Last night I took care of a man who was on suicide watch. This crops up occasionally, usually when someone has taken an overdose or has some other acute medical issue going on that prevents them from being directly admitted to psych. Instead they come to the ICU, where we can monitor them closely until they are stable enough to go to the psych ward or be discharged. I had the luxury of plenty of notice that this patient was on his way (something that has been in short supply lately), so I was able to set up the room to my liking, restock supplies, even read through the patient's chart for the back story I knew I wouldn't get in report. I brought my coffee into my room, despite the fact that this is forbidden, and tried to drink as much as I could before my patient arrived. I had grabbed a mug from the break room that said "HO HO HO!" in clusters all around, and as I sipped and perused the chart I looked around and thought of the scene that this must set. Working leisurely, with an out of season and forcefully cheery mug in hand, thinking detachedly about the man on his way to me who appeared from his chart to be severely depressed and unable to cope.
When my patient finally arrived, at his side was his wife who had obviously been crying. I suppose this shouldn't have been surprising, but the truth is that most of the time patients on suicide watch have families that have long gone home by the time they reach me, tired of yet another emotional crisis from their loved one; that is, if they have any family at all. So the crying wife got to me. I got my patient hooked up, assessed, and settled. He seemed plainly depressed to me, slow in his movements and though process, with a flat affect. No tears from him. When I was done the wife came back in and they talked in low voices, with lots of sniffling. I sat outside, "HO HO HO!" in hand, and tried to chart, but mostly I was thinking about how just another day at work for me was another worst day ever for my patient and his wife. What would I do if it was my husband lying in that bed, trying to explain to me why he had decided to empty the rest of his painkillers into his belly, then changed his mind and decided to, of all things, take the bus to the hospital? What if it was me sitting there sniffling, trying to understand this awful situation while a stranger sat just outside, drinking coffee out of a Christmas mug?
Thursday, March 17, 2011
Monday, January 24, 2011
Oh, poop
I remember the moment I first learned there was such a thing as a rectal tube. I was in my last semester of nursing school (a school that, it should be clear, was more focused on community rather than hospital nursing) and was in a clinical with a fellow nursing student. We were talking with a nurse manager and he mentioned a rectal tube. My schoolmate and I looked at each other. We looked at him. I asked him, trying to muster all of my professionalism, "A rectal tube? Like a Foley? But for poop?" It's hard to be professional when you are simultaneously floored and trying not to laugh.
One has to be pretty sick to earn a rectal tube. And, I suppose, to allow someone else to shove something up your butt. My husband continues to be amazed that such a thing exists and has a personal fear that I will, shall we say, bring my work home with me some fateful night. But those tubes do come in handy, because as any nurse knows a good part of the job is wiping butt. It is for the patient's benefit as well, of course- the last rectal tube I placed was in an unfortunate gentleman who was having frequent loose stools and a perineum that was getting redder and more sore with each one. I knew I had made the right decision when the small amount of fuss he made over having the tube placed was minuscule in comparison to the pleading and moaning he did with each wipe of his sore butt.
Placing a rectal tube, at least in my experience, is a nursing decision. You are the one caring for the patient, you decide, you do it, and then you notify the doctor. Most of the Drs I've worked with seem fine when I call them to inform them of what I've done. I did have one Dr tell me that she "didn't like" rectal tubes. Well, I'm sure the patient isn't a big fan either, but it sure is working isn't it?
At my facility we have a fancy new rectal tube with a fancy name that I won't mention. There are a few "fecal collection systems" on the market, and they all work about the same- insert the business end into the business and add a very specific amount of water in order to inflate the business end to an alarming size... inside the patient. By alarming, I mean donut size. Really. In your butt. Because this fancy system is so expensive, there is an actual decision tree posted to help nurses decide if the cost is worth it. Patients pretty much need to have a wound or very near one in order to justify the cost of inserting a donut up their butt, which I guess is again the lesser of two evils.
My absolute favorite thing about the fancy fecal collection system is their advertising- if you read any nursing journal you may have seen this. The bag and tubing is pictured, with a white background and some generic text that only hints at the actual usage, while simultaneously praising the product. Looking at the picture of the bag however, the bag appears to be filled with dark clouds and lightning. There's a storm a' brewin' folks, you guessed it- a shit storm. Which again, is far preferable to the Niagara falls of poop, which I have personally experienced. But that, my friends, is a story for another day.
