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.