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The Sort of Stuff Nurses End Up Getting For Christmas

Someone gave me mono for Christmas this year. Since I was scheduled to work, I had to go in with mono. I carried it around with me and eventually others learned that I had a stomach-ache as well. Then they demanded to see my athlete’s foot!! Ew.

All in all, my maladies ended up amusing almost everyone who was exposed. And I’m actually kind of looking forward to acquiring an ulcer. I wonder if they take requests… an MRSA or clostridium difficile mascot would look great in the isolation rooms….

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Women of child-bearing age beware!!

Taking antibiotics while on birth control pills will decrease the effectiveness of the pill.

Not much time around here to blog, but I wanted to put something up really quick… The other day, I heard about yet another baby being conceived because the mother had been taking antibiotics while also using birth control pills. I know of 4 babies that are in the world right now due to those very circumstances.

In all cases, the mother has said that NO ONE informed her when she was prescribed antibiotics that they would decrease the effectiveness of the pill. I find this to be extremely sloppy practice, and that’s putting it nicely. I’m supposing it’s possible that it was mentioned as a “by the way” while the patient was gathering their things getting ready to leave. And I’m sure it’s on the leaflet that the pharmacy hands out, written in small print. Actually I’m not entirely sure of that, and although it is the patient’s responsibility to read about medications that they are prescribed, it is also the responsibility of the prescriber to notify the patient of any drug interactions or possible side effects.

I was thinking of this the other day, and maybe someone can answer it… Would antibiotics also interfere with the effectiveness of the other forms of hormonal birth control? Depo shots, Norplant, or the new patch?

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Da-dum-dum

The other night I took care of a man who was hypoxic and needed oxygen in the form of an oxygen mask. Most people tolerate the mask fine, but there are a few that just can’t handle having something on their face.

My patient was one of those few.

Even though the little nasal prongs were doing the trick, the pulmonologist wanted us to use a mask because “he will probably take a turn for the worse eventually.” (Side rant: This is also the same pulmonologist, who upon walking onto the unit unable to find this patient’s chart, came up to me and said, “Geena, when you have a critically ill patient, wouldn’t it be at the forefront of your mind to have the chart available?” To which I replied, “Dr. B, the very fact that I have a critically ill patient who is hypoxemic and trying to climb out of bed actually explains why I don’t have the faintest idea where the chart is.”)

Anyway, due to other circumstances, I didn’t immediately connect that the patient became severly agitated when we applied the oxygen mask. I had to give him an antipsychotic shot and spent as much time as I could at his bedside to avoid having to restrain his arms (which I correctly assumed would make him worse and wouldn’t work anyway… when another nurse watching him for me went ahead and restrained him, he just bent over and put his face to his hand to take the mask off). While I was there trying to chat with him about other things to help take his mind off the bothersome mask, he finally stopped struggling against the restraints and laid back on the pillow.

After a few moments, he looked at me. He asked, “How long have you been working here?”
“Three years,” I replied.
“So before that, did you get your Bachelor’s, or your Master’s….”
Before I could answer him, he finished, “IN TORTURE???”

I’m sure it is not good nursing etiquette, but I laughed quite hard at that. Which made him laugh. I eventually decided that the amount of energy he was exerting to remove the mask was far outweighing the benefit of it, so I switched him to the nasal prongs again. After a few minutes of low oxygen sats, he calmed down considerably and actually drifted off to sleep. His O2 sats came up perfectly and the rest of the night was fabulous.

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I HAVE HAD IT!!

I had no idea, as a young impressionable eager nursing student, that I would eventually be SO inundated with paperwork once I became a nurse.

It is truly unbelievable how much crap we have to fill out and keep track of. I have no idea why this can’t be streamlined somehow, but then again, it may be impossible by this point. I just thought you might like to have an insight into the amount of utter banal paperwork I must keep track of. Keep in mind that any particular patient may have only some of these. But some of them actually have ALL of them.

First there’s the ABG flowsheet. It’s where we write down the patient’s ABG’s so we can keep an eye on trends at a glance. Never mind that every single day at 4pm the printer spits out up-to-date lab sheets on every lab test the patient has had. We need to have this one particular one for ABG’s.

Then there’s the blood glucose flowsheets. Even when the patient isn’t diabetic, if they are started on TPN, they have to have twice daily blood sugar checks. And you guessed it… there’s a separate sheet for that. If the patient is a diabetic and receiving insulin, it’s a good sheet to have to keep track of what the patient’s blood sugars are and if the amount of insulin is working.

