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.