Over at Nursing Voices, there was a recent post about working the night shift as a new grad.

I worked 11p-7a right out of school. I trained on evenings (3p-11p) for a few weeks then switched to night shift. There were no day/evening shift positions at the time. I’d worked nights during school on the weekends as an aide, so it wasn’t completely new to me.

But it still completely sucked.

I sleep best at night. I like it dark and quiet. Sleeping during the day, for me, was horrible. Room darkening shades helped, but nothing much helped the noise. The majority of the world is awake during the day, and there are lots of traffic sounds, lawns to be mowed, and doorbells to be rung. At first it was kind of neat, being a full-time child of the night… but the novelty wore off quickly. Driving home in the new day’s sunlight made my brain resistant to sleep. Even if I slept 8 hours, I still woke up groggy. And trying to keep up with the rest of the world (friends who kept “normal hours”) was hard. I found myself staying home on my days off and vegging in front of the TV or computer. I gained weight by eating carbs during the day, trying to perk myself up. I used to fall asleep again when it got dark outside and have to wake up again to go to work and literally cry because I could not fathom staying up all night again.

Once I got to work, though, I was usually fine. I worked on a very busy unit and there was plenty to do to keep me occupied. After 6 months, though, I moved on to CVICU, where there were only two shifts – 12 hour days and 12 hour nights. Of course there were no day shift positions. The plus was that I’d only work 3 nights a week instead of 4 or 5. The minus was that I was no longer able to take that nap at night when it got dark. I had to get good quality sleep in during the day, which was hard for me to do. I tried to sleep for only a few hours on my days off in order to sleep that night, but that just made me groggy and again I found myself vegging on the couch instead of out and about.

I jumped at the chance when a day shift position opened up. I had been watching the job board for months, and even secretly wished that someone working days would transfer to a different unit or hospital. A few of us put in requests for it, but I managed to snag it with only a few weeks seniority over the others.

It was a different world for me from then on. Never again will I work night shift. Day shift is much different from nights with all the comings and goings, but I wouldn’t have it any other way. Within a month after starting days, it was like a fog lifted from my brain. I felt so much better. I was so thankful to be able to sleep at night again. Unfortunately, one of nursing’s occupational hazards is candy and goodies brought in by family members and former patients – so the weight situation didn’t change much. Everyone knows that day shift eats all the good stuff before the night shift comes on anyway :)

What’s your story? There’s a poll up at Nursing Voices. Were you forced to work nights starting out? Did you immediately switch to days when you could, or did you discover that you liked being up at night?

Change of Shift is up at Emergiblog.

Remember this baby?

Well, he turned into this 1 year old:

I have never done anything so simultaneously frustrating and rewarding. Mostly rewarding :)

I was tagged by PixelRN, so here goes:

1. I have a few goals in life: I want to someday design and build my own house, see the northern lights and visit the 7 wonders of the world. That last one might be a little difficult, though, seeing as how I’m not very fond of traveling.
2. For one summer in college, I worked at Eastman Kodak in a lab. I’m amazed that I can’t remember exactly what I did, but I know it had to do with testing the silver emulsion for…. something. Anyway, it was a fascinating job and I still remember my coworkers there, although I don’t keep in touch with them anymore.
3. I make mosaics.
4. If I could have any job in the world, I would want to be an astronaut.
5. I was married on Halloween.
6. I love playing video games. I can remember playing Mah Jongg on my dad’s old 386 and Missile Command on the Atari. I’ve graduated to Nintendos and Xbox’s now, but it has truly been a life long “hobby.”
7. Last and least, I have ADD. I’m sure no one noticed, but I posted only 7 times during my pregnancy last year. That’s because I wasn’t taking my meds and the desire to write pretty much vanished. I was diagnosed and started treatment in college. One semester I was about to flunk out of the nursing program and the next semester I was on the dean’s list. Pretty
impressive turnaround. Think what you will about ADD, but finding out how to manage it changed my life.