Of course there is our “vitals” flowsheet where we write down vital signs (as often as every minute sometimes), keep track of titrating drugs, add up our Intake/Outputs, chart unscheduled meds. This one is most important and every single patient has one.

Next is the Blood Transfusion Consent form, along with Blood Transfusion Fact Sheet. Before, we just gave blood to whoever needed it, with a verbal consent. Now we have to get it in writing.

Let’s not forget the Advance Directive sheet. If someone comes in with no Advance Directive, we have to give them an information sheet describing what one is, and if they want to sign one right then and there, by golly there is yet ANOTHER sheet to give them to do that. Even if they don’t want an Advance Directive, we still, by law, must give them an information sheet.

The newest sheet is the Flu Vaccine consent. It comes bundled with 2 different flu vaccine info sheets, and another checklist to complete to determine if the patient is eligible to get the vaccine. Thank God that one’s only seasonal.

There’s the sheet we use to mount EKG strips to.

There’s also an admission sheet. We have to fill this out at the bedside, then go back to the computer and enter in all the information. As a side rant, after we’re done filling in the patient’s entire health history (never mind if someone’s already done it on a previous admission… this computer system is over 30 years old and apparently didn’t take that into account… we have to fill in EVERY blank for EVERY admission), we have to do a “teaching assessment” where we write what we think the patient’s knowledge of their current condition is, the steps we are going to take to educate him, and THEN we have to document somewhere that we’ve actually done the teaching. And don’t forget to include that you taught the family as well. THEN we have to come up with a “nursing care plan” whereas we come up with “problem statements”, desired outcome, deadline, and interventions that we will take to fix the “problem.” More on nursing care plans in another post. I hate nursing care plans.

Then there is the “basic care needs” that we must fill out, clicking this and that to add to the Master Care Plan that the patient has an NG tube, ET tube, ostomy, what lines they have, when those lines were put in, when the tubing changes were on what drips, right down to how much help they need bathing themselves, for God’s sake. Basic Care Needs are pointless as well. No one ever looks at them on the care plan, and they’re hardly ever updated. Go look at the patient! Don’t rely on a stupid care plan to tell you whether the patient has a foley catheter. I hate updating the tubing changes, because the tubing is always labeled with the date and time that it was hung. Charting it AGAIN is redundant.

If you make a med error, or even if your patient’s dentures are lost, or really for anything under the sun, you have to fill out a Quality Assurance form. Those are fun.

My least favorite is the restraint sheet. Many of our patients have restraints, usually to keep them from pulling out various tubes and wires whilst they are in their drug-induced haze. Restraints are a really huge issue with The Powers That Be. The restraint flowsheet is total bunk. You just initial boxes saying that you’ve checked the restraints to make sure they aren’t too tight, that you’ve offered food/drink every 2 hours, that you’ve asked the patient if they need the bathroom every 2 hours, that you’ve provided range of motion exercises and untied the restraints every 2 hours, and oh by the way, why exactly ARE you using restraints? And have you told the patient and family why? And have you made a f#@$#@$ing nursing diagnosis problem statement about it?? Thing is, our patients that are restrained are already receiving tube feedings, and have numerous tubes to take care of potty concerns, and basically have no clue about anything at all. I’m not saying those things aren’t important; they are. But they aren’t always applicable. And I feel that it’s pointless, because sometimes you just initial the box even when you haven’t had time to actually DO all of that.

Who could forget the wound care sheet? Whenever the patient develops or presents with any kind of wound, be it surgical, pressure ulcer, vascular, whatever, we have to take a Polaroid picture of it (using the little stick-on ruler papers for scale) and fill out a wound sheet, where we circle the area on the body that the wound is located, the measurements, what it looks like, smells like, what treatment we’re doing for it, and any other comment we care to contribute. One wound sheet for each wound. And the Polaroid (which may or may not turn out) gets taped to the Progress Notes for the docs to ignore.

Did I mention that there is a consent form for the patient to sign giving us permission to take a picture of their wound?

The lastest sheet that’s come out is going to be a doozy. Every charge nurse on every 8 hour shift is going to have to fill out this legal-paper-sized form saying what nurse has what patient, when the patient was transferred out if applicable, when a patient was admitted, when the nurse took her break, blah blah blah. I think these sheets are supposed to protect us due to the law that starts on January 1st, but come on. These stupid sheets need to be kept for 3 YEARS in case there’s ever a question that the new nurse:patient ratios weren’t followed to the letter. For my unit ALONE, that’s 1,095 pieces of paper PER YEAR that will have to be filed. Add in all the other units (at least 8 others) and you’ve killed a small forest with having to file away 8,760 pieces of paper. At the end of 3 years, we’ve accumulated 26,280 papers.