One has to be pretty sick to earn a rectal tube. And, I suppose, to allow someone else to shove something up your butt. My husband continues to be amazed that such a thing exists and has a personal fear that I will, shall we say, bring my work home with me some fateful night. But those tubes do come in handy, because as any nurse knows a good part of the job is wiping butt. It is for the patient's benefit as well, of course- the last rectal tube I placed was in an unfortunate gentleman who was having frequent loose stools and a perineum that was getting redder and more sore with each one. I knew I had made the right decision when the small amount of fuss he made over having the tube placed was minuscule in comparison to the pleading and moaning he did with each wipe of his sore butt.
Placing a rectal tube, at least in my experience, is a nursing decision. You are the one caring for the patient, you decide, you do it, and then you notify the doctor. Most of the Drs I've worked with seem fine when I call them to inform them of what I've done. I did have one Dr tell me that she "didn't like" rectal tubes. Well, I'm sure the patient isn't a big fan either, but it sure is working isn't it?
At my facility we have a fancy new rectal tube with a fancy name that I won't mention. There are a few "fecal collection systems" on the market, and they all work about the same- insert the business end into the business and add a very specific amount of water in order to inflate the business end to an alarming size... inside the patient. By alarming, I mean donut size. Really. In your butt. Because this fancy system is so expensive, there is an actual decision tree posted to help nurses decide if the cost is worth it. Patients pretty much need to have a wound or very near one in order to justify the cost of inserting a donut up their butt, which I guess is again the lesser of two evils.
My absolute favorite thing about the fancy fecal collection system is their advertising- if you read any nursing journal you may have seen this. The bag and tubing is pictured, with a white background and some generic text that only hints at the actual usage, while simultaneously praising the product. Looking at the picture of the bag however, the bag appears to be filled with dark clouds and lightning. There's a storm a' brewin' folks, you guessed it- a shit storm. Which again, is far preferable to the Niagara falls of poop, which I have personally experienced. But that, my friends, is a story for another day.
Wednesday, January 5, 2011
Another day, another...
Today it's another confused patient. He's mostly concerned that he's gotta go potty, despite his Foley, although for a while he was very upset I wouldn't let him have a dog. Sigh.
Last night the tiredness hit me at the end of the night like a ton of bricks. I didn't get much of an afternoon nap but I wasn't feeling too bad until 4am, when I went to draw labs and just couldn't. I don't know what the problem was, really, aside from the fact that my patient was soooo shaky. Usually I give up after 2 tries and ask someone else for help, but the guy wasn't with it and I was determined so I tried it again... major fail. Because I was so tired, I almost started crying. That, on top of the choice 4 letter bombs I was dropping, create the professional picture of today's modern nurse. You know; tired, cranky, and prone to emotional outbursts. Hah.
That end of the night tiredness happens a lot, actually. I can usually gauge it by how long my morning report is. More rambling = more tired. When I see the day nurse's eyes start to glaze over, I know it's time to wrap it up, finished or not. Also, I like to take the stairs down to the parking lot, but it's four flights down, which is a lot of winding around and around. On more than one occasion I have found myself at the very end of the stairs in the the basement, needing to climb back up to my exit and not sure how it got past me. When I first started working in the ICU and was constantly feeling overwhelmed, I would routinely be surprised by the door to the parking lot in the stairwell, as if it had materialized out of thin air right then. Good thing there are no snakes in the hospital. I hope. Don't even ask about the drive home.
Still, I can't help but think that I would be equally groggy at 5am if I had just woken up, the disadvantage there being that the shift would just be starting rather than almost over. maybe it's not my less-than-succinct report that creates that glazed look. I'm going to have to go get another cup of coffee and ponder that. Well, that, and what kind of dog would be best suited for a combative alcoholic in restraints.
Last night the tiredness hit me at the end of the night like a ton of bricks. I didn't get much of an afternoon nap but I wasn't feeling too bad until 4am, when I went to draw labs and just couldn't. I don't know what the problem was, really, aside from the fact that my patient was soooo shaky. Usually I give up after 2 tries and ask someone else for help, but the guy wasn't with it and I was determined so I tried it again... major fail. Because I was so tired, I almost started crying. That, on top of the choice 4 letter bombs I was dropping, create the professional picture of today's modern nurse. You know; tired, cranky, and prone to emotional outbursts. Hah.