Honestly, I don’t know who to tag – I feel like I’ve read this meme from pretty much everyone, but I guess I don’t remember seeing one from Kevin MD or GruntDoc.

As of this week, I’ve been blogging here at codeblog for 5 years.

I know I’m not the most updative poster. I know I only post a few times a month, if that. But I still love being a blogger, and I love knowing that codeblog is here when I want to write.

This blog has been mentioned in Newsweek, the Wall Street Journal (couldn’t find a link to that), and Nurseweek.

I’ve hosted Grand Rounds four times.

I still remember starting… My husband and I spent all day coding the site. Well, it was mostly him doing the coding – I just told him what colors I wanted and how I wanted things to look. :) Here’s the very first post.

Who knew it would still be here in 2007? Happy Blogirthday to me!

From “psychosis buster, RN:”

(For the longest time I kept reading it as “psychosis butter.”)

Way back in the eighties I was working on a 40 bed acute psychiatry ward in a fairly large Canadian city. One day, one of our repeat customers, a chronic paranoid schizophrenic patient, was admitted from Emergency. She hadn’t been looking after herself and she was covered in lice, as was her (expensive) fur coat.

Two of my co-workers figured they’d do her a favor and send the coat down to our laundry department for cleaning. Unfortunately, they thought it would be a really good idea to send it in a red “contaminated laundry” bag – this was before the advent of universal precautions. What they didn’t know was that the laundry department didn’t open those bags – they just tossed the whole kit and kaboodle in the washer, along with very hot water and strong soap.

The next day, a plastic bag arrived on the ward from the laundry department. It contained what looked like a hairy collar, with several strings dangling from it and some ratty fur, with a note asking “what was this?”

Well, it had been a fur coat valued at something like five thousand dollars. Fortunately, the hospital agreed to reimburse the patient. To this day, I don’t know which was funnier: the pathetic remains of that coat or the expressions on my colleagues’ faces when they saw it.

Nursing ratios are very important. When I worked in IL, I once had to take 3 critically ill patients. I had never been so busy at work in my life and I constantly felt as though I was way behind. I was very scared of possibly missing something. There simply was not enough of me to pay very close attention to each patient.

There were a few nights on med-surg that I took 9-10 patients, mostly fresh post-ops. That’s a lot of patients. And that was over 10 years ago. Even in the last decade it seems like patients have been getting more and more complicated what with their chronic medical problems.

Here in California, there’s a law protecting ICU nurses in particular; it says that we can only take 2 patients in ICU. Even if they require a lower level of care and are overflow from full med/surg units, even if they have transfer orders – if they are physically in ICU, they are to be 1RN:2pts. California has been moving towards staffing ratios on transitional care units and med-surg floors as well.

There’s a bill that’s been introduced – the Registered Nurse Safe Staffing Act of 2007 (HR 4138). It would provide a staffing system that has input from nurses who give direct patient care. This is a very good thing. It is something that we do in my ICU all the time and I can’t imagine it any other way.

PixelRN has also written about this issue, perhaps a bit more eloquently than I. WashingtonWatch.com provides information on the current status of the bill and a wiki where you can put forth your arguments for or against the bill. There’s even a link on their sidebar where you can write to your state representative. I plan on doing so right after posting this. They don’t know if you support it if you don’t tell them! They all have email; it’s very fast.

There have been more and more regulations lately from JCAHO, the most recent and notable being those which state hospitals will not be reimbursed for care related to preventable complications such as pressure ulcers and UTI’s. We do the best we can with what we have. More nurses = more care = less complications.

This is one regulation from the government that actually makes sense. I’m so glad it’s been taken to a national level. We really need to get behind this bill.

I had a patient a few weekends ago that was elderly and had many acronyms wrong with him (COPD, CHF, CAD, s/p CABG, HTN, DM, PVD, was HOH, CRF, past CVA, TIA’s and, um, osteomyelitis). During report, I asked the nurse to just tell me the diseases he didn’t have.

