That blog is The Adventures of Bob the Nurse and was started by none other than Keith at Digital Doorway.

Bob the Nurse is an action figure that lives a very, well, adventurous life.  His blog is a photo blog depicting his various antics.

I’m very fond of this concept (you know, stealing your neighbor’s garden gnome and taking pictures of it in front of Niagara Falls or some such place).  When I moved to California, I stole borrowed took the coffee pot from the dialysis office with me.  I bought it a little wig and some googly eyes and took pictures of it at interesting places along the way as I drove here from the midwest.  The dialysis nurses were some serious pranksters, so this was my final prank on them.

So I find The Adventures of Bob the Nurse very amusing.  My favorite picture so far is this one.  I think it’s hilarious.

Keith explains the concept for Bob the Nurse in this post.  If you think you can broaden Bob’s horizons even more and would like to have him as a guest, contact Keith or leave a comment on Bob’s blog.  I have already offered – there are lots of places around here I can take Bob :)

Sinus arrhythmia then wrote a response post about nurses and salary. Both the posts and the article are a very intriguing read.

But of all the reasons a nurse would leave the bedside, one of the biggest reasons must be injuries, and this was not mentioned anywhere at all. There are a few articles about injuries and nurses; feel free to get your facts and figures there.

I personally know of nurses who have had such severe shoulder and back injuries from caring for patients that they required months and months off of work and surgical intervention. I know of one nurse who was kicked in the head by a patient. She was not harmed in any serious way, thank goodness, but the potential was there.

There is also the concept of repetitive stress injury. This is where you perform the same action (pulling patients up in bed, assisting them to the bathroom, etc) again and again over years. Then one day, you’re pulling a patient up in bed, and wham! You pull a muscle in your back or sprain a ligament in your shoulder, even if you’d had no problem with those areas before. Even with practicing good body mechanics, you can still incur these types of injuries over time.

Consider a scenario: You are working in a critical care unit that is crazy busy. You have a 350 pound patient that stooled in the bed and needs to be cleaned up. This patient has horrible skin problems and laying in stool will really exacerbate those problems. Literally every other nurse is busy with issues just as important. The only person you can find to help you is 5 feet tall and might weigh 110 pounds after a large meal.

What do you do? It’s a horrible dilemma. You could try to turn the patient by yourselves, but you wouldn’t be acting in a safe manner at all. In order to practice good body mechanics, the person who would be turning the patient towards them should have the side rail down. 350 pounds is a lot of weight… get a tiny bit of momentum there and the patient could literally fall off the bed if the nurse/aide wasn’t able to keep them on it! Not to mention the fact that you’d be seriously risking your back by doing that.

Some nurses would actually attempt cleaning the patient with only one other person to help them. Some would let the patient lay in stool until enough personnel were available to help turn the patient safely. Both situations have major drawbacks.

What’s a nurse to do??

There are some solutions – lift teams, no-lift policies, and lifting equipment that can make moving patients easier. We have several pieces of equipment that help us move patients…. from bed to gurney, from bed to chair, from laying down to dangling. But I don’t know of any equipment that would help in the above scenario other than having at least 3 other human beings in the room with you to help move that patient. Yes, there are some beds that inflate/deflate in weird ways to make it easier to move the patient over, but sometimes you have to move them way over. And that takes manpower.

On a crazy busy unit, it can take a long time to find 3 other nurses/aides who are all free and can help you with something that could easily take 15-20 minutes.

So I know that nurses are leaving the bedside due to salary, lack of opportunities to advance, and even hostile work environments. But one should never forget what a physically demanding job it is to be a nurse. Some nurses leave the bedside and never come back because they have been injured just doing their jobs.

Now, as perfectly healthy people driving around, do any of you feel comfortable sharing the road with someone possibly having a heart attack? I think not. You see, to simplify things, a heart attack is when the heart muscle is deprived of oxygen. When deprived of oxygen, the heart muscle begins to die. If a certain area of the heart begins to die, the person not only feels chest pain, diaphoresis (sweating), short of breath, etc. – their heart may go into a fatal rhythm. A rhythm not conducive to safe driving. Or driving at all.