That end of the night tiredness happens a lot, actually. I can usually gauge it by how long my morning report is. More rambling = more tired. When I see the day nurse's eyes start to glaze over, I know it's time to wrap it up, finished or not. Also, I like to take the stairs down to the parking lot, but it's four flights down, which is a lot of winding around and around. On more than one occasion I have found myself at the very end of the stairs in the the basement, needing to climb back up to my exit and not sure how it got past me. When I first started working in the ICU and was constantly feeling overwhelmed, I would routinely be surprised by the door to the parking lot in the stairwell, as if it had materialized out of thin air right then. Good thing there are no snakes in the hospital. I hope. Don't even ask about the drive home.
Still, I can't help but think that I would be equally groggy at 5am if I had just woken up, the disadvantage there being that the shift would just be starting rather than almost over. maybe it's not my less-than-succinct report that creates that glazed look. I'm going to have to go get another cup of coffee and ponder that. Well, that, and what kind of dog would be best suited for a combative alcoholic in restraints.
Tuesday, December 28, 2010
It's a hospital, not a Hilton
There's a Facebook group called "It's a hospital... Not a Hilton." I used to check it with some regularity about a year ago but haven't really kept up with it. The thing is, it's a place for nurses (or other direct patient care personnel) to bitch about the craziest demands they've heard from their patients. I will admit that it's pretty funny and cathartic in a way to be able to vent about being treated poorly by the general public. I don't know of a nurse that hasn't had a patient be overly demanding or rude before, and few nurses that haven't had to deal with a violent patient. It can be mentally taxing enough to take care of those patients who are confused and argumentative because of dementia or delirium, but even more to take care of a patient who is otherwise in his right mind but seems to think that he has been assigned a new slave. However, I think I am over the constant complaining.
When I was in nursing school, I did a group project about Virginia Henderson, one of the historical figures of the nursing profession. We did a little skit in which I actually played Miss Henderson herself, the result of which was that my only real recollection of Miss Henderson's contribution to the nursing profession was her belief that nurses should "do for patients only what they cannot do for themselves" (I believe this was my only line in the skit, repeated ad nauseum). Most of the complaints that nurses seem to have about the expectations of their patients is that patients just expect too much. They are sick (or at least perceive they are); they want to be fed, they want to be bathed, and they want to be waited on. One of my favorite nursing lines is the one that goes something like "at what point in your hernia repair did they break your arms?" Virginia was right, of course; unless you actually did break your arms then you should be able to manage getting that fork to your mouth, and you should do it now because god know I'm not coming home with you. Annoying as this may be, however, this is an opportunity for patient (and family!) education, which is another big part of the role of the nurse.
Then there's the customer service aspect. Every freakin job these days is a customer service job, I don't care what it is you do. I spent many years in menial customer service jobs before I became a nurse, and after a while I learned that it was easier to just give people what they said they wanted (or at least give them the perception that that's what you were doing) than to waste time arguing about it. This made them happy, and got them away from me more quickly. If for some reason this didn't work, the fallback position is to apologize and compromise. All of these things were easier to do once I truly understood that these people did not know me and could therefore not be angry with me personally. In fact, this wasn't really about me at all. I tried to make you happy, really I did; if you are still not happy then you may never be.
So, if you come to my hospital and I am assigned to take care of you, I try to make you happy. If you have completely unreasonable demands then I apologize and try to compromise. I cannot produce miracles; if I could I would just cure you and then we would both be happy. So I do what I can, try to find a creative solution or bend the rules if need be. And if that doesn't work then I try to remember that I tried, that you don't know me, and try not to take it personally. I mean, I can't if I expect to be a nurse for much longer. But seriously, if you do come to my hospital, just be reasonable. It makes my job so much easier.
