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.