So while the patient started out with a mere heart attack, he may end up with a car accident to boot…. not only taking out himself, but possibly others.

There are many reasons to call for an ambulance. Symptoms of a heart attack or stroke are high on that list. Another equally important reason to call for an ambulance is as Kim at Emergiblog touched upon in a recent post. An ambulance is a mini ER on wheels. People who know what they’re doing come to your house and start taking care of you WHILE transporting you to a place that you need to be. They have nitroglycerin, IV fluids, EKG’s and can start to diagnose and treat your condition en route. And if your heart stops beating, they can try to shock it back to life right there. Last I checked, defibrillators had not been added as options on modern cars.

If you feel as though you are having a heart attack or stroke, definitely don’t drive yourself to the hospital. Don’t have your spouse drive you. Please call 911 to get an ambulance. It could save your life and the lives of others.

GPI’s product is Medi Binder and I think it’s an extremely helpful product. As Grunt Doc says, “I like this product idea, and personally recommend it, especially for people who have more than 3 medicines / allergies, more than 3 doctors, or more than three surgical scars on the body.”

I have to say that I completely agree. This is a great tool that can guide you in keeping important medical information up-to-date and handy. As a nurse, I can tell you with 100% certainty that if all of my patients handed one of these to me when they rolled into the unit, my job would be SO much easier.

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?

Henceforth, I’m not sure what the current working ratios for med/surg are. I floated once to telemetry and had 5 patients. I thought that was okay, but one in particular took up a LOT of my time, thus leaving less time to deal with the other 4. AB 394 puts forth minimum staffing ratios. Critical Care will remain 1:1-2, but most other floors (excluding nursery, ante- and post-partum) will eventually phase to 1 licensed nurse to 4 patients. I believe this to be fair.

However… did you notice I said licensed nurses, not registered? There are two classifications of nurses – RN’s and LVN’s. LVN’s (or LPN’s – they’re the same thing) are Licensed Vocational (Practical) Nurses. I have searched for quite awhile tonight to find out just exactly what the difference is between RN’s and LVN’s and haven’t really come up with anything concrete.

From what I’ve heard over the years, LPN’s can’t do as much clinically as an RN. I’ve read sources saying that LPN’s cannot assess patients, and sources saying that they can. Most LPN’s cannot give IV medications, but some can if they are specifically trained to do so. As a rule, an RN is to thoroughly assess their patients and formulate a nursing diagnosis for each, devise a plan, implement the plan, then evaluate the outcome and change the plan as needed. Nursing care plans are the bane of a nurse’s life. But more on that another time :-) It is my understanding that LPN’s may assess patients in more of a “fact gathering” capacity than an “assessment” capacity and are not able to formulate a nursing diagnosis. Big deal, I say. Nursing care plans are overrated!

Unfortunately, I’m also getting the idea that LPN’s can only work under the supervision of an RN. THAT is distressing to me. Say that AB 394 is implemented in January 2004, and hospitals must then staff their floors at 1 RN for 4 patients (1:4). Theoretically, this means that hospitals can hire LPN’s – after all, an RN’s scope of practice is wider than that of an LPN, so RN’s cost more. Hiring LPN’s to pick up the staffing slack would make a lot of sense. However, this also means that because an LVN works under an RN, it is possible to assign one RN to 10 patients, if the LVN takes 5 of them. This would meet staffing ratios, but would then require the RN to care for her own 5 patients and supervise the care of the LVN’s patients as well.

Most RN’s I know hate supervising anything. After all, if you want it done and done correctly, you do it yourself! Certified Nursing Assistants are invaluable to nurses in helping them turn and clean up patients, empty foley bags, and check fingerstick blood sugars. Other than that, it’s Me RN who will be control freaking on every other aspect of my patient’s care. If I had to o.k. an assessment that an LPN under me does, or determine that one of their patients can have some IV pain medication and then have to go give it, what is the point? It still takes up my time.