When I was in nursing school, I did a group project about Virginia Henderson, one of the historical figures of the nursing profession. We did a little skit in which I actually played Miss Henderson herself, the result of which was that my only real recollection of Miss Henderson's contribution to the nursing profession was her belief that nurses should "do for patients only what they cannot do for themselves" (I believe this was my only line in the skit, repeated ad nauseum). Most of the complaints that nurses seem to have about the expectations of their patients is that patients just expect too much. They are sick (or at least perceive they are); they want to be fed, they want to be bathed, and they want to be waited on. One of my favorite nursing lines is the one that goes something like "at what point in your hernia repair did they break your arms?" Virginia was right, of course; unless you actually did break your arms then you should be able to manage getting that fork to your mouth, and you should do it now because god know I'm not coming home with you. Annoying as this may be, however, this is an opportunity for patient (and family!) education, which is another big part of the role of the nurse.
Then there's the customer service aspect. Every freakin job these days is a customer service job, I don't care what it is you do. I spent many years in menial customer service jobs before I became a nurse, and after a while I learned that it was easier to just give people what they said they wanted (or at least give them the perception that that's what you were doing) than to waste time arguing about it. This made them happy, and got them away from me more quickly. If for some reason this didn't work, the fallback position is to apologize and compromise. All of these things were easier to do once I truly understood that these people did not know me and could therefore not be angry with me personally. In fact, this wasn't really about me at all. I tried to make you happy, really I did; if you are still not happy then you may never be.
So, if you come to my hospital and I am assigned to take care of you, I try to make you happy. If you have completely unreasonable demands then I apologize and try to compromise. I cannot produce miracles; if I could I would just cure you and then we would both be happy. So I do what I can, try to find a creative solution or bend the rules if need be. And if that doesn't work then I try to remember that I tried, that you don't know me, and try not to take it personally. I mean, I can't if I expect to be a nurse for much longer. But seriously, if you do come to my hospital, just be reasonable. It makes my job so much easier.
Tuesday, December 14, 2010
A touch of the AR
So, yeah, I'm a little AR. You know, anal-retentive? Which I think is a good thing in a nurse, right? Better than lasseiz-faire nurse ("just put that stool sample anywhere"). I am totally AR when it comes to charting, partly because of CYA (cover yer ass!) but also because I like having all the holes filled in. It just looks better when everything is in place. The charting we use where I work is a grid system, kind of like what an Excel page looks like. Pages are based on body systems, and there are a lot of add-in variables depending on what is going on with the patient (fluids, drains, skin problems/incisions, etc.). If there isn't a pre-made option, you can always create your own. The individual boxes are small and designed for 1-2 word descriptions (yes/no, wound type=incision, NS@ 100/hr, etc.), but you can comment on any box and explain yourself ad infinitum. Vital signs are fed into the system automatically, all that needs to be done is to click on the numbers to agree. I&Os are similarly quick to chart. The best part is that once you have saved your entries, the next time you click on that box your last saved entry pops up- if there are no changes you can just click "enter" to agree and shazam! Assessment charted. Which is why I don't understand why some nurses can't be bothered to chart.
Recently I got report from a day nurse who specifically mentioned several things that had happened over the course of the day. Nothing too exciting, but all things that were included in the orders as needing to be done. She goes home, I get started and log on the computer, pull up the chart and it's practically blank. Vital signs are mostly filled in (remember these are automatic), and I believe she had initial assessments charted, but other than that... what was she doing all day? Internet shopping? Helping with a code? So busy proving care she didn't have time to chart it?
We have charting guidelines we are expected to follow. Many are set by JHACO, the hospital accreditation board, some are facility guidelines, some are unit guidelines. In the ICU, our minimum vital sign charting parameter is every 2 hours, although almost everyone takes VS every hour as that is the default parameter for our monitors. Temps are taken every 4 hours (this is usually not automatic and is more frequently missed). We are expected to chart a full assessment every shift and update that assessment with any changes. We are also expected to provide personal care for our patients, feed them, turn them, ambulate them, and measure I&O down to the last milliliter. This is what nursing care is all about. Maybe this nurse did these things, maybe she didn't, but the saying around here (and probably every hospital) is "if it's not charted, it wasn't done." Two years down the road when the kids decide to sue because it wasn't grampa's time, there's going to be a chart review, and eventually someone will look at your shift and see your 12 hours basically unaccounted for. And in the unlikely event that you end up on the stand to defend your actions, you can try to tell the jury that you turned grampa every 2 hours like you're supposed to (if you even remember that night, let alone that guy), but the fact that you didn't write it down is going to make your statements about that and pretty much anything else you did or didn't do seem questionable. C. Y. A.