For the love of God and cotton candy, this has all gone WAY out of control. Everytime Joint Commission (you’ll notice I’ve not provided a definition for these jerk-offs… I wouldn’t know where to begin) gets their knickers in a knot over something, we seem to have to add yet another flowsheet to cover our asses. Basically, when I get a new admission, it is entirely possible that I will have to utilize every single one of these sheets on them. (Let’s not forget the OR checklist and consent forms) in addition to starting IV’s, mixing medications, inserting various tubes, monitoring urine output, vasoactive drips, etc, writing down vitals, tagging IV tubing, teaching the patient and family about everything under the sun, drawing labs, calling docs, IT HAS BECOME MADNESS.

I swear I spent JUST as much time filling out paperwork and computer crap as I did at my patient’s bedsides tonight. I’d be surprised that anyone actually read this entire thing. Filling out all this baloney is Tedious with a capital T. I just can’t wait to see what paper they throw at us next.

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Well, What Else Are They Good For?

Nancy writes:

This is one of those “Can you believe the gall” stories.

I worked as a nursing supervisor for a local clinic… a clinic that is known for being “cheap.” I didn’t know how cheap until I went to a supervisors meeting the month before Nurse’s Day. The Director of Nursing had the audacity to ask us to contact drug reps and ask THEM to provide food for the nurses on Nurse’s Day. I laugh out loud every time I think of the look I had on my face… The place was too stinking cheap to buy us breakfast!!! Boy did we feel appreciated! :)

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Happy Thanksgiving Everybody!

I found a really lovely Thanksgiving post today. What this doctor writes really portrays what the holidays are like for health-care workers.

the thanks part

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The Very Definition of Tragedy

I have had this story sitting in my inbox since the beginning of August. It was written by an EMT. I thought it almost a little too raw and too sad to post, which is why I’ve held on to it. I re-read it today and decided that if someone had to live through this, who am I to say that such an experience is too uncomfortable to post for others to read? Jason, EMT writes:

Yesterday was terrible. Words cannot explain just how bad it was. It’s
enough to make anyone in my line of work question why they do what they do.
A 4-year-old girl died, a freak accident. I know the person who killed
her. It’s hard to decide who needs consoling most, the father of the young
girl or the person who was responsible for her death. Here’s the story,
and it’s a very hard one to tell.

About a mile south of our fire station, on a major US 2 lane highway, there
lives an older couple (in their 80′s). They have a large lake on their
property across the highway from their house. Yesterday, a man brought
his children to go fishing there. It was supposed to be the idyllic day
out for a father and his kids, fishing in the country. He parked his truck
there at the gate going into the pond, and walked across the road to get the
key to the gate. The little girl and her brother (I don’t know an exact
age, but he was under the age of 10) were waiting there at the gate. When
the father walked back from the house to the road, the little girl saw him.
In her excitement, she started to run across the road to meet him. As she
stepped out into the road, a friend of mine that I graduated with was going
to his wife’s parent’s house in his truck. He never saw her. He hit the
young girl doing well over 55 miles per hour. This little angel was not
only killed, she was utterly destroyed. I won’t tell you how bad her body
was mangled, but I will say that it will definitely be a closed-casket
funeral. Since I was at work, I didn’t get to be there when the ambulance
got there, but I got there in time to see her loaded up and going to the
funeral home. I also got to help pick up pieces of this little girl.
That’s right, pieces. If there’s any form of good in this act, it’s that
she never suffered. She died instantly.

To hear our crew tell of pulling up on the scene and seeing the father sitting there on the side of the road, holding the little girl, cradling what was left of her head, sobbing uncontrollably, trying to get the child out of his arms, realizing
that there was nothing that could be done, no matter what. It was
horrible. Her young brother was thirsty, so one of the state troopers and
our driver took him over to get a Gatorade. He was walking across the road,
looking at all the flashing lights, the people picking up parts of his
sister, his father utterly destroyed, and he looked up, with tears in his
eyes and said “This is the worst day of my life”.

I’m a Christian. I believe in God. I know that everything happens for a
reason of some sort, but I have to admit that it’s hard to understand why
this little girl had to be ripped from life in such a violent way. What on
earth could be the reason for that? The only thing that I’m 100% sure of
is that another little angel got her wings yesterday.

