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.

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.

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!