As an aside to the fellas, if I've not made this clear enough already, my charted assessment is very thorough, which is why I'm always over at the damn computer typing away (not, I repeat, NOT because I'm cruising Craigslist looking for secondhand toys for my kids. Or blogging.). One of the little boxes I'm filling in once a shift is "meatus assessment." That's right boys, I'm charting about your dick. Please, please don't give me a reason to go on ad infinitum.
Recently I got report from a day nurse who specifically mentioned several things that had happened over the course of the day. Nothing too exciting, but all things that were included in the orders as needing to be done. She goes home, I get started and log on the computer, pull up the chart and it's practically blank. Vital signs are mostly filled in (remember these are automatic), and I believe she had initial assessments charted, but other than that... what was she doing all day? Internet shopping? Helping with a code? So busy proving care she didn't have time to chart it?
We have charting guidelines we are expected to follow. Many are set by JHACO, the hospital accreditation board, some are facility guidelines, some are unit guidelines. In the ICU, our minimum vital sign charting parameter is every 2 hours, although almost everyone takes VS every hour as that is the default parameter for our monitors. Temps are taken every 4 hours (this is usually not automatic and is more frequently missed). We are expected to chart a full assessment every shift and update that assessment with any changes. We are also expected to provide personal care for our patients, feed them, turn them, ambulate them, and measure I&O down to the last milliliter. This is what nursing care is all about. Maybe this nurse did these things, maybe she didn't, but the saying around here (and probably every hospital) is "if it's not charted, it wasn't done." Two years down the road when the kids decide to sue because it wasn't grampa's time, there's going to be a chart review, and eventually someone will look at your shift and see your 12 hours basically unaccounted for. And in the unlikely event that you end up on the stand to defend your actions, you can try to tell the jury that you turned grampa every 2 hours like you're supposed to (if you even remember that night, let alone that guy), but the fact that you didn't write it down is going to make your statements about that and pretty much anything else you did or didn't do seem questionable. C. Y. A.
As an aside to the fellas, if I've not made this clear enough already, my charted assessment is very thorough, which is why I'm always over at the damn computer typing away (not, I repeat, NOT because I'm cruising Craigslist looking for secondhand toys for my kids. Or blogging.). One of the little boxes I'm filling in once a shift is "meatus assessment." That's right boys, I'm charting about your dick. Please, please don't give me a reason to go on ad infinitum.
Monday, December 13, 2010
CCRN
So I recently got certified in my "area of expertise," that being CCRN (Adult Critical Care Nurse- yes, I know the acronym doesn't match. Take it up with the AACN). My new certification is important to me because it makes me look like I know what I'm doing, plus I get to wear a snazzy gold "CCRN" pin on my name badge, but most importantly it earns me a $2000 bonus from my employer. I've been a critical care nurse for all of 2 years, and an RN for all of three. I guess that although I can add another set of letters behind my name, what I really feel like is a fraud. A fraud that tests well.
A friend of a friend on Facebook (not someone I'm friends with, but, oh nevermind) recently posted a status update stating not only that she had passed the CCRN test but that then went on to reveal her score in each content area, most of which were in the 90s or 100%. Let me tell you, I certainly shared with my Facebook friends the glad tidings of my passing; however, I chose to keep those 70% just barely passing scores to myself. I could go on and on about why I scored low (I was on maternity leave! Um... the test is hard!), but really, I got nothin', except that maybe I just need more experience.
Think back to when you were in school. Getting good grades seemed sooooo important, didn't it? Okay, maybe it didn't to you but it did to me. I was even on the dean's list (only my last semester, but hey that counts). I'd like to think it helped me get a job, but probably not. In my everyday work life? Who gives a crap. I make the same amount of money as those who barely skated by, and although I earned a BSN, make just a smidge more than those who have an associate's degree. We are all in one big happy nursing pool. I bring this up not to seem bitter because really, I'm not, but to point out that grades and intials aren't everything. Many of those "just barely passing" nurses are still fine nurses. And some of those dean's list nurses would make me leave AMA if I were the patient.
So I'm feeling a little conflicted about my CCRN. Like I stole my gold pin from someone more qualified. However, I'm going to go ahead and keep my $2000 bonus. And no, it did not get prorated down based on my passing score. 70% rules!
