngest son's final season baseball game because i was so nervous. amazing how one test will do this to you. arrived at the testing center early.... sure didn't want to be late! lol.
went through the entire ordeal of security measures to enter the testing room... took the test. it cut off at 75 questions and then came several days of nausea, nervousness, lack of concentration, etc until i finally gave in and called the bon to see my results....... i was prepared for the bad news, but they told me that i PASSED! i literally cried lol. cried from relief of all the anxiety i had been feeling the past few days. my nausea instantly disappeared. i felt 100 feet tall. how dare them make me feel like that LOL!

i just find it also amazing that 75 questions determines a person's competency to be a nurse. the questions i had were... well HARD as hell. no doubt about it. i felt like an idiot when i left that place. i had medication questions for drugs i wasn't even sure were in the drug book :) lord knows i had never heard of them.. how was i supposed to tell the nclex people what side effects or interventions to look for/do?? but it is all water under the bridge now. i no longer have to sign my name with RN-A (A = applicant) anymore! i can push forward in my preceptorship toward my goal of working the ICU. I externed in there for 9 months, and was hoping to get a job in there after school, but unfortunately, my manager, and probably wisely so, does not hire new graduates to work in the unit. so i will do my time in med-surg. learn my time management, charting, and so on, so that i can move my career forward. i owe them at least 6 months on the floor until i can change positions, but if i do have give my employer 1 year for certain.

i would entertain the possibility of working in the ER, but there are some things that just simply gross me out... like protruding eyeballs for one lol. but other than that, i know i would do much better with a faster paced environment. so we will see where the future takes me. i just know that there are several places i would entertain the thought of working and some places i have absolutely no interest in working. now that i am officially an RN, i hope many doors open for me wherever i choose to land.