I know that there are many areas that are perfect for an LPN/LVN. CCU will never be one of these, but I doubt that that would happen anyway – I’m more concerned about the above happening on med/surg and telemetry floors. There is also a raging debate going on regarding how RN’s treat LPN’s (as though they aren’t “real nurses.”) Regarding LPN’s, I say go for it – use them if that’s the best fit. Just don’t ask me to supervise.

We were in traffic yesterday, and decided to use the carpool lane. It
got me to thinking: What makes people NOT use the carpool lane? I see
all kinds of one-person cars out there – what makes them not just kind of
scoot over a little for a few miles or so?

I rarely see police cars around. When carpool lanes “came out,” were
there stiff penalties for using the lane alone? Does riding solo in the carpool lane elicit ridicule from other drivers? Being newish to the area awhile back, I
was driving in the carpool lane one night by myself during the posted times,
and no one seemed to notice or care.

Anyway – not a pressing topic for sure, but one I’m curious about nonetheless. In a society where the road becomes a parking lot for hours every day – why aren’t more people tempted to break free and use an
almost completely empty lane?

First and foremost, an RN is the eyes and ears of the MD. We carry out the orders that MD’s prescribe, after assessing if the order is appropriate. Doctors are human, too, and sometimes will order a drug that a patient is allergic to, will forget to order finger sticks on diabetics, or neglects to order tube feeding on that intubated guy. RN’s then implement these orders and evaluate the response. If that dose of diuretic didn’t make the patient’s output increase, or those 2 units of blood did nothing to raise the patient’s blood count, we don’t just let it go and assume that the doctor will find out tomorrow on rounds. Not only do we notify the MD of the outcome, we also learn to anticipate what the MD’s orders will be. If the order differs from what we’re used to, we question it and in some cases ask for justification.

We are the ones that are at the bedside the most. Other disciplines come and go – dietary, the ultrasound tech, the phlebotomist, the x-ray tech, the social worker – they drop in here and there, but your nurse is going to be the one to sense that something isn’t right…. if there is actually continuity of care and your nurse has been able to take care of you multiple days in a row, this is a real asset.

A benefit of this is that a nurse will advocate for his/her patient. If their patient is at risk for skin breakdown, the nurse is the one who pushes for that special air bed. If the patient doesn’t like what came on their dinner tray, the nurse calls down to find something else. I’ve gone to visit 4 different floors to find a can of Sprite for a patient long after the cafeteria had closed. If the patient becomes nauseated at 3:30am, we go to the phone to bug the MD for an antiemetic. Better yet, if you luck out with an experienced nurse, they will have already lined up some anti-nausea medicine long before you need it.

When the doctor has ordered a medicine to be given stat, and an hour later pharmacy hasn’t gotten it to the unit, the nurse harrasses the pharmacist until it gets there. The nurse makes sure that you get medications on time, that it’s the right drug for the right patient administered at the correct dose via the right route. The nurse makes sure the phlebotomist shows up on time to draw your labwork (or draws and sends it off herself), remembers to check for the result, interprets the result, and either calls the doctor for orders, or carries out orders that have already been written on condition.

When infusion pumps start beeping for no reason, the EKG monitor suddenly goes blank, or the computer freezes up, the nurse doesn’t just call up biomed without first troubleshooting the problems themselves. When I worked dialysis, part of my cart included a plumber’s wrench and several washers and faucet aerators. When I had to hook up the dialysis machine in the patient’s room, I never knew what kind of sink I’d end up with – sometimes the hose wouldn’t fit right and I’d have to change the aerator. We change the batteries in the mini-infusers, we empty the garbage, and if we’ve urgently transferred a patient to another floor to accomodate a “crash and burn” from ER, sometimes we even clean the room if housekeeping hasn’t had a chance to clean it as fast as we need it.

We teach new doctors how to use the computer system, we show them for the 100th time where we keep the progress notes, and we put the charts back in the rack so that they’re easy to find for the next person. We run controls on several types of machines… we check the crash carts every single day, and test the defibrillators. My particular unit has 6 defibrillators that are checked every night for battery power, recorder paper, and overall function.