A friend of a friend on Facebook (not someone I'm friends with, but, oh nevermind) recently posted a status update stating not only that she had passed the CCRN test but that then went on to reveal her score in each content area, most of which were in the 90s or 100%. Let me tell you, I certainly shared with my Facebook friends the glad tidings of my passing; however, I chose to keep those 70% just barely passing scores to myself. I could go on and on about why I scored low (I was on maternity leave! Um... the test is hard!), but really, I got nothin', except that maybe I just need more experience.
Think back to when you were in school. Getting good grades seemed sooooo important, didn't it? Okay, maybe it didn't to you but it did to me. I was even on the dean's list (only my last semester, but hey that counts). I'd like to think it helped me get a job, but probably not. In my everyday work life? Who gives a crap. I make the same amount of money as those who barely skated by, and although I earned a BSN, make just a smidge more than those who have an associate's degree. We are all in one big happy nursing pool. I bring this up not to seem bitter because really, I'm not, but to point out that grades and intials aren't everything. Many of those "just barely passing" nurses are still fine nurses. And some of those dean's list nurses would make me leave AMA if I were the patient.
So I'm feeling a little conflicted about my CCRN. Like I stole my gold pin from someone more qualified. However, I'm going to go ahead and keep my $2000 bonus. And no, it did not get prorated down based on my passing score. 70% rules!
Sunday, December 12, 2010
Flip Flopper
When you work the night shift, one of the big decisions is whether to stay on the night schedule on non-work days or to flip back to a day schedule. People do one or the other for various reasons; I choose to flip back to a day schedule (did I say choose? I meant am forced) by my family. As much as I'd like to sleep the day away, when my two year old gets up at 6am I am the one who is responsible for him (does this mean I don't let him run around the house for a little while while I lie in bed trying to sleep for just 5 more minutes? No). I do know of night shifters who manage to stay on a night schedule even though they have kids, but there is usually some other party available for childcare- a spouse, school... in my house, on weekdays anyhow, it's just me. Sure, my husband is home on the weekends, but just try sleeping when there is a baby crying off and on, a toddler running around shrieking, and the sporadic venture into the bedroom to retrieve just one more thing. At night, everybody sleeps. Well, not the baby so much, but that's another blog post entirely.
Different people have their methods, but mine is this: on days off, I get up early, I go to bed early(ish). On the first day I work, I get up as late as possible, which might be 9am if my husband is home or more typically 7am if it's just me. Commence toddler-exhausting activity. When my kids nap at noon, so do I- I try to get at least 2 hours in. This is not always possible. Once I get up, I get ready for for work & go. The following days I do sleep once I get home and get up around 7 hours later, except that after the last night in a row I usually try to get up around noon so I can try to get stuff done, which means that by 9pm I'm ready to pass out and... Voila! Back on day schedule.
Honestly, sometimes I think that if I had my choice I would spend all of my off time sleeping. Or at least most of it, with a few hours of waking time to work on whatever crafty project I had going. In some ways, I'm glad my kids force me to get up and get some sunlight in my life, even the heavily cloud-filtered sunlight we get here in the NW. There is something about waking early and having the whole day to accomplish, even if all that actually gets accomplished is feeding yourself and maybe cursory hygiene. Being a flip flopper isn't so bad now, is it?
Different people have their methods, but mine is this: on days off, I get up early, I go to bed early(ish). On the first day I work, I get up as late as possible, which might be 9am if my husband is home or more typically 7am if it's just me. Commence toddler-exhausting activity. When my kids nap at noon, so do I- I try to get at least 2 hours in. This is not always possible. Once I get up, I get ready for for work & go. The following days I do sleep once I get home and get up around 7 hours later, except that after the last night in a row I usually try to get up around noon so I can try to get stuff done, which means that by 9pm I'm ready to pass out and... Voila! Back on day schedule.
Honestly, sometimes I think that if I had my choice I would spend all of my off time sleeping. Or at least most of it, with a few hours of waking time to work on whatever crafty project I had going. In some ways, I'm glad my kids force me to get up and get some sunlight in my life, even the heavily cloud-filtered sunlight we get here in the NW. There is something about waking early and having the whole day to accomplish, even if all that actually gets accomplished is feeding yourself and maybe cursory hygiene. Being a flip flopper isn't so bad now, is it?
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