I want to say to all my friends here a very heartfelt thank-you. The
people who listen to me, who think I’m so great for doing this…it’s no fun
at all. We in the EMS have what we call a Critical Incident Stress
Debreifing. This is my form of that. This is my therapy. Thank you so
much for letting me tell stories like this. I cried like a baby while I
was on that scene, cried all the way to the station, held my partner when I
got back to the station as she broke down, and then went home and held my wife and cried some more. Hell, I’m crying right now. I’m here at
work, trying to make a deadline. My wife has gone to her mother’s house to
pick up our four-year-old daughter. I’m going home sometime tonight, and will just hold her
for a while. Any of you with children, I’d encourage you to do the same
thing. And while you do, say a prayer for this family that has lost a
child, and a prayer for the guy who never saw what he did.

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Showing Appreciation

Jane writes:

My husband was in the ICU for over a week. During that week I watched as the nurses and doctors did their amazing job. They also made sure I was ok and had support to get through a very tough week. I was so impressed with their caring and compassion. I would really like to do something special for them (the whole ICU), other than just a thank you note. Can you suggest what may be appropriate or offer up some ideas?

Yes! Yes I can!!

It’s sweet of you to think of us during such a difficult time in your life. Whenever a patient and/or patient’s family shows appreciation for us in some way, it never goes unnoticed that they already have 1,000 other things to think about. In our ICU, little gifts of appreciation are always, well, appreciated.

Patient families have given us as a unit (and sometimes individual nurses) several different things. Sometimes they give us flowers, which are pretty, but not edible. Sometimes they write a letter to the CEO, which is forwarded to the unit manager, who puts it up on our board. We have a little bulletin board where she puts cards and letters that we as a unit receive. Families have given us home-made treats (breads, jams, etc) or donuts. By far, the most common thing we receive is boxed candy, almost always from See’s (the Midwest equivalent being Fannie Mae, I suppose).

We once got a gift card to Noah’s Bagels, but it was really quite difficult to use, as someone had to go get the bagels, the charge nurse always had to keep an eye on the card, and we had to keep track of which shift used how much.

I can only speak for my particular unit, but candy or food of some sort is always always always appreciated. There have been times when we’ve been so busy that we’ve been unable to take any breaks at all, and someone will come in with a box of candy… yum :-) Typically, families give one box for each shift (and write on each box “days,” “evenings,” and “nights.” Otherwise… it’s all fair game!). Include a little card saying who it’s from. A big bag of bagels with some different kinds of toppings always goes over well, too.

Again, thank you for taking time out of your situation to show appreciation for us. We as nurses really do like all the goodies our patients and families bestow upon us.

Sometimes we even share with the doctors. :)

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Best of codeblog
The Patient’s Perspective

I am fascinated by hearing patients’ perspectives. Their realities are so very different from mine while they are in the hospital. I need to keep hearing what it’s like for them, lest I take my position as RN for granted. Sometimes patients are just a “Pneumonia in room 5″ because it’s easier that way. But I think in my unit, patients who have been there awhile become our pet causes and we really do see them as people with feelings going through a huge life change. We do care about what happens to them, even the ones that are “difficult.” We realize that they’re difficult for a reason, and we are also acutely aware that we may very well be the same way if the shoes were on different feet. With that said, Jim writes:

I was hospitalized 02/03 with pneumonia in both lungs. After being hospitalized for two days I rapidly went “downhill” and was placed on a vent and put into a drug induced coma. I awoke 04/03 **unable to move** with all the tubes that go along with a prolonged vegitative state (PEG tube, central line (CVP), foley catheter, etc…) and still on the vent, I did not remember what happened to me or where I was.

I have spent my time since April first of this year in intense physical rehab, both in-patient and out-patient. The diagnosis is Gullian Barre, I have seen many specialists over the last several months. They have told me I will not recover any more function than I have now. I use a quad cane and a walker to get around and have to wear AFO’s bilateraly. I am only 28 and I have lost my chosen carreer because of this.

This is so hard to get used to. I imagine it is tough for medical professionals to see cases like mine and you can’t get wrapped up in the patient’s story because some are indeed too painful to dwell on, but please try to remember that we are people too, we have lives and families outside of the emergency room or ICU or wherever you may find us. We are not just the respiratory distress in bed five, or the broken leg in bed eight.

Well said. I’m wondering what AFO’s are, and what your chosen profession was? I’m also curious… you say that you “woke up” and didn’t remember what happened to you. When did you find out? My coworkers and I almost always try to re-orient the patient as they are “coming out” of sedation, but I think we don’t do it often enough. Or if we do it once as they’re groggy, we forget to do it again as they’re more awake. Thank you for your submission.

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  • profileI am Gina. I have been a nurse for 15 years, first in med/surg, then CVICU, inpatient dialysis, CCU and now hospice. This blog is about my experiences as a nurse, and the experiences of others in the healthcare system - patients, nurses, doctors, paramedics. We all have stories!

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