We competently use and troubleshoot computers, infusion pumps, balloon pumps that sit in your aorta, continuous dialysis machines, ventilators, non-invasive positive pressure machines, suction equipment, defibrillators, nerve stimulators, crash carts, external pacemakers, dopplers, medication machines, and transport monitors. We calibrate and maintain the various tubes that the patient has in their bladder, rectum, nose, mouth, trachea, vein, artery, abdomen, and brain. We constantly assess, treat, evaluate, and alter the treatment plan.

We fill out and file TONS of paperwork: admission forms, blood product consents, surgical consents, pre-op checklists, nurse’s notes; blood sugar, restraint, lab, and wound care flowsheets; EKG strip papers, advance directives, flu shot consents, care plans, x-ray reports, MD orders, and Internal Audit forms. Yep, we even have to write each other up for the mistakes that happen: med errors, inappropriate transfers, missing eyeglasses, and faulty equipment.

We are the ones who re-explain what the doctor told you 3 hours ago that has just now sunk in. We explain the squiggly lines, why the vent is alarming, and just what those squeezy boots are for, anyway. We teach you about what’s going to happen tomorrow during your open heart surgery. We gently tell you when it’s time to let go, time to keep fighting, or time to just … wait and see.

When a complex patient goes to CAT scan, we coordinate respiratory therapy, transport, flex nurse, and accomodate the schedule of the CAT scanner. Do you have any idea how difficult it can be to make sure that 3 very busy people are in the same place at the same time? We find the old medical records, we deal with patient’s meds that aren’t in the hospital formulary, and gather every supply needed when the doctor suddenly needs to insert a chest tube, endotracheal tube, ventriculostomy drain, swan ganz, art line, or central line, or God forbid, open someone’s chest emergently at the bedside. If we’ve been there awhile, we even automatically bring the right size sterile gloves and the kind of suture the MD prefers. After we’ve assembled the supplies, we are there to expertly assist with these procedures.

We deal with every single kind of person imaginable: those who are demanding, scared, out of control, manipulative, unappreciative, violent, combative, crying, screaming, uncompliant, chatty, mentally ill, angry, depressed, confused, disoriented, critically ill, on the mend, thankful, kind, sleepy, or dead – both expected and unexpected. Some people hate where they are and why they’re there, some people are desperate to stay within the comfort zone that a hospital can provide. We must remain objective, in control, calm, competent, and kind to those who are disrespectful and rude. We must always be available to the patient at their bedside – we don’t get to poke our heads in, check out some labs, write a progress note, and leave. When the patient has put on their call light for the 50th time (I am NOT exaggerating here) so that we can change the channel, find a new TV remote, put them on the bedpan, get them off the bedpan, bring them their pain medicine, put a cool cloth on their head, rearrange tubes/wires, find the phone, help them out of bed, clean them up, change the sheets, reposition, suction, fix monitor leads, or shut the blinds, we are there. We must be diplomatic with angry patients, visitors, family members, doctors, and other nurses. We interact with every single department in the hospital, and several outside: coroners, organ banks, funeral homes, ambulance services, and other hospitals.

We must ensure adequate and safe staff for our unit. If there is a sick call, we either have to rearrange patient assignments, or sit down at the phone and start calling people to come in. We arrange transfers with other units and other hospitals, we organize float nurses, give days off, and we are always at the ready to accept patients, both planned and very … unplanned.

We are constantly exposed to every bodily fluid you can imagine, and several that you can’t. We don’t get to refuse to care for infectious patients – if a patient is in isolation, we don the gown, gloves, shoe covers, and mask every single time we enter the room, even if we have to enter it 30 times a shift.

There are a lot of rewards. Every so often you’ll get that patient that is genuinely a joy to care for. A nurse takes care of people that are at a low point in their lives, or at an especially high point. We must display compassion, intelligence, confidence, and adaptability. We are supported by amazing coworkers consisting of other nurses, doctors, nurse aids, pharmacists, phlebotomists, nutritionists, physical therapists, managers…

It takes a lot of teamwork, personnel, and skill to run a hospital. Every department is invaluable and contributes fully to the success of the hospital. But while not every department can contribute in a nurse’s capacity, a nurse can contribute in the place of almost every department. We are able to do at least a little of what everyone else can do.

Happy Nurse’s Day!