Anyway, his CRF was turning into a nasty case of ARF and the primary care doc came in and ordered renal-dose dopamine. Does anyone actually still prescribe renal dose dopamine? Well, obviously, because this one did. But does anyone else? Being the dutiful nurse that I am, I started it at a whopping 2mcg/kg/min and sort of rolled my eyes at the whole situation.

The patient was one of those cantankerous sorts that I love taking care of:

Me: I have to give you a shot in your abdomen. It’s a blood thinner that will help prevent blood clots in your legs.
Patient: In my stomach? It sounds like that will hurt.
Me: It won’t hurt that badly.
Patient: Who’s the patient here, me or you?
Me: I’ve had shots in the abdomen before. They aren’t that bad.
Patient: (regarding me warily) Well, okay…

After I gave him the shot, he winced and said, “I thought you said it wouldn’t hurt!!” To which I replied, “No, I said it wouldn’t hurt that bad.” Ha :-)

Anyway, about 15 minutes later, my patient started to desat. Out of the blue. I did all the usual things to fix it, but nothing worked. I finally resorted to putting an O2 mask on him. I went in later to turn him and he complained of being nauseated. I checked the residual on his tube feeding and got what I’d gotten an hour before – less than 10 cc’s.

A lot of weird things were suddenly happening with my patient.

Because he was nauseated, he kept taking his oxygen mask off. Then he would desat. I went to talk to the pulmonologist, hoping we could just sort of settle for a sat of 88% or so, but he told me to tell the patient that if he didn’t keep his mask on, I would have to restrain him. Come on!!! He’s an old man with some really bad acronyms!! Leave the poor guy alone! My advocating went nowhere, however, and I had no choice but to deliver the news: “The doctor says that if you don’t leave your mask on, I’ll have to restrain your arms.”

He looked at me as though I was nuts. Well, I felt nuts. The guy was quite oriented, not confused at all and here I am threatening him with restraints. Sometimes I really hate this job.

So I went back to the doctor and said, “Can I interest you in a Phenergan order for his nausea?” He was agreeable to that, but before he put the order in he paused for a moment. “But why is he nauseous all of a sudden?”

Well, a tiny little light bulb went on in my head and I smacked the doctor’s arm and said, “It’s the dopamine!” I remembered a patient we got from the cath lab a few years ago. The patient was on like 10mcgs of Dopamine and she was constantly green and dry heaving (Great for groin punctures!). It could be chalked up to quite a few reasons (pre-op medications, the fact that she’d just had an MI, etc) so I didn’t think much of it. No antiemetic worked, however. But as I came down on the Dopamine, her nausea started to abate. When we had to put her back on it a few hours later, it came back.

So I went back to my patient and turned off the Dopamine to see what would happen. He had no idea that I’d even started it or that I was shutting it off. 15 minutes later I went back in because his sats (which were about 91% on a mask) had risen to 96%. I asked him if he still felt sick to his stomach.

Nope. No longer nauseated. And his sats were up, so I put him back on nasal prong oxygen. The sats stayed up.

Has anyone else seen this? Dopamine, even at a ridiculously low dose, really screwed this guy up on a couple of different levels. I explained the situation and all he said was, “Yeah, I figured you were probably a good nurse.”

Well there ya go. Can’t argue with that.

Ohhhh I have been away for awhile. I did not think anything could rival my blogging addiction, but my husband wanted to get an Xbox. Many hours have been sucked up playing Catan, Carcassonne, and Viva Pinata :-) I am completely hooked.

Anyway.

A patient I had a few weeks ago was intubated, even though she told her family she did not want to be. When the chips were down, they chose to tube her. She was pretty pissed when the tube came out.

I tried to talk to the doctor about it. I told him she didn’t want any of this, and that her wishes should be respected. He said that she had been unresponsive at the time that the decision was made, the family chose to tube her, and in the absence of documentation to prove her DNI wishes, that was that. But the thing that really got me was this: “It’s between her and her family. I’m not getting in the middle of it.” He said that to me twice.

For some reason it really bugged me that he said that. Isn’t that our job? To get in the middle of it? I understand the lack of documentation, but he brushed it all off, wanted to get on to his next patient.

The other thing that bugged me: When he came to see her, he sat at the computer, looked at her labs, wrote a note and left. He didn’t even go in and see the patient. Was it because she was sedated on a vent? Or was it because I was doing a sedation vacation on her and she was actually awake but difficult to communicate with?

It is very difficult to communicate with people on ventilators. They try to talk but they can’t. It’s hard to lip-read around a tube. If you untie the restraints to let them write they either go for the tube in their moment of freedom, or what they write isn’t legible. Communication boards are a nice idea, but when someone’s coming off sedation, their limbs feel as though they weigh a ton. It’s actually quite difficult for an elderly person to even hold their hand steady enough to point at a picture. If they can even see the pictures and words.

Still, I managed to ascertain that she was ready for the tube to come out whether the docs thought it was appropriate or not. It took me a long time to figure this out and I had to watch many bouts of frustration while she tried to get her message across. Many patients gesture wildly and when the guesses I proffer aren’t correct, the frustration in their faces is heartbreaking. They sometimes literally throw their hands down and close their eyes in defeat.

It’s hard when people who are in charge of your well-being can’t understand what it is you’re saying. It’s scary to be tied down to the bed with a tube you never wanted stuck in your throat while you wait for test results to come back. Test results that determine whether we remove the offending tube, or whether we put you back to sleep to wake you up another day and try again.

I managed to figure out what she wanted, though. It took some time, lots of guessing, and perseverance. It took some patience waiting for her to get over her frustrated moments enough to try again. And then, finally, the tube came out, and she confirmed her wishes to me immediately.

After all that… I summarize the major plot points for the physician and all I get back is, “I’m not getting in the middle of it. She needs to work it out with her family.”

Well good for you. Problem solved (for you). Now you can get on to the next patient. You may as well have written your progress note from home and faxed it in for me to put on the chart. Enjoy the fee you collected on your “patient visit.”

When I started out in nursing, the hospital I worked at required CNA’s to wear cranberry, RT’s to wear teal, and RN’s to wear royal blue, etc. We could wear certain scrub tops that were approved and that matched the royal blue pants. The hospital did not pay for them.

When I moved and got a new job, there were no standard uniforms. We could wear whatever we wanted. Some people took this too far and started looking a bit unprofessional – scrub pants with little t-shirts that actually showed off belly buttons, that sort of thing. One or two nurses wore street clothes, but they actually looked fine to me. It wasn’t like they were wearing jeans or anything. It looked appropriate in my opinion.

A committee was formed to discuss the possibility of requiring standard uniforms. Most of us in ICU (and the rest of the hospital) were completely and totally against it. We liked our individuality and we didn’t want to look the same. I realize that there are professions that wear standard uniforms (police, EMT’s, firefighters, the military, etc), but some of us felt as though we should not be told what to wear.

Patients often comment on our scrub tops, usually compliments :). Then again, it was argued that if we told patients at the outset that all RN’s are wearing blue, they’d be able to discern who they were talking to. Or, you know, the person could just tell them that they were the RN. Why make things so hard?

Most of us felt it was up to the manager to take care of those who were dressed inappropriately.

The idea was eventually shot down, but I found it most interesting that the hospital was prepared to buy everyone’s uniforms for them, the number of which was to be based on how often one worked. I couldn’t believe that they’d spend so much money on dressing everyone.

So what do you do? Once again, there’s a poll up at Nursing Voices if you care to weigh in there!

To my sweet Secret Pal: YUM!!!!. I had to hide the box from